Since the 1970s American health economists have promoted competition to decrease health care costs and therefore increase the access to health care. In the 1980s some of them became policy advisers of Democratic leaders and, in the 1990s the Democratic Party adopted the “managed competition” as the core of its health policy program.
Yet at the end of the 1990, the « managed care backlash » made the language of “competition” unpopular when applied to health and therefore politically unwelcome.
Consequently politicians and their policy advisers turned to another « solution »: the increase of the quality of care to decrease costs. The vocabulary of “quality” replaced the one of “competition”.
But what does “quality” mean exactly? Is it so different from the frame of “competition”? In other words, does a change in political discourse imply necessarily a change in policy programs? If not, why do political leader prefer to change words rather than real programs when these ones turn to be unpopular?
This paper describes the process in which political and policy actors turned to another discourse and insists on the political motivations of their choice for the “quality” vocabulary. This vocabulary includes the discourse around prevention, coordination, NTI, and primary care. But this program is far from being contradictory to the one of competition, since these solutions would be implemented inside “integrated healthcare organizations”, the ones that the “managed care backlash” movement rejected. To explain this paradox, the paper highlights the role of policy experts consulted by political leaders. These advisers did not change after the “managed care backlash”. Mostly economists, they looked for a solution that could combine the core of their program within a more acceptable wrapping.
The empirical research consists of 77 interviews and analysis of experts and policymakers’ discourses.
