Until recently, only one major purchaser had vertically integrated with providers. This situation has arisen mainly due to a political consensus around the undesirability of growing vertical integration in the Dutch context. Proposals that could expand current levels of vertical integration - for instance, the proposed set up of a co-operative in 2008 involving a regional health insurer, a regional physician co-operative and other health professionals, in order to take over a local hospital in financial distress - have been strongly opposed in Parliament, based on concerns about professional autonomy and free choice of provider by users. Insurers are free to compete for enrolees through adjustments to their community-rated premiums and this has resulted in strong price competition among insurers. Stronger competition for enrolees through policy prices quickly translated into financial pressure on insurers, whose general reaction has been two-fold (Schut and Van de Ven, 2011). First, there has been wider experimentation and adoption of measures to reduce operational and managerial costs.