THEORETICAL REFLECTIONS
5. HEALTH CARE PLANNING
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According to Williams and Torrens (1993), empirical data from national health services, such as the one in the United Kingdom, as well as U.S. data from self- contained and centrally managed health care systems, such as Kaiser Permanente and the Veterans Administration, show that centrally controlled, aggressively managed planning does work on a mandatory basis. They concluded that privately held institutions or provider systems seek to maximize market share, profits, and other objectives. Thus, when health care planning is left as a voluntary activity of the marketplace, it results merely in a type of regulatory intervention aimed at forcing compliance with socially mandated government goals related to access, costs, and quality. Institution of a comprehensive mandated approach to health care planning therefore appears to be necessary to its effectiveness and success.
5.2 The Argument for Government Involvement
Despite widespread dislike of the idea of a greater role for government in health care, a reasonable argument can be made that government not only has a legitimate interest in health care from the perspective of a payer but also has a wider and more extensive obligation toward society that justifies, mandates, and even necessitates its acceptance of a dominant role in health care. Government-imposed or mandatory regulatory oversight promotes collective social objectives, such as accessibility and quality of health care. It provides opportunities to develop and maintain the rational allocation of resources by focusing on meeting the collective social objective of universal access to a reasonable level of health care services at a reasonable price.
Meaningful levels of government involvement and market intervention also enhance opportunities to develop comprehensive health policies and programs. The responsibility of government to ensure universal and adequate access to health care does not imply an assumption of this challenge solely on its own power. The government’s mission does not exclude proprietary systems of health care insurers or providers from participating in and cooperating with the government in its efforts to fulfill its responsibility. The inclusion of proprietary business does not negate the unique responsibility and interest of the government in health care planning to ensure that the health care needs of society can be met fairly under reasonable resource constraints.
Thus, in order for this particular cooperative arrangement to be morally legitimate and organizationally effective, all parties must have a shared understanding of their respective objectives. For that understanding to happen, universal acceptance of the notion of genuine responsibility is critical. When both parties share the goal of promoting individual, community, and social values, they are more likely to achieve their objectives within a social community concept of the marketplace. The transformation to a community model can be facilitated more easily when the notion of genuine responsibility is widely accepted and incorporated into the social fabric.
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5.3 From Theory to Practice
With the role of government more clearly defined and an improved transparency in the relationship between government and the private sector in health care, attention must be given to health planning activities, implementation strategies, and monitoring systems. As Jonas (2003) pointed out, health planning can be successful only when the goals and objectives of the enterprise have been clearly stated and agreed to by all of the interested parties.
In a similar vein, Daniels and Sabin (2002) highlighted the fact that limit-setting decisions require clarity about the authority of the decision maker. Thus, there must be agreement on the conditions under which society would grant authority to individuals or institutions to set limits on health care (Daniels and Sabin 2002). The preliminary conclusion therefore must be that, if establishing a community-based market model in health care is the first challenge, then formulating and agreeing on goals and objectives as well as ensuring moral legitimacy certainly rank second.
Determining the boundaries of an acceptable health care benefits package and the structure of a regulatory oversight body complement the full magnitude of the challenges still ahead.
5.4 Discussing the Options
Before examining the formulation of practical solutions, I will review the assumptions underlying the proposals brought forward herein. The first assumption is that society will continue to support the political choice to position health care in a procompetitive environment, implicitly rejecting a nationalized health care model.
The difference from the current situation is that the moral standing of the procompetitive environment would be modified to the extent that, at least within the context of health care, all parties accept a social community marketplace model within which business organizations would compete with each other.
Furthermore, there is an assumption of agreement among parties that government is a somewhat unique partner in that it has a legitimate interest in, as well as an extensive responsibility toward, health care. However, in contrast to the existing marketplace concept, all parties within a community market model are committed to sharing the responsibility of promoting broader individual, community, and social values.
It is also assumed that all parties acknowledge and respect the leading role taken by government in health care planning and monitoring, because they all recognize that it is the primary responsibility of government to ensure that society can meet health care needs fairly under reasonable resource constraints. In turn, government accepts the responsibility for securing the legitimacy of the decision-making institution and for protecting legitimacy and trust in the continual process of distributive decision making.
Finally, society as a whole and its individual entities are prepared, in principle, to accept the need for implementation of substantive rules governing the health care 187