(Menzel, 1990, p. 3) Fisher, Berwick, & Davis alude to the idea of integration in health care, with providers linking as well as creating networks of electronic medical records and other cost improvement tactics. The United States and other nations over the last twenty or so years, have begun a sweeping change in health care delivery, regarding the manner in which health information is input, stored and accessed. Computer use in the medical industry has greatly increased over the last thirty years the culmination of this is fully networked electronic medical record keeping. (Berner, Detmer, & Simborg, 2005, p. 3) the electronic medical record trend began in the largest institutions first, as hospitals and large care organizations attempted to reduce waste and improve patient care, while the adoption has been much slower among physician's practices and smaller medical institutions. (Hillestad, et al., 2005, pp. 1103-1104) Prior to this time medical records were painstakingly handwritten or dictated and then recorded by an outside party and then compiled in a patient file that was limited to the setting in which it was collected, (Mandl, Szolovits, & Kohane, 2001, p. 283) took up a great deal of space and required a great deal of time on the part of the provider to review and stay abreast when providing patient care. (Kahnamoui, 2004, pp. 2-3, 19) the literature, as well as the political climate contends that the universal application of electronic medical records will universalize the efficiency of the medical care system.

While experts like Epstein argue that this is a scare tactic that demonstrates a waning system attempting to apply the Freudian sour grapes defense mechanism to the situation as it stands, i.e. that healthcare if it were altered in any significant manner away from the private pay consumer system would automatically result in health care rationing, and extremely long wait times for even basic services. Epstein also points out that these market driven healthcare delivery models skirt the issue of cost prohibition and limited access by utilizing disclaimers to claim that even those who cannot pay are still owed care, yet as many point out the delivery service still then has the right to bankrupt the individual to attempt to recover the cost of care after it has been provided. "The most common formulation of the egalitarian ideal skirts these difficulties by holding that everyone has a right to health care regardless of ability to pay." (Epstein, 1999, p. 112)

In a sense the argument is that the "quality" services provided by the health care delivery system will likely disappear if consumers do not pay the prices outlined by the system. (2006, p. A15) Though there is very little evidence of this actually occurring, in any structured universal health care system, it is still the argument most often used to dismiss those who believe that health care costs in a competitive capitalistic system are becoming, or have become, cost prohibitive too far too many people. (Dranove, 2000, p. 3) Many believe that the above arguments are a smoke screen, attempting to challenge the consumer, based on limited knowledge of the system and services, and developed by those who have economic interest in the high profitability of health care delivery to throw the consumer off the trail of the real problem of healthcare, which is clearly cost. Yet, when one looks at a relatively moderate analysis of public payer systems, all of which have living examples all over the world and discusses the ways in which each of the various types of those systems is strong and weak, such as is the case with the article Choice and competition in publicly funded health care by LeGrand it is clear that there is real reason for concern in some of the arguments. (2009, pp. 479-488) LeGrand systematically describes the four basic models of health care delivery; those that rely on trust, on command and control, on voice, and on choice and competition and details the positive and negatives of each, and surprisingly each does have both. According to this expert the trust model is driven by providers, where the system provides funding and then the providers are trusted to utilize that funding in the best way they can for their patients. The trust model is also a public provision type, and can result in This model according to LeGrand can result in high quality but can also open the system up to ambitions...

The command and control model, again in the public sector according to LeGrand, requires a great deal of administrative oversight and regulations and can be very efficient in delivery but that it is only a good short-term model as in the long run it can create; "…the demoralization and demotivation of those on the front line of service delivery -- especially if they are professionals who are not used to receiving orders and have been trained to believe that they will have substantial autonomy and independence in their work." (LeGrand, 2009, p. 481) the voice model according to LeGrand is another public option where consumers are given voice to drive change in the system, according to what they believe they want or need at any given time. She notes that a complaint driven system has its merits, as in most public systems there is no voice, but if it is used in a publicly funded system it relies on the goodwill of the individual listening to complaints and the desire of providers to implement change and since there is no alternative option, especially for those with limited resources if change does not occur they have nowhere to turn. (2009, pp. 481-482) LeGrand then goes on to describe what we can only assume he or she sees as an ideal system, that of a quasi-public system, that incorporated best practices from both the consumer driven aspects of public delivery and offered real alternatives for consumers.
Publicly funded health care systems that incorporate quasi-market elements…must be properly designed & #8230;There must be mechanisms for ensuring: that the entrance for new providers is easy; that exit can take place, and that the relevant decisions are immune from political interference; that patients are given the relevant information and are helped in making choices, especially the less well off; that there is help with transport costs, preferably again targeted at the less well off. And the opportunities and incentives for cream-skimming should be eliminated, either through not allowing providers to determine their own admissions or through properly risk adjusting the fixed price system. (LeGrand, 2009, p. 488)

Overall the work describes an ideal system, where the publicly funded option is utilized but where real consumer/market driven principles are present. To some degree this is one of the best examples in the literature of a moderate or compromise between the two debates, either for or against a public healthcare delivery system in the U.S. Though it must also be made clear, that any form of public payer system would likely be highly resisted, as many within the current delivery system have been indoctrinated to believe that it will do everything from decrease wages in health care to create an unsafe low quality system. (Kant Patel, 2006, pp. 42-47) (Flood, 2009) "In a few nations, such as the United States, the insurance system is voluntary and incomplete, many people are uninsured and underinsured, and many must pay personally." (Glaser, 1991, p. 5)

The actual cost of medical care has increased exponentially over the last fifty years, and far outstrips the increases in costs of other goods or services. Medical treatment costs in the United States are unacceptable and can and should be lowered to better meet the needs of the consumer. A change that has taken place within the system of health care delivery that is of the most interest to this researcher is the concurrence of health care cost increases with the changing manner in which the delivery system was viewed, namely going from being viewed as a social good to one being viewed as an economic good.

In recent years hospitals have experienced what many observers feel are "fundamental, turbulent and even revolutionary changes" (Fottler, Blair, Whithead, Laus, and Savage, 1989). These changes have profoundly affected the management of hospitals and have resulted in a shift from ". . . health care as a social good to health care as an economic good." (Shortell, Morrison and Friedman, 1990). As a result, hospital executives now must respond to an increasing number of active and powerful stakeholder groups who influence issues ranging from hospital governance to financial management to quality of patient services. (Kumar & Subramanian, 1998, p. 31)

It would seem that stakeholders desire to profit from the system tend to override the assumption that health care is a universal right and that it meets the common good by attempting to keep people as healthy as…