beneficiaries the greatest protections. The farther government moves along the continuum of tightening controls and acting as a purchasing agent, however, the greater the likelihood of loss of flexibility and competitiveness in the market, and thereby a reduction in the number and types of health plan choices.

In discussing the role of government in holding the system accountable, a fundamental question that arises is whether this is government purchasing or, in fact, purchasing by elderly beneficiaries. For example, is the government a patron allowing some choice on the part of its clients, or is the government effectively providing people with vouchers and providing beneficiaries with the freedom to decide how to use those vouchers?3

The unique leverage of a $180 billion program such as Medicare needs to be considered, however. By virtue of its sheer size and as a public purchaser, the federal government has the power to profoundly influence the market and to drive health plans from the market by setting conditions of participation extremely high and then deciding the plans with which it wants to do business. Historically, government has not acted in this capacity.

Strengthening the Role of Consumers

Strengthening the role of consumers would require providing them with sufficient relevant information about health plans to help them decide whether to join a managed care plan and, if so, how to choose a plan that meets their needs. To provide better information, one must understand what information consumers want, how they want to obtain that information, and what kinds of information they should know.

Here, opportunity may lie in strengthening ombudsperson-type organizations. Today, many employee benefits offices serve an ombudsperson function in which they assist employees with complaints or other health plan issues that may arise. Senior


At the symposium, Mark Pauly indicated that the level of choice afforded Medicare beneficiaries is affected by whether or not Medicare beneficiaries are viewed as owning the benefits awarded to them.

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