We thank Dr. d’Orbcastel for his update on the evolution of the French system of home care for patients with respiratory insufficiency. He reflected on the key role that Dominique Robert played in the initiation and development of the French system, and commented that, “such pioneering is more difficult today with budget restrictions and immediate value for money being demanded.” How our societies will support and encourage innovation as we seek cost-effective systems that will increase the quality of life for people with chronic disabilities remains a fundamental question for the future. The interactions between publicly financed and privately financed medical care organizations and the academic enterprise are complex, and, to our knowledge, have not been thoroughly worked out in any industrialized nation. While private enterprise has the potential to encourage innovation and to develop new and more cost-effective paradigms for the delivery of care, there is also the very real potential that privately financed medical systems will seek to “cream” the less complex and less severely afflicted patients. Thus, the public sector is at risk for being left with the care of only the patients with the most costly conditions. In addition, the private market is limited as a mechanism for promoting innovations because of the low profit potential, which can be a problem with technology that is designed for small, highly specialized markets of disabled consumers, who are more likely to be unemployed or living on low fixed incomes when compared to the general public.