This article was written by John Steen in February, 2006 for the AHPA publication, Health Planning TODAY. Reprinted with permission.

In this brief but remarkable statement is contained the federal government's position on health care delivery in America, a position that was introduced within the conservative economic agenda during the Reagan years. "Impersonal" here is tantamount to "unthinking," and that rules out all forms of planning and regulation save those aimed at attempting to secure and support marketplace health care, were there such a thing. And so with health policy, we are given a policy that is the very negation of all health policies.

Health care delivery is not provided in the "impersonal working of the marketplace." It is provided in local communities by community-oriented providers, it should reflect community values and needs, and it should lead to empowering communities through planning. Additionally, it is provided in a highly regulated and controlled environment that is not consistent with a free market. "Free market competition" is inconsistent with:

• Patient demands for care that are not discretionary;
• Purchasers' lack of information about prices and costs;
• The assurance of third-party reimbursement;
• Philanthropic subsidization of services;
• Caregivers' control of services received by patients;
  • Community input for more appropriate, acceptable, and accountable services;
• Mission-directed and/or status-building institutional health care delivery;
  • Legislatively mandated health care services;
  • Ensuring the safety and efficacy of health care services and avoiding malpractice;
  • Legislatively mandated health insurance benefits;
  • "Social safety net" services like Medicare and Medicaid;
  • Measures to serve under-served populations and meet unmet needs;
  • Priority for public health;
  • Equity in a health care system that embodies principles of social justice.

In May 1999, the Board of Directors of AHPA adopted a Mission Statement that had this to say about competition:

"The longstanding commitment of providers to a community mission which built public trust is being eroded by corporate business practices which generate profits, often without any community benefits. The reliance on market competition for "healthcare reform" is a political and economic experiment which is resulting in dislocations throughout society. The challenge to public policy is to facilitate the development of a responsible marketplace, one in which the sought-after benefits of competition are realized. …

"To achieve benefit from this process for all residents, it is necessary for legislators to take a more active role in shaping the transformation of the market. Government is obligated to exercise sound stewardship of the public's resources, much of which it controls as the primary payer of services. Health care is a social good like safety and education which, in a democratic society, requires intelligent government oversight in order to balance competing needs and priorities."

To see all of our Board-adopted policy statements, go to: http://www.ahpanet.org/Policy_perspective.html. And for a cogent discussion of the illogic of reliance on market forces to improve the efficiency of health systems, see "Are Market Forces Strong Enough To Deliver Efficient Health Care Systems? Confidence Is Waning," by Len M. Nichols, Paul B. Ginsburg, Robert A. Berenson, Jon Christianson and Robert E. Hurley, in Health Affairs, Vol 23, Issue 2 (March/April 2004), pp. 8-21, accessible at http://content.healthaffairs.org/cgi/content/abstract/23/2/8 .

In my Policy Perspective (3-06), the report on specialty hospitals illustrates how competition plays out in delivery systems, emphasizing once more that there are no private (profit-making) solutions to public problems. Yet this is the mantra of the Bush administration, that government should deed to private investment all functions where there is profit to be made. The excellent publicity that the VHA has gotten for its achievements in solving the quality/cost conundrum must be driving conservatives nuts. May they suffer a fatal case of ideological dissonance. (See my article at http://www.ahpanet.org/files/Universal%20Health%20Care%20II.pdf  ) . What I see as one of the worst applications of their marketplace ideology is the shift of health care information itself from government to the private sector, a threat to states like New York, Pennsylvania, and California that consider information about health care to be a civil right, and to planning and regulatory programs everywhere. In an address to the Healthcare Information and Management Systems Society on Feb.13, David Brailer, national coordinator for health information technology, Department of Health and Human Services, said, "We have ensured that the federal government will not build, own or operate the infrastructure of America's health information." ( http://www.healthimaging.com/content/view/3839/85/  ).

The current administration's position on an unregulated marketplace is much more than the denial of a health care system. It amounts to the denial of a role for government itself, and of the very concept of government on which our founding fathers established this nation. And government functions that are supportive of communities and social values are compromised in order to condemn them as dysfunctional (post-Katrina New Orleans is a case in point), thereby preparing the way for their elimination.

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Thomas Hobbes

Portrait of Thomas Hobbes

Hobbes finds three basic causes of the conflict in this state of nature: competition, diffidence, and glory. By contrast, "the passions that incline men to peace are fear of death, desire of such things as are necessary to commodious living, and a hope by their industry to obtain them." Man forms peaceful societies by entering into a social contract. The only escape from danger is by entering into contracts with each other — mutually beneficial agreements to surrender our individual interests in order to achieve the advantages of security that only a social existence can provide.

Hobbes provides us with a useful insight into better understanding the promotion of unfettered competition when he quotes Cicero who approved the Roman practice in criminal cases of asking, "cui bono; that is to say, what profit, honour, or other contentment the accused obtained or expected by the fact. For amongst presumptions, there is none that so evidently declareth the author as doth the benefit of the action."

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For a half-century, we had traditional indemnity insurance that supported our use of healthcare, a threat the industry labeled a "moral hazard." From the supply side, the industry introduced "managed competition" to reduce service utilization. The newest trend reduces utilization from the demand side by making it unaffordable to the consumer. Known as "consumer-directed health care" (or "consumer-driven health care"), it is being promoted as the new market-based solution to cost inflation. Consumer-directed care refers to health plans in which employees have personal health accounts from which they pay medical expenses directly. It threatens important societal values -- in particular, the goal of establishing relationships between patients and clinical professionals based on trust. See, "Which Way For Competition? None of the Above," by Robert A. Berenson, Health Affairs, Vol. 24, Issue 6 (Nov/Dec 2005), 1536-1542. Online at: http://content.healthaffairs.org/cgi/content/abstract/24/6/1536 .

The Administration is spinning its health savings accounts as introducing competition into the pricing of health care, the idea being that once patients are forced to pay more costs out-of-pocket, they will begin to comparison shop and request quality data, eventually driving down the cost of health care. But the information consumers need to most effectively manage these accounts is how much their out-of-pocket costs will be for a particular service and not how much, for example, a hospital charges for a particular service. Here we have an artifact of insurance marketing, not an indicator of health system cost, and it's an artifact designed to promote a race-to-the-bottom in health insurance coverage while getting consumers to think they are saving money. As with almost all of the administration's health policy initiatives, it is hard to tell how much they are driven by incompetence, and how much by meanness. Calling this Bushcare is Bushit.

The justification for having any government at all is to have a way of satisfying needs that cannot be satisfied adequately by individuals. The leaders we elect, and the people they employ, are the stewards whose responsibility it is to meet our needs. What we have here is the perversion of that contract, where our burdens are magnified and returned to us at the very time when we are least able to handle them.

"Markets are designed to facilitate the free exchange of goods and services among willing participants, but are not capable, on their own, of taking care of collective needs. Nor are they competent to ensure social justice. These 'public goods' can only be provided by a political process." (The Bubble of American Supremacy, George Soros, 2003).

Let us not miss the greatest insult in this love of market competition. When we promote competition at the expense of all other motivation, we depreciate the interest we have in compassion, thereby depreciating our own humanity. That our collective humanity is already depreciated is evident in daily news reports. On Valentine's Day, The Washington Post reported on the administration's proposed budget, and the news was dire. Staff Writer Ceci Connolly wrote that Bush "has requested billions more to prepare for potential disasters such as a biological attack or an influenza epidemic, but his proposed budget for next year would zero out popular health projects that supporters say target more mundane, but more certain, killers."

The president's 2007 budget would wipe out federal support for such key public health programs as "inner-city Indian health clinics, defibrillators in rural areas, an educational campaign about Alzheimer's disease, centers for traumatic brain injuries, and a nationwide registry for Lou Gehrig's disease. It would cut close to $1 billion in health care grants to states and would kill the entire budget of the Christopher and Dana Reeve Paralysis Resource Center."

Portrait of Thomas Hobbes was taken from http://www.politicalinformation.net/encyclopedia/Thomas_Hobbes.htm.