In every field of endeavor, change is brought about by entrepreneurs. These are the creators. The innovators. They rarely stop thinking. The only question is: What are they thinking about?

In a normal market, the entrepreneurs wake up every morning and ask themselves: How can I make costs lower, quality higher, and access to my product better today?

But in a bureaucratic system – where revenues are determined not by customer satisfaction, but by complicated payment formulas – they tend to wake up and ask: How can I get more money out of the payment formulas today?

In the Medicare Advantage program you can find both types of entrepreneurship.

Imagine that UnitedHealth care or Humana or Cigna discovered away to cut health care costs in half – with no reduction in quality or in access to care. The stock price of the company that made this discovery would go through the roof. Right? Not quite. Under rules imposed by the Obama administration, the company would be forced to give virtually all of its newfound profit back to Medicare.