⁵The comparison of Medicare and private insurance has been criticized on the grounds that the switch to HMOs in the 1990s lowered out-of-pocket expenses for the privately insured. This is true, but of course the theory of HMOs was that the switch would also lower cost trends for insurance, so the criticism is not entirely relevant. In addition, the balance of adjustments due to reduced out-of-pocket spending is not so clear as the critics say. See Boccuti and Moon 2003b. [Return to Text]