The administration promises that managed competition will guarantee quality of care. Indeed, Clinton’s health-security plan proposes an elaborate structure to assure quality that relies almost exclusively on data collected from patient-satisfaction surveys. The problem is that such mechanisms fail to grasp how HMOs can rig the game.

As one health-care professional puts it, “Most patients don’t have the strength or the energy to scrutinize quality of care.” To do this, they need help from providers. But managed-care companies have little interest in constructive criticism. At McLean Hospital in Belmont, Massachusetts, for example, executives were told that Blue Cross/Blue Shield did not award them a managed-care contract in part because the staff had taught patients how to stand up for themselves and family members. BC/BS learned through patient satisfaction surveys that physicians and nurses had even suggested that patients sue the insurer for refusal of care. They informed the hospital that unless its staff ceased such practices, no future contract would be awarded.

This kind of economic blackmail muzzles providers who have firsthand experience of assembly line health care. Almost every doctor and nurse we spoke to about the cost-driven practices that increasingly dominate the health-care scene was afraid to talk on the record. Tracey McKnight, director of a nonprofit home health-care agency in Holland, Michigan, expressed their worry: “How active do you become exposing all this, when you might lose referrals?”

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