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About 7 million people are expected to buy insurance through the marketplaces in the first year. But it's more important to watch who signs up rather than how many. For these new insurance markets to thrive, they'll need to take in more in premiums then they spend on health care, so they need more healthy buyers than sick, economists say.

Most in the Pioneer group achieved quality improvements, but only 18 produced cost savings.

It remains to be seen whether it functions profitably or not," said Alan Miller, chief executive of Universal Health Services, which operates more than 200 hospitals, behavioral health facilities and outpatient centers."There has been a lot of discussion of moving away from fee- for-service to something like this, but we are a long way from there," Miller said.

If it became necessary to do something to be competitive, we might change our mind, but right now we think we can continue to grow our business without spending the capital dollars and replacing what managed care companies can do well, just by contracting,"

and nearly half have less than $1,000 on hand to deal with such expenses, according to a recent study by the disability insurer Aflac.

ut-of-pocket costs continue to rise even as healthcare inflation remains low.