ESTABLISHING public policy for health care is difficult at best. But when policy decisions result primarily from the application of the "squeaky wheel" principle, the difficulty is compounded. Decisions are then more likely to deal with the concerns of a small group of individuals rather than the broader interests of society, with private patient care rather than public health needs, and with short-term expenditures rather than long-term savings. A story on the front page of the New York Times on November 12, 1990, focused my attention clearly on an issue that exemplifies this problem.
The story reported, "The Blue Cross and Blue Shield Association has agreed to pay a share of the costs of a clinical study of an experimental treatment for advanced breast cancer." The association would expend at least $10 million during the 3-to 4-year study of 1200 women who will undergo autologous bone marrow transplantation in conjunction