If there is little dissension over the need for public accountability and informed purchasing, the question of how to ensure it is far more contentious. Some will argue that market competition and informed purchasing are the best guarantees of access to high-quality services. Others argue for a strong federal regulatory and oversight role and advocate for extensive regulations in a number of areas including marketing, access, quality, appeals and grievances, data collection, and solvency. Others propose a middle ground that would permit a greater role for the market, with its potential to be more efficient and innovative and as a better expression of consumer wants and desires, yet leave to government the role of limiting the number of market entrants to those that meet certain minimum standards of performance and that offer certain minimum protections. Each of these three models (market, directed, and assisted) results in a different matrix of accountabilities.
Without adequate, reliable, comparable, and timely information, it is not possible to exercise informed choice. At its first meeting, the committee discussed the problem that even under the best of circumstances, some elderly people, particularly extremely frail and cognitively impaired individuals, would not be able to exercise choice on their own. The committee was struck by a report from the Alina Health Plan, a major HMO in Minnesota serving a large Medicare population, which reported that for almost half of the plan's elderly enrollees, major decisions about medical care are made not by the enrollees but by a spouse, a family member, or a caretaker (Mastry, 1995). The committee wanted the title of its activity to reflect the reality that for a significant part of the Medicare population, the responsibility of informed purchasing will need to be delegated in