Exit and Voice in American Health Care

Until the 1960s, the main way for patients to affect health care institutions was by choosing their doctors or hospitals or leaving those with which they were dissatisfied. They had few avenues to exert their voice to bring about change through complaints, politics, or other means. The balance between exit and voice shifted in the 1960s, as the women’s health and disability rights movements brought about change by increased use of political voice and, to a lesser degree, by exit. With the growth of managed care since the 1980s, enrolled individuals have had fewer opportunities for exit and greater potential to exercise voice to influence managed care organizations. However, that potential has not yet been adequately realized. Current debates about consumer rights focus on appeals of decisions by managed care organizations to deny services. They generally ignore the role of members in organizational policy or governance. This Article explores the relation between exit and voice in American health care and its prospects for the future.