In mid-2009, the California HealthCare Foundation (CHCF) released reports on six California health care markets — Fresno, Los Angeles, Oakland/San Francisco, Riverside/San Bernardino, Sacramento, and San Diego — as part of its California Health Care Almanac.

There isn’t an area of California, or perhaps even the country, with more challenges — both socioeconomic and those facing the health care system — than the Fresno region. The regional market report does an excellent job of highlighting the region's many challenges: a weak economy; a threatened agricultural sector with water and work supply problems; low wages; high unemployment; poverty; lower income, education, and health insurance levels; a small commercial insurance base; low priority of health care for county governments; an inadequate physician and dentist supply; low reimbursement rates; rapid population growth; worse health status; a large, geographically dispersed area contributing to access problems; high levels of chronic disease such as asthma and diabetes; reduced mental health services; overwhelmed emergency departments — the list goes on. One thing is sure, for all the indicators are the same: This pressure cooker presents extreme challenges in health care delivery, costs, and quality. The tag for Fresno, "Appalachia of the West," perhaps accurately captures the tenor of the entire region.

Such a picture is overwhelming, yet area residents often criticize themselves as being their own worst enemy. They carry these problems almost as a badge of courage. One benefit touted for living in the area is that it is easy to get to almost anyplace else! This translates in health care to a steady flow of patients to the Bay Area and Los Angeles, as questions of confidence in local health care quality remain for much of the population.

The Fresno region is historically known as an area of health care delivery system competition, even though collaborative efforts abound. Competition between health care facilities has been criticized as being detrimental to the quality of health care in the communities. This seems logical — more collaboration avoids duplication of scarce resources and better efficiency, and allows for more focus on patients and health care quality. Certainly, the size of the region's patient population provides more than enough business for everyone. With the discussion of health reform raging at the national level, however, a debate on the value of competition versus federal leadership and control is being played out across the country. We all know of the turmoil created by the recent meltdown of our free-enterprise competitive financial markets, where greed overcame ethics and common business sense. A controversial federal bailout ensued to sustain these financial institutions.

This begs the question: In the Fresno region, what role should competition play in this health care system under stress? If competition isn't beneficial in health care, will health reform provide better coordination of this massively complex, fragmented, and fragile system?

Norma Forbes has worked in health care administration for more than 30 years, with a background in strategic planning and information technology in a variety of health care organizations. Forbes is the executive director of Fresno Healthy Communities Access Partners (HCAP). This nonprofit partnership of 12 safety-net organizations is dedicated to ensuring access to affordable and appropriate health care for the underserved populations of Fresno County and the San Joaquin Valley, focusing on enhancing insurance coverage and improving delivery systems.