In 1970 the rising cost of health care coverage as a percentage of U.S. gross domestic product attracted political attention. Health maintenance organizations as they are conceived today arose under the Richard Nixon administration in an attempt to control federal health spending (Rodwin, 2010). The federal government created subsidies to start HMOs, encouraged their use in Medicare and Medicaid, and encouraged commercial HMOs (Rodwin, 2010). Because of differing policy goals, the framework not only included efforts to control costs through oversight of medical practice, payment of physicians, and influence on medical care decisions, the legislation also included benefits to lay the foundation for those Policymakers seeking a path to nationalized health insurance. including comprehensive benefits, open enrollment, and community assessment (Rodwin, 2010). These competing goals have led to HMO premiums costing as much as traditional plans (Rodwin, 2010). The many common features of today's health plans began with HMOs, such as coverage for preventive services and prescription drug benefits (Kongstvedt, 2013). Other characteristics of HMOs were: a) closed networks where only services could be provided by an HMO physician, b) a fee where providers were paid a fixed amount based on the number of patients covered, c) primary care provider as “gatekeepers” for referrals to specialists, d) requiring pre-authorization for elective procedures to ensure medical necessity, e) encouraging outpatient procedures over inpatient procedures, and f) supervision to reduce the length of hospital stay (Kongstvedt, 2013).Additional trends for HMOs during the 1970s and 1980s to control costs that continue today were the process of reviewing the use of ... half the paper ...... and the 1990s. and consumers who had not previously experienced utilization controls began to have requests for services denied. This heralded a backlash against HMOs and legislation that protected patients' right to appeal denials. Both cost and access are major issues in health care today. The ACA's requirements for expanded coverage and oversight of premiums and medical loss rates, as well as reimbursement under Medicare and Medicaid, are driving premium adjustments in the private insurance market, increased consolidation in health care systems and an intense focus on reducing preventable readmissions and hospital admissions. acquired conditions. Managed Care has not been influenced by a single goal or voice, but by a balance of conflicting goals and stakeholders as costs, access, quality and choice are balanced by providers, insurers, government and patients.