Physicians, payers, and power. The United States is witnessing a struggle for control of healthcare

From its earliest days, healthcare in the United States has been controlled by providers, that is, by physicians and by hospitals (which, in turn, were also usually controlled by physicians). But this situation is changing. In the 1920s and 1930s, providers created health insurance companies like Blue Cross and Blue Shield to help patients pay for healthcare--to pay, in other words, for those services offered by providers. After World War II, the Hill-Burton program covered the nation with new hospitals. In the 1960s, Medicare and Medicaid eased the healthcare burden of older Americans--and also recapitalized hospitals. Thus providers called the shots in the creation of both the delivery and the payment systems. But in the 1970s, payers began to become more powerful. Now, in the 1990s, they have joined employers in acting to contain rapidly escalating healthcare costs. But even those long disturbed by the arrogance of some healthcare providers are now asking themselves: Is this really what we wanted? Payers are governed by the market; they may well seek, not the best, but the cheapest healthcare available. This is not in the interest of either patients or physicians. A middle ground--a new power alignment--will have to be worked out by patients, physicians, payers, and government.