From medical patients to health care consumers: decisional capacity and choices to purchase coverage and services

The USA is undergoing a fundamental shift in health and long-term care fina ncing and delivery away from extensive government regulation and toward gre ater consumer choice and direction in both the public and private sectors. An enhanced emphasis on consumer choice and control in a competitive market place of health insurers, managed care plans and service providers may pose special challenges for older and disabled persons. This is so because olde r and disabled persons are more likely than others both to be eligible for, and dependent on, public financing for services and cognitively and/or emo tionally impaired to some extent. This article examines issues concerning t he evaluation of decisional capacity to act as a health and long-term care consumer in the new marketplace model, as well as questions pertaining to s urrogate decision-making for individuals deemed incapacitated to make choic es independently as health and long-term care consumers.