ABSTRACT
The idea that health care should be left to competitive market forces presumes a good deal about the behavior of ordinary people; it presumes very little about institutional constraints on that behavior. Prospective patients are expected to act like rational consumers, choosing judiciously among a variety of health insurance options, medical professionals, and hospital services. In this way, according to economists such as Alain Entoven, health-minded citizens might think more about early and less costly medical intervention and consequently reduce costly catastrophic medical needs. Yet today the options available for preventing catastrophic medical needs are not readily available and, in the present competitive marketplace phase of hospital care, they show few signs of emerging. In the best of all possible worlds, with 100 percent employment and full insurance coverage for the elderly and disabled, health care could become a buyer’s market. Our present situation is characterized by strictly limited alternatives, few of which encourage preventive health care. First, noninsured and underinsured patients have haphazard access to medical care. Many take what they can get: public clinics, public hospitals, or emergency wards. Second, many fully insured patients now confront a health system geared for medical catastrophes rather than their prevention. These restraints apply especially to the area of reproductive medicine, in which many medical problems are exacerbated either by too little health care or too much.
