A calculator, a stethoscope, and a stack of money rest on a table.

Why Our Health Care Is Incomplete: Review of “Exposed” (Part II)

By: Daniel Aaron

Just last month, Professor Christopher T. Robertson, at the University of Arizona College of Law, released his new book about health care, entitled Exposed: Why Our Health Insurance Is Incomplete and What Can Be Done About It. Part II of this book review offers an analytical discussion of “cost exposure,” the main subject of his book with a focus on solutions. Read Part I here.

Baby solutions

Prof. Robertson writes two chapters on solutions. In the first, titled “Fixes We Could Try,” he offers reforms, from mild to moderate, that would make cost exposure less harmful. The chapter largely retains the analytical nature of the prior chapters, but it comes across like a chapter he might have rather not written. This is evident in the following chapter’s title, “What We Must Do.” It’s also evident because some of the proposals do not seem fully considered, and in some ways appear more controversial than the more comprehensive solution offered later.

The oddest policy suggestion Prof. Robertson offers is providing full transparency on what everything costs to patients and altering the medical standard of care to consider the patient’s ability to pay. If a physician prescribes a drug that is financially harmful to a patient, the patient can sue the physician for malpractice. Thus, people will not go bankrupt from health care anymore—and if they do, they can sue their doctor. It does not seem like Prof. Robertson fully considers the ramifications of this proposal. Importantly, it threatens to undermine poor people’s access to important but expensive care—physicians may be torn between prescribing life-saving treatment and tort liability, which is an impossible divide and a conflict with physicians’ ethical duties. This proposal also hyper-commodifies health care beyond what cost-exposure already does in that it not only permits provision of inferior health care to the poor, but legally requires it. Therefore, it undermines the book’s earlier-stated concern with commodification. Finally, it does little to address the underlying problems hampering our health care system.

Prof. Robertson also suggests tailoring cost exposure to ability to pay, so that access to care is not affected. Perhaps there could be a sliding scale by income for copays, deductibles, and coinsurance. Prof. Robertson does not fully delve into the complexity this would engender, and the problem is that sliding scales by income complicate costs and reduce transparency for patients.

Perhaps the best reform offered is using cost-exposure only for low-value care. Issues with health equity, access to care, and bankruptcy are far less if cost exposure is only applied to unnecessary care. Of course, Prof. Robertson’s expositions on the difficulty of identifying high-value care undermine the targeted cost exposure approach. In addition, notions of individual-based medicine, in which low-value care could be high-value for some people, present a problem. Perhaps cost exposure could be applied to care that is proven low-value by strong evidence.

What we must do

One of Professor Robertson’s most interesting points is a proposal to eliminate cost exposure. Keeping people healthy and financially solvent is fundamental to their participation in the democratic process and to our greater sense of equality.  His points are thus: Much of medicine is based on weak evidence. Journal articles do not properly and visibly disclose conflicts of interest that influence their findings. Medical care varies from provider to provider and from region to region. Medicine is inevitably imperfect, and cost exposure assumes too much and goes too far in assuming that consumers can make intelligent decisions—let alone providers. Further, if reducing health care costs is imperative, let’s go after the real causes. It’s not health care use. It’s the system.

Off-hand comments

One weakness of the book is that it offers a number of off-hand comments that seem out of place. Given how much research Professor Robertson marshals toward cost exposure, it is surprising what he concedes without evidence in other domains. At times it seems he is writing to a particular audience and is ceding claims to appear reasonable. This approach defies his customary dedication to the evidence.

Part of Prof. Robertson’s argument against cost exposure is that health insurance is different from other goods. He writes, “Laissez-faire is a fair default rule; it’s the presumptively right approach to any policy question.” This claim is suspect in at least two ways. First, Prof. Robertson’s argumentative framework implies that public health problems are not soluble through the free market. In fact, he notes that public health is a collective action problem that requires coordinated buy-in and policymaking. A quick look at current problems such as e-cigarettes and opioids makes it clear enough that laissez-faire is far from the presumptively right approach. It is odd that Prof. Robertson writes something out of tune with the rest of his book, and his health care exceptionalism comes across as an off-hand comment to placate a segment of his readers dedicated to traditional economics.

He also makes interesting assignments of blame or non-blame. He denies blaming insurance companies, which are simply behaving “rationally” given the “incentives that the policy domain has established for them.” This analysis comes across more as defensive than analytically revealing. Every member in the system is arguably behaving according to the incentives, but this makes these actions neither rational nor ethical. To absolve corporations of all responsibility weirdly foists blame on a combination of patients, doctors, and policymakers. A broader view of the literature suggests that corporations have some social responsibility. As two-hundred executives recently declared, corporations are responsible to the people. The idea that corporations are mere profit-driven entities was born within the last few decades and is still not true in many countries.

Third, Prof. Robertson makes an odd comment about how scientific fields are “really contingent sociological cultures of prestige, hierarchies and incentives, populated and organized by humans.” We are at a time when expertise is coming under fire to the detriment of public health. This is most obvious with vaccines. We are seeing loss of trust in vaccines and doctors, and concomitant epidemics of diseases that were all but eradicated. It is unclear why Prof. Robertson writes a brief aside deriding science without caveat or nuance.

Finally, he emphasizes his agnosticism on “whether insurance should be provided publicly or through private insurance, and . . . single-payor versus managed competition.” But he adds that the “final solution will likely be some mix of both.” After reading about 200 pages of his writing about cost exposure—largely a feature of private insurance—it was interesting to see this forecast on the final page of the book without any explanation and contradicting his apparently agnosticism.

These off-hand comments are small potatoes but are interesting if only to show the challenge in appealing to multiple types of readers in an increasingly polarized world.

Conclusion

Exposed is a fantastic read. It combines research from a litany of scholarly areas, while acknowledging the human touch that is always present in health care discussions. Prof. Robertson’s book is more than a book about health care. It discusses how we organize society, how resources are distributed, and how we are failing to reach the equality that we so often profess as fundamental to the American Dream. This review provided a survey of the issues presented in the book, but there is far more to it. Prof. Robertson is a powerhouse of knowledge and social understanding, and his book is a worthwhile read.

 

Daniel Aaron

Daniel Aaron

Daniel grew up in Newton, MA just outside of Boston. He graduated from Brown University and is currently studying law and medicine between Harvard and Boston University. Daniel Aaron hopes to improve public health by changing law and policy. His research foci include food and drug law, obesity, opioids, tobacco products, constitutional health law, and health contracts, and his research has been covered by the New York Times, CNN, Time Magazine, and others.

2 thoughts to “Why Our Health Care Is Incomplete: Review of “Exposed” (Part II)”

  1. Thanks for the review.

    One of those “offhand comments” about laissez
    faire was actually a foil, that an entire section of the book argues against, distinguishing markets for consumer goods from markets for health care.

    The idea that science is contingent and must be evaluated critically motivates another section explaining how we have failed to invest in rigorous and reliable science about the efficacy of healthcare. Nonetheless, to be clear, vaccines are an area where we can be very confident of safety and efficacy.

    As to public versus private insurance, keep in mind that Medicare (public) has huge cost exposure that is uncapped and unscaled.

    1. Hi Professor Robertson,

      Thanks for you comment on the review. The first thing I’ll say is a substantial amount of the praise I wrote for the book was edited outside my control. I think the above review reads more critically than the original version written by me.

      The “off-hand comments” that I referenced were small potatoes, as I admit. I fully agree that they may matter little in the grander scope and argument of your piece. But on reading your comment and looking back over the text, I do still think my critiques run true. I quote (p135):

      “This sort of hands-off approach (aka laissez-faire) reflects a standard starting point of economic reasoning. Indeed, we can assume that because consumers know their own situations and preferences best, laissez-faire is sensible in a wide range of applications. . . . Laissez-faire is a fair default rule; it’s the presumptively right approach to any policy question. Consequently, before considering various reforms below, one has a burden of proof as to why health insurance, and cost exposure in particular, is different. . . . Why not laissez-faire? Why interfere with individual choices?”

      The next section then begins, entitled “Health Insurance Is Different.”

      It strikes me that laissez-faire is a foil here but only with regard to health insurance. Laissez-faire is appropriate for food selection, for example (p135) — even though there may be good reasons to help steer consumers toward particular foods. For example, arugula tainted with E. coli is a great reason to steer shoppers toward spinach. I totally respect if you think laissez-faire should be the default rule, but I think that statement is open to critique given how many hazards are present in today’s society, and these hazards’ links to laissez-faire.

      As to public vs. private insurance, your example of Medicare is arguably a public-private mix. Medicare, despite its usefulness, is not constructed to be complete insurance in my eyes, hence the vast majority of beneficiaries being on additional plans. (Although how much insurance is complete? Going back to the title of your book.) I defer to your expertise on which aspects of Medicare have come under greatest critique, public or private, and why Medicare is built the way that it is. (Largely a political question I would believe.)

      I hope this helps explain that I very much like your book, that some of my fondness was edited out for brevity, and the only critiques I could come up with were fairly ancillary to the main thrust.

      All the best.
      -Dan

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