Editor's Note: On Government's Role in the Crossing of Chasms

One does not generally view the Institute of Medicine (IOM) as a source of amusement. But there is something comical (albeit tragicomic) about the series of IOM reports produced since 1999 that address quality shortfalls in American medicine. It's not their titles, which are more evocative than amusing: To Err Is Human, Leadership by Example, and Crossing the Quality Chasm. And there is certainly nothing funny about the shortcomings they document: "tens of thousands of Americans die each year from errors in their care, and hundreds of thousands suffer or barely escape from nonfatal injuries that a truly high-quality care system would largely prevent" (IOM 2000: 2).

The (sadly) amusing aspects of these reports involve the sorts of remedial policies that they discuss. Or, more precisely, those that they don't discuss. It is as if the committees involved in these reports were given a common charge: See how long you can write about dramatic and persistent failings of performance in the health care system without ever mentioning government regulations that might remedy those failings. It's like some perverse game of policy charades: the reports can act out the need for regulatory intervention, as long as they never actually mention regulation directly.

The IOM committees prove to be quite astute at this game. Although they call for government action, they would limit its role to acting as a purchaser (i.e., "leadership by example"), collecting information, or disseminating reports on system performance. They do go so far as to recommend that government actually mandate that health care providers report performance measures, but only after carefully weighing the potential for voluntary reporting. All told, out of thirty recommendations in the three reports, only one even mentions regulation. And this recommendation is a carefully worded call for additional study about the ways in which regulations governing professional practice might either "facilitate or inhibit" improvements in quality (IOM 2001: 20).

If it is amusing to see how hard the IOM committees worked to not discuss regulation, it is far sadder to consider the consequences of this omission. Although the reports document "the absence of any real progress toward restructuring health care systems to address both quality and cost concerns" (ibid.: 3) and warn that "the current set of activities has not closed the quality gap and is unlikely to do so in the future" (IOM 2002: 4), this purblindness regarding regulatory interventions means that none of the reports even considers changing the basic legal rules under which the health care system operates. Because the IOM was unwilling to endorse any exercise of government authority, the potential for fundamental change is lost. A series of modest incremental recommendations take its place, yet these incremental reforms lack the scope to effectively address the pervasive factors that currently undermine quality in American medicine. To recall the advice of Winston Churchill: one does not cross a chasm in two strides.

Possible Barriers to More Effective Government Regulation in Medical Care

The Institute of Medicine is not alone in its unwillingness to seriously consider expanding government regulation. Particularly within the Beltway, policy makers have grown quite averse to the notion of regulating medical care. This is illustrated by the failure of Congress to pass any form of a patient bill of rights, even though comparable legislation has been enacted in a number of states.

Obviously, this antiregulatory sentiment reflects the current dominance of conservative ideology in federal policy making. But there is more to it than ideological or partisan framing among policy elites. Some observers attribute this turn against regulation to trends in prevailing public opinion. For example, one assessment of changing public opinion toward medical care over the past fifty years concluded that health care reform had become more difficult because "Americans are clearly less willing to see expanded government regulation in general than they were during the 1960s" (Blendon and Benson...