Which way for competition? None of the above.

Despite growing documentation that the conditions needed to support competition in health care do not exist, consumer-directed health care has been offered as the new market-based solution to cost inflation. Yet typical consumer-based insurance products undermine the very logic of expecting consumers to make good health care decisions by making preventive services--the category of services about which consumers are best able to make informed decisions using their own money--exempt from cost sharing. Consumer-directed care threatens important societal values--in particular, the goal of establishing relationships between patients and clinical professionals based on trust.