access lower-income citizens had to basic healthcare is not available here at this time. 1990s growth and ubiquity By the late 1990s, U.S. per capita healthcare spending began to increase again, peaking around 2002. Despite managed care's mandate to control costs, U.S. healthcare expenditures have continued to outstrip the overall national income, rising about 2.4 percentage points faster than the annual GDP since 1970. Nevertheless, according to the trade association America's Health Insurance Plans, 90 percent of insured Americans are now enrolled in plans with some form of managed care. The National Directory of Managed Care Organizations, Sixth Edition profiles more than 5,000 plans, including new consumer-driven health plans and health savings accounts. In addition, 26 states have contracts with MCOs to deliver long-term care for the elderly and individuals with disabilities. The states pay a monthly capitated rate per member to the MCOs that provide comprehensive care and accept the risk of managing total costs. Techniques One of the most characteristic forms of managed care is the use of a panel or network of healthcare providers to provide care to enrollees. Such integrated delivery systems typically include one or more of the following: Designated doctors and healthcare facilities, known as a provider network, which enrollees are required or incentivized to use Formal utilization review and quality improvement programs including disease management and case management An emphasis on preventive care including wellness incentives and patient education The techniques can be applied to both network-based benefit programs and benefit programs that are not based on a provider network. The use of managed care techniques without a provider network is sometimes described as "managed indemnity". Cost sharing High-deductible health plans are used by insurers to keep costs down by incentivizing consumers to select cheaper providers and possibly utilize less healthcare. Reference price schemes are another method to share costs, where a health insurer will only pay a certain amount and anything above that must be paid out of pocket. Provider networks Insurance plan companies, such as UnitedHealth Group, negotiates with providers in periodic contract negotiations; contracts may be discontinued from time to time. High-profile contract disputes can span provider networks across the nation, as in the case of a 2018 dispute between UnitedHealth Group and a major emergency room doctor group Envision Healthcare. Maintaining up-to-date provider directories is necessary as CMS can fine insurers with outdated directories. As a condition of participation,