March 2005

Risking the Social Contract

In an “ownership society,” the notion that we are consumers of health care should be a positive one. But there are so many different notions of what this means that we may be consuming ourselves into confusion.

For example, advocacy organizations like AARP and Families USA use“ consumer” to describe a political constituency whose interests they hope to protect and enhance. Politicians use the term interchangeably with such terms as “citizen” or “public.”

Some doctors want us to think of ourselves as choice-driven consumers if things go wrong. Employers and government purchasers of health care use the word to distinguish their own role from that of their constituents who choose from among the services they have procured. Insurers use the word “consumer” to describe an economic actor making choices.

Those who use “consumer” in its economic sense assume that people can and will make rational choices among available options, while those using it in its political sense believe that consumers should be protected from either having no choices at all or making bad choices.

The difference between these two views with regard to health care may ultimately have far-reaching consequences for health policy.

The market notion of being a health consumer entails a number of assumptions about the individual behavior and the context of health care “purchasing” that we know are myths:

• All people will act to maintain and improve their and their family’s health.

• Individuals have choices about their exposure to health risks and their access to healthcare.

• Providing the right information will lead to changes in behavior.

• New technology provides clear, transparent information about cost, quality and availability that people need in order to be able to make informed choices about health and health care.

• Doctors make use of this information and encourage their patients to use it.

Under the cover of virtuous language that connotes freedom and egalitarianism, insurers, employers and government purchasers delegate responsibility for health decisions to us “consumers,” who, for the most part, do not have the knowledge to make complicated medical judgments even if the information is widely available.

For example, consider the challenge faced by a low-skilled worker in assessing the relative merits of three diverse benefits options relative to the multiple needs of a family. Or an ill cancer patient deciding which chemotherapy regimen is right for her, given her diabetes and heart disease.

To the extent that individuals are expected to take on these roles without support, there is a risk of abrogating the social contract between physicians and patients, between public policy makers and the people whose health they seek to protect and, most broadly, between the health care sector and the society that it’s supposed to serve.

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