When we were flush with firecrackers in the neighborhood of my youth everyone’s favorite target received appropriate attention. When we ran short, however, we fought over whether a pile of cow manure was a better target of our remaining explosives than, say, a can of spray paint that might blast “Sky Blue” all over the place.

Things in short supply, whether fun with a fuse or money, are always more precious, and the shorter the supply, the more intense the debate about how to expend them. Nowhere is that more true than in the progressively intense competition between American business, the health care industry, and the health insurance industry over shrinking dollars available for health care of the American employee with employer-funded health insurance.

Several recent trends will make the competition uglier than the answer to the old question of whether a boy can outrun exploding cow manure, and a lot uglier than it has been in the past.

First and foremost are the double whammy of the gimpy American economy and dramatic increases in the cost of health insurance premiums for American business. The slowing economy has made it impossible for employers to absorb that cost, and left them little option but cutting benefits and increasing employee’s share of health insurance premiums.

Second, the entire future of the managed care industry is now on the line. There is legitimate debate about whether managed care is a viable model for controlling health insurance costs for business. In fairness, its success has been limited by the fact that managed care generally has less success controlling health care costs in a good economy. It is more successful in a depression, when unemployment is going up, everyone is afraid to lose the job they have, and employers do not have to compete in a tight labor market by offering great health insurance packages. Managed care therefore ought to be at its most powerful and successful controlling health insurance costs for business in this shrinking economy. If it fails in a recession, its future as a cost-control model that American business is willing to pay for will be in jeopardy. That will make the industry especially aggressive in its cost control efforts during the recession.

Third, the good old days of relatively small health insurance companies limited to one state have receded faster than my hairline. A recent study by the American Medical Association found that fewer and fewer health insurance companies controlled more and more of the market. In 19 of the country’s 40 major metropolitan markets, one insurer controls more than 30 percent of the market. It found similar trends in many states, especially rural ones. In Maine, for example, Anthem Blue Cross and Blue Shield controls more than 60 percent of the managed care market.

This trend makes it much more difficult than it has been in the past for doctors and hospitals to stand up to the health insurance companies, especially in small states. As most hospitals and doctors belong to small groups, their ability to withstand pressures to accept lower payments from large insurers are rapidly diminishing. Big health insurers will be able to play doctors and hospitals off against one another to cut payments.

When there are only four health insurance companies left in a state, as there are in Maine, and each is large, they are hard to play off against one another in return. When a small state has just a few insurers they can hold the state over the proverbial barrel by threatening to leave unless state insurance rules favor them.

Fourth, having failed to control rising prescription drug costs, managed care companies must be more successful cutting hospital and physician costs, and insurance benefits to patients; they must save dollars somewhere.

Finally, we as consumers are getting ugly about rising health care costs, saying that we are not going to take it any more. We are prepared to let just about anything happen in order to see our costs cut as long as our benefits are not also reduced.

These trends are likely to produce more dramatic and drastic efforts to cut health care insurance costs to business than we have seen thus far.

Managed care is going to be more aggressive than ever cutting payments to hospitals and doctors, and limiting expensive benefits to patients. Business will cut health care benefits, or pass along cost health insurance premium increases, at a rate which will rapidly increase the numbers of uninsured and underinsured Americans.

We were all a little more willing to swallow increasing health insurance premiums when the American economy was great, the shares of eRathole.com we bought at five cents were at $100, and the future looked brighter than a lit fuse. But every fuse I ever played with led to a bang and this one is no different. The slowing American economy is a fuse lit to the fireworks of health care cost control, and the result is going to be more of an ugly mess than my buddies and I ever made (on any single day, that is).

Erik Steele, D.O. is a physician in Bangor, an administrator at Eastern Maine Medical Center, and is on the staff of several hospital emergency rooms in the region.