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To the Editor: The article by Dr Cunningham and colleagues,¹ which documents the difficulty for physicians enrolled in managed care plans to meet their time-honored benevolent obligation to assist the poor by providing necessary medical care, is important and timely. Paradoxically, Dr Fletcher's Editorial² seriously downplays the damage that managed care has inflicted on the patient-physician relationship in general, and specifically on the physician's responsibility to provide care to those left out of the system who, in ever-increasing numbers, are being excluded by that flawed system. Instead of faulting managed care for its inability to provide all Americans with equal access to quality health care, obviating the need for charity care in the first place, Fletcher apparently has convinced himself that "[the nation] decided that universal health insurance was unacceptable . . . " and that " . . . the United States made a collective decision in favor of this way of managing costs and quality."²