real-life counterpart. However, he suggests that a global budget could be added at a later date to the framework of managed competition if health care costs continue to accelerate at an unacceptable rate. Uwe Reinhardt points out that global budgeting is still in its infancy in the United States, and lacks an infrastructure for effective implementation.

A number of interesting additional perspectives on global budgeting are provided by Robert Blendon, Vickery Stoughton, James Bentley, and Paul Griner. Robert Blendon spoke about an article he coauthored that examined global budgeting from the perspective of practicing physicians in Western Germany, Canada, and the United States. Vickery Stoughton addresses the effects of global budgeting on the Canadian health care system, particularly as it relates to resource allocation, waiting times, and the availability of certain technologies. James Bentley speaks to the issue of global budgeting from the perspectives of the hospital sector. He notes that some forms of global budgeting are already in existence through programs operated by the Veterans Administration, the Public Health Service, and to some degree, Medicare and Medicaid. Mr. Bentley suggests that for global budgeting to succeed, greater emphasis must be placed on the delivery system to provide the structure, and on information and shared financial interests to provide the required framework.

During the year in which these lecture programs were conducted, the dialogue and possible agenda for health care reform has moved forward at unprecedented speed. In November 1992, Bill Clinton was elected president on a platform dedicated to the goals of universal coverage and lowering the rate of health care costs. This new, sharpened focus on reform adds to the value and timeliness of the presentations included in this volume. The topics addressed in these pages help to inform and illuminate issues at the heart of current efforts to reshape and improve America's health care system.