Last month, the Advisory Commission on Consumer Protection and Quality, established in September 1996 to fulfil the president's campaign promise to deal with the growing public backlash against managed care, presented its final report to him.

The commission has 34 members, including government officials, managed care executives, labour and consumer representatives, and academic quality experts.

It began its report by requesting that the president articulate a statement of purpose for the healthcare system as follows: 'The purpose of the healthcare system must be to continuously reduce the impact and burden of illness, injury and disability, and to improve the health and functioning of the people of the US.'

While the commission did not define quality, it did examine evidence of deficiencies in the healthcare system. It examined both the underuse of health-enhancing services (such as the estimated 18,000 people who die each year because they do not receive beta blockers following a heart attack), as well as the overuse that has a deleterious impact on healthcare (such as the 20 per cent of unnecessary hysterectomies performed in the US each year). They also examined variations in practice.

Among the commission's 50 recommendations were an Advisory Council for Healthcare Quality to identify national objectives for improving quality of care and track progress.

And it called for a forum for healthcare quality measurement and reporting responsible for developing standardised quality measures and measurement tools.

The highlight of the report was a proposed consumer bill of rights, which would give consumers the right to:

accurate information about their health plans, health professionals, and health facilities;

health providers that ensure access to high quality services;

access emergency services;

participate in treatment decisions;

receive consideration and respect from their health plans and the right not to be discriminated against;

confidentiality of medical information;

a grievance procedure to resolve differences with their health plans;

assume responsibility for their own health promotion.

When this bill of rights was first proposed last November, the commission said it planned to determine how to achieve these rights in its final report. But it did not. The final report says the commission could not determine whether the bill of rights should be a government-enacted protection or whether it would be up to managed healthcare plans to comply with it voluntarily.

This has created a particular problem. While a recommendation from the commission would make things easier, it would not guarantee the suggested outcome. But without such a recommendation, there is little support on either side.

President Clinton has, in fact, recommended that Congress enact the bill of rights, while issuing an executive order requiring the federal government and agencies to comply with it. Republicans in Congress and the health maintenance organisation community argue that this should be voluntary, while Democrats and consumer groups want legislation.

The vast majority of Americans who have employer-provided health insurance receive it from companies which are self-insured; that is, the companies are themselves at risk for the costs of healthcare. These self-insured health plans are covered by federal legislation called ERISA. People in ERISA-protected plans cannot sue the plans for damages if they are injured by delayed or denied medical care.

While they can sue for the value of the services they were denied, or force the plan to begin covering the benefit, they cannot receive anything more than that. This has been a cause of concern among those in these plans, who had hoped that the issue would be part of the commission's deliberations. But the commission suggested no resolution.

Despite these problems, the work of the commission has been well regarded. It is significant that it made a special appeal to find a way to deal with the growing numbers of uninsured and underinsured Americans as part of its quality improvement strategy. The concept of the 'iron triangle' of healthcare - the idea that access, cost and quality of care vie with each other, and only two dimensions can be controlled at any one time - comes and goes in health policy discussions. Bringing up the uninsured in a discussion of quality, therefore, has a therapeutic effect on such deliberations by removing all the talk about cost.

It has long been assumed in the US that its medical care is the best in the world. And it has been argued that costs are so high because of the need to maintain the high quality. But the data examined by the commission suggests that quality of care is extremely relative, and that all Americans - not just the poor - are subject to varying quality.

The commission's report will have a clear impact on discussions in Congress and the states on regulating managed care. Many of the recommendations of the national commission are also being discussed at state level by different, but similarly focused, groups. It is certainly likely that earlier in the Clinton administration a recommendation for federal legislation would have been the outcome of such a group. The fact that it did not come out of this group may suggest that Americans are still wary of government control and regulation of the health system, and would prefer to see voluntary adaptations. It is likely, though, that the publicity that the commission has received will inspire consumer groups to demand more and better quality improvements by their health plans one way or the other.

Howard Berliner is associate professor and chair, health services management and policy, New School for Social Research, New York.