On Values and Democratic Policy Making: The Deceptively Fragile Consensus around Market-Oriented Medical Care

Abstract

Market-oriented strategies, embodied in managed competition, have become the primary focus of contemporary U.S. health policy. This dominance reflects the emergence of a bipartisan coalition of support among political elites. This study traces the historical evolution of elite support for the market and suggests that the consensus favoring managed competition is deceptively fragile, with support riven by cleavages in the values used to judge fairness in the allocation of medical care. A unique data set of matched questions asked of both policy elites and the general public is used to document these differences in ethical norms. The implications of these cleavages help to explain three puzzling aspects of contemporary U.S. health policy: (1) the persisting inability to translate the principles of managed competition into politically feasible reforms, (2) the repeated failures to implement demonstration projects intended to test competitive pricing within the Medicare program, and (3) the inability of state regulations to assuage the public's concerns about managed care. Some prescriptions for a more revealing and effective treatment of market reforms in health policy conclude this study.

Health, Health Care, and Incompletely Theorized Agreements: A Normative Theory of Health Policy Decision Making

“…More recent work on values and democratic decision making adds more evidence to a lack of coherence among the public (and political elites) regarding deep values for health reform. At the same time that Americans strongly supported health reform that would help them personally, they also supported the notion that health care should be provided based on medical need, not ability to pay, and that the medical care system should treat everyone equally (Schlesinger 2002), but conflict among these principles failed to lead to a widespread value that could support health reform.…”

“…The American public has expressed strong support for equal health care treatment (65 -93 percent) and for health care needs (38 -84 percent) (Schlesinger 2002). Alternatively, they could have argued that health care is important for ensuring equal opportunity since it gives every American the opportunity to get ahead meritoriously.…”

Restoring Public Legitimacy to the Nonprofit Sector: A Survey Experiment Using Descriptions of Nonprofit Ownership

“…Although surveys document that 25% to 40% of Americans doubt the ethics of nonprofit administrators, no research considers whether these concerns could be ameliorated through greater accountability. Although the finding that Republicans have a more jaundiced view of nonprofits than do Democrats is consistent with market values undermining nonprofit legitimacy (Schlesinger, 2002), no studies have directly linked consumer empowerment to more negative views of nonprofit performance.…”

“…Conversely, individuals who embrace market reforms in health care, become better informed about their treatment options, and more involved in decisions about treatment may well be less concerned with the purported trustworthiness of nonprofits because they feel less at risk (Schlesinger, 2002). We measure consumer empowerment with two variables: (a) an index, based on four items, capturing different aspects of health care decision making (79% reported high levels of knowledge), 17 and (b) an index based on respondents' understanding of grievance systems for complaining about health care problems (two thirds felt well informed).…”

The Politics of Public Health Policy

“…Indeed, some analysts argue that elected officials and interest group leaders seldom use public opinion as a guide to setting priorities and formulating proposals, and instead employ "crafted talk" to generate public endorsement of policy proposals in which they have already invested their resources (85). Market-oriented conservatives have long labeled their plans to promote enrollment of Medicare beneficiaries in private health plans as "improvement and modernization" and have effectively reinvented high-deductible, catastrophic health insurance as "consumer-driven" health plans and health savings accounts, despite considerable evidence that few health care consumers have any interest in either model of reform (110,122,128,162,172).…”