Vanderbilt Law Review

First Page



Throughout the 1970s, the two major political parties espoused some form of national health insurance. Faced with a fiscal squeeze, however, the Carter Administration gave national health insurance a relatively low priority.The political movement for comprehensive national health insurance rests on an ideological commitment that the federal government should underwrite the cost of providing universal access to medical services. The objective is essentially redistributive in nature: equitable concerns for the disadvantaged loom as the major focus. The selective expansion of coverage to encompass those identified as needy and worthy, but only those so identified, is anathema to those who traditionally support broad national health insurance. These proponents would contend that a universal and comprehensive program is necessary to avoid a dual system of medical care delivery--one for the poor and another for then on poor. Advocates of a universal program would, in effect, compel the nonpoor to fund and participate in a governmentally sponsored program designed to benefit the poor so that the medical care system operated under government auspices would not be confined to lower income persons and, implicitly, stigmatized as welfare medicine of lower quality and lower status.The access gap between rich and poor-a disparity that underlay much of the political initiative for national health insurance-has been narrowed in recent years at least partly because of Medicaid and Medicare. Overall expenditures on medical services have escalated dramatically during the past two decades and occupy an increasingly large component of our national income. Few people would now maintain that aggregate medical care spending is substantially too low. To the contrary, skeptics point out that structural institutional relationships in the medical sector encourage ever-expanding medical expenditures." Coupled with a growing awareness of the importance of nonmedical factors in the promotion of health, this fact has led to general questioning whether individuals and society collectively are getting their money's worth from surging medical services expenditures. Pragmatically, factors such as lifestyle have assumed a more visible role in affecting health status. Politically, the sense that illness is fortuitous has been challenged, which in turn has suggested a more tight-fisted response to claims for more munificent redistributive programs. Moreover, other pressing claims on public budgets and cries for tax relief have recently emerged. These nonhealth demands make less money available for public programs with strong redistributional orientations...

This Article examines the market-oriented approach, describing what it is and what its rationale is. It then focuses on the problem of equity within the market system. In addition, the Article analyzes and evaluates prior regulatory experiences and examines the emerging directions of health policy. Finally, the Article considers selective developments from the perspective of the competitive alternative.