Representing consumer interests: imbalanced markets, health planning, and the HSAs.

The health planning legislation of 1974, establishing HSAs, represented an important attempt to break recurring patterns of decision making in public choices. One widely heralded strategy for controlling contemporary medical care--consumer involvement through accountability, representation, and participation--is flawed by failure to recognize that political markets are always imbalanced because of unequal interests and disproportionate resources. How can we represent broad, diffuse interests when all the incentives point to domination by a minority of intensely interested producers? Solutions favored at the local level may not best serve the entire nation; they cannot mirror the full spectrum of constituencies. Adjustment of mechanisms both internal to HSAs and external to them are suggested--yet, even so, their mandate reaches beyond possibility of accomplishment.