“Government, at both the federal and the state levels, is no longer merely an umpire. It is not just setting rules and impartially enforcing them, government all too often is taking sides and picking winners and losers. Overall, Americans accept and expect government as a regulator, but in the world of health care, it is also a purchaser and competitor. There are countless examples in Medicare and Medicaid in which the federal government and states have re-written the rule book to favor a particular hospital or type of provider, or block competition. Special accommodations that were justified (or rationalized) in the past as ‘one-time deals’ or ‘transitional’ somehow become embedded parts of the program.”