Some problems with pro-competition reforms.

As the search for effective cost-containment policies continues, health care reform along pro-competition lines has gained considerable backing in the United States. By offering market competition to achieve allocational efficiency and vouchers and tax credits to achieve distributional equity, pro-competition reforms appear to satisfy what many believed were incommensurable goals. A critical review of this strategy reveals two practical difficulties, however. The first concerns the ambiguity arising from the proposals' reliance on the concept of equal access to some basic level of health care as its distributional objective and the second concerns the ethical dilemma arising from the proposals' reliance on physicians as rationers of health care. In considering the distributional goal of guaranteeing access to a basic minimum of health care, we argue that, despite its theoretical attractiveness, there exists no acceptable way of determining or justifying its content, and without a clear definition of the basic minimum there is no guarantee that any equity objective will be achieved under the pro-competition strategy. With regard to the use of physicians and other providers as society's gatekeepers, we point out that this role is in direct conflict with traditional responsibilities that patients expect providers to assume. Requiring doctors to ration services in response to market incentives may further erode the trust relationship between physicians and patients, and clearly puts the more seriously ill at a disadvantage.