Health care at the crossroads.

• Author: Birenbaum, Arnold

During the debate over health care reform, the worry expressed about a bureaucratized system was that the quality of care would be worse than it had been. Little did anyone think that quality would become a concern without health care reform. As the editors of Consumer Reports concluded in October, 1996, "managed care was a profit-driven, marketplace response to the healthcare crisis."

Some Americans are beginning to feel that this system is out of control, but who put it in the driver's seat? The spotlight falls on employers who made health maintenance organizations (HMOs) the preferred way of purchasing health care for employees. It is true that the market forces which had been taking over health care during this decade did slow the growth of costs for the under-65 population. Nevertheless, there are many complaints about the lack of concern showed for consumer needs and the providers' judgments about how to practice competently in these closely watched and tightly controlled systems of care.

What scares ordinary people even more is that what previously had been routine testing in order to rule out serious and often life-threatening conditions now is being regarded routinely as not worth the effort. In a few notorious incidents, overlooking a serious sign or symptom meant that treatment was started very late when the correct diagnosis was made, often at a point in the stage of disease that made medical care both difficult and more heroic than it need have been or, more disturbingly, too late to save the patient.

These concerns were noted during the 1996 presidential campaign. With Pres. Clinton's newly expressed sensitivity to problems he could do something about and with much lowered expectations for change, he announced in September, 1996, that he would appoint a Federal advisory commission to recommend ways of protecting consumers from poor quality care. The National Commission on Health Care Quality members would be selected from the various stakeholders, including representatives of providers, insurers, labor, consumers, and business executives.

The shift to managed care is one of a number of social changes that has left many Americans anxious about whether their hard work and conforming behavior will provide them with the financial security to raise a family, develop their personal interests, share a life with a partner, participate in community life, or do any of a thousand other worthwhile endeavors. The economic rewards for the...