Business Reality Meets Political Imperative: Competition Loses

In the lead paper of the inaugural issue of Health Affairs,a brash and brilliant young Republican, David Stockman, setout his ideas in an essay titled, "Premises for a Medical Marketplace:A Neo-conservative’s Vision of How to Transform the HealthSystem." Even twenty-three years later, it still makes for interestingreading. Shortly before we published his paper, Stockman hadresigned his seat in the House to become director of the Officeof Management and Budget under the new Republican president,Ronald Reagan. Ever since, many policymakers and analysts havefollowed in Stockman’s philosophical footsteps in advocatingdevelopment of market-based competition as the best way to improveaccountability and performance in health care. Often times,this dialogue has ensued with only tenuous connection to conditionsin communities where we live and work.

Nine years ago the Washington-based Center for Studying HealthSystem Change (HSC), which is supported entirely by the RobertWood Johnson Foundation, began to track and report on changesin the U.S. health care system and how they affect Americans’health care. At its core, the center has conducted a longitudinalstudy of selected communities across the country. In our leadpaper Len Nichols and colleagues, analyzing the results of theirexhaustive research in twelve communities, identify the challengesfacing any effort to implement a market-based strategy in healthcare. The center, which is directed by Paul Ginsburg, has developeda reputation for dispassionate, reliable research, based largelyon the community voices they survey, rather than on the dialogueof Washington, D.C. In this issue we feature a half-dozen papersthat showcase the work of HSC, one of the crown jewels of theJohnson Foundation.

John K. Iglehart

Founding Editor

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Business Reality Meets Political Imperative: Competition Loses