The Misappropriation of Health Care Reform: The Case of Washington State

摘要

Business interests in Washington recognized "managed competition" for what it was―a new form of regulation―and opposed it. In Washington, the implementation process became the method for maintaining the status quo. It can be fairly said that the popularity and the acceptability of this concept to the voting public lay primarily in the word competition. This facilitated the appropriation of the concept and its use in ways that were in the best interests of the various users. Failure to implement the plan as an integrated whole played a major role in its eventual failure. The problems in insurance markets associated with its implementation were logical consequences of deletion of necessary components. The intended goal of managed competition―integration of financing and delivery of care with a view to quality (and cost-effective) service to all Washingtonians―became unachievable. While much health care reform was ostensibly organized in the framework of managed competition, none was actually modeled on the integrated plan set forth by its proponents. Most reform was incremental, taking one or two features from the model in an attempt to satisfy the call for reform while at the same time maintaining the ideal of "free market competition." This approach exhibited a complete misunderstanding of the concept, a blatant disregard for it, or simply an example of conservative resistance to change based on the maxim used by Veblen, "Whatever is, is right" (1963). Debates generated throughout the process were directed at the way of doing things rather than at an understanding of the nature of social insurance or the desired resulting outcomes. The political debate centered not so much on what was best for individuals in the community but rather on whether the system would be private or public, voluntary or compulsory, as did previous debates. Also historically consistent was the outcome of the legislative process―health care in Washington State was to be organized as a private, voluntary system. Once this had been decided, consequences of this type of organization could be anticipated.