Markets and Public Values in Healthcare

Abstract: Discussions on the role of markets in healthcare easily lead to political and unfruitful polarized positions. Actors arguing in favour of markets as a solution for the quality/cost conundrum entrench themselves against others pointing out the risk of markets for the delivery and governance of healthcare. These binary options of more or less marketization preclude a more empirical analysis of how markets, as multiple arrangements, are constructed and what their consequences are for public values like affordability and quality. To empirically explore the relation between markets and public values in healthcare, in this paper we analyze the construction of a market for hospital care in the Netherlands, based on a system of diagnoserelated groups (DBCs), and the development of a market for long term care based on care-load packages (ZZPs). In these cases we address the intended result of care markets according to various policy actors, the visible and invisible work done by various actors to make markets work and the values enacted in market practices. We show that where policy aims within these markets focus on providing choice and increasing diversity of care institutions, the instruments of DBCs and ZZPs rather produce isomorphism and homogenization. Furthermore, the strong influence of financial instruments in shaping healthcare markets assume that cost and quality can both be strengthened while it in fact has a profound influence on how public values like quality get defined in practice. These translations between values pursued and outcomes produced indicate that conceptualizing the role of the state as defining public values that markets (have to) implement is problematic, as this removes crucial normative work in the shaping of our welfare states to the realm of the technical operationalization of markets. An alternative relation between state, market and society can be conceived once we accept that such values are shaped in practice and that the relationship between policy aims and policy consequences can never be fully captured through a logic of implementation. This then calls for an experimental role of the state: a state that sees market developments as experimental devices in which the aim is a good composition of public values. We propose this experimentation could for example focus on market developments that do not ascribe a privileged status to financial devices and price-mechanism, such as a market for the DBC A-segment, in which prices are not freely negotiable. Such experiments could allow competition to focus on other public values like quality and maintaining accessibility while at the same time function as learning laboratories for reconceiving the role between state, market and society.