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02/11/2020 - 9:50am

According to a recent CDC survey, one in four cancer survivors struggle to pay their medical bills. An even higher number worry about whether they’ll be able to scrounge up the money to pay off their out-of-pocket healthcare costs. I’m quite comfortable blaming the healthcare industry, writ large, for this problem. Healthcare prices in the United […]

The post One In Four Cancer Survivors Can’t Afford Their Medical Care–And We’re Blaming The Wrong People appeared first on Peter Ubel.

02/11/2020 - 7:12am

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. This book review will offer an analytical discussion of “cost exposure,” the main subject of his book.

What is cost exposure in health care?

Cost exposure is payments people make related to their medical care. There are many ways patients pay – here are a few common ones.

  • Deductible – Patient is responsible for the first, say, $5,000 of their medical care; after this point, the health insurance kicks in. Resets each year.
  • Copay – Patient pays a specific amount, say $25, when having an episode of care.
  • Coinsurance – Patient pays a specified percentage, say 20%, of care.

These forms of cost exposure greatly complexify patient considerations on whether to obtain care. Patients who want to see a doctor must consider not just medical need, but the predicted cost. One story of cost exposure involved a woman who recently had her leg trapped in the Boston subway; rather than pleading for help, she insisted: Don’t call an ambulance. She knew that her cost exposure to an ambulance ride may have cost her thousands of dollars. Despite this story, economists and policymakers have offered reasons for cost exposure. As seen in figure 1.1, cost exposure continues to increase in the United States.


The effects of cost exposure on health care

Cost exposure has two functions, according to Prof. Robertson.

First, consider that insurance is a pool of money that pays for individuals’ health care. Cost exposure, then, puts costs back on the individual. It serves a distributional function.

Second, cost exposure affects the health care people seek. When you know you will face costs to see the doctor, you are less likely to obtain care. Thus, cost exposure serves a behavioral function.

Cost exposure thus is a double-win for insurance groups, who save money by re-imposing costs and reducing medical care.

Why do we have cost exposure?

Professor Robertson notes that cost exposure is frequently justified by “moral hazard.” Moral hazard describes how money is easier to spend out of public pockets than out of one’s own. When you have health insurance, without any cost exposure, you can spend the pool of money with no cost to yourself. This, in theory, contributes to U.S. health care waste. So, the theory goes, by making patients pay money to see the doctor, they will have some “skin in the game” and will reduce their use of unnecessary care.

Prof. Robertson doesn’t gloss over this argument; instead, he spends a large chunk of his book analyzing whether moral hazard justifies cost exposure in health care.  He lays out a nimble critique of the evidence that was used to connect moral hazard to cost exposure, spending quite some time on the famous RAND Health Insurance Experiment of the 1970s, which randomly assigned thousands of Americans into either “free care” or to care with variable levels of cost exposure. The study found that a large but bearable deductible caused a 50% drop in health care costs for the typical person, without a significant impact on health outcome. In other words, people selectively dropped low-value care, and retained important health care. Despite some doubt that people could possess the expertise to differentiate between high- and low-value care, the study appears to show that patients did just that.

However, Prof. Robertson interprets the study differently: more than a third (37%) of the highest cost-exposure arm dropped out of the study, compared with 12% of the free-care group. Most likely, the people who could not afford the cost exposure due to large medical bills or low socioeconomic status dropped out. It’s great the study saved money through cost exposure, but it did so likely by causing the most vulnerable and sick people to drop out.

Problems with cost exposure

Cost exposure is predicated on people behaving as “rational actors,” who can measure how valuable each episode of care is, and selectively decrease low-value care. High-value care will continue to be worth it for the cost. However, Prof. Robertson identifies numerous problems with this ideal, rationalized view of cost exposure.

Cost exposure hurts poor people’s access to health care

According to the so-called access theory, cost exposure reduces access of poorer people to important health care. A poor person with high blood pressure is less likely to fill the blood pressure prescription if there is a $20 copay, putting them at long-term risk for heart disease, kidney disease, and stroke. Notably, American health care does not tailor cost exposure to ability to pay, so these payments hit much harder for poorer people. In fact, they sometimes increase health care costs in the long-term, as shown by a 2015 study finding that patients with multiple chronic conditions who were subject to cost exposure for medications, while spending less money in the short-term, eventually increased total health care costs by seeking care for complications of their diseases.

Cost exposure causes intense stress, financial and otherwise

Prof. Robertson marshals an array of evidence showing that cost exposure causes stress. His arguments have some likeness to those of Senators Elizabeth Warren and Bernie Sanders, who frequently discuss how health care throws families into financial ruin. He notes the alarming frequency with which Americans delay or forego care due to cost or inability to pay—a phenomenon almost never seen in the nearby U.K., which has a national health care program.

Beyond financial stress, medical debt greatly increases emotional stress in a way that has been shown to be medically harmful. Medical debt, controlling for other factors, is associated with higher perceived stress and depression, lower self-reported health, and higher blood pressure. Other studies have found associations with obesity, substance use, and even suicide. Prof. Robertson hits a dark note when he points out that death has become a form of bankruptcy, wiping away medical debt and sending loved ones’ life insurance and retirement funds that are protected from creditors.

Cost exposure is unpleasant and commodifying

A frequent refrain throughout the book is that health care is more than finance. People want their diseases to be treated. They value their health. Nobody wants to have to consider how much health care costs when receiving care. We also pay monthly health care premiums, so it is not immediately clear that there should be additional payments on delivery of care.

More than unpleasant, cost exposure commodifies the non-monetary. Fundamentally, there are some things that are outside the world of money. Prof. Robertson cites the work of Glenn Cohen, who argues that there are certain things that cannot be bought or sold, such as children. Health, like children, is fundamental, and while money is inevitably involved in high-level policy, it should not be incorporated into day-to-day decisions, such as with people make quid pro quo decisions of buying their child’s life through the purchase of health care.

Cost exposure fails to account for actual human psychology

Humans are not always rational. They are subject to numerous biases and limited knowledge—a proposition Prof. Robertson supports, as usual, with a tall wave of evidence. We discount the importance of our future selves in favor of the present. We do not understand which medical treatments are most effective. We over-rely on our doctors’ advice. We are sick, which causes us to make worse decisions (if they can even be called decisions at all). We rarely know what anything costs in the complex world of medicine. And, in one of the most innovative arguments of the entire book, medicine has been somewhat corrupted by financial interests that have denigrated the standards of medical evidence and caused even doctors to be misled about what treatments are appropriate. A quick look at the opioid epidemic, in which pharmaceutical marketing changed doctors’ standard of care to encourage the prescribing of more and stronger opioids, emphasizes the difficulty of identifying high-value care. Amidst all these barriers, Prof. Robertson argues that patients with no medical training cannot differentiate between high-value and low-value care. Exposed to cost, they are prone to indiscriminately reduce care.

The post Why Our Health Care Is Incomplete: Review of “Exposed” (Part I) appeared first on Bill of Health.

02/11/2020 - 3:00am

Last Tuesday, February 4, 2020, the Texas Second Court of Appeals held oral argument in the Tinslee Lewis case. A recording of the 49-minute argument is here.

A key issue in the case is the existence of state action. Only with state action is constitu...

02/11/2020 - 3:00am

Last Tuesday, February 4, 2020, the Texas Second Court of Appeals held oral argument in the Tinslee Lewis case. A recording of the 49-minute argument is here.

02/11/2020 - 3:00am

Last Tuesday, February 4, 2020, the Texas Second Court of Appeals held oral argument in the Tinslee Lewis case. A recording of the 49-minute argument is here.

A key issue in the case is the existence of state action. Only with state action is constitu...

02/10/2020 - 1:24pm

I am joined by Christopher Robertson, Associate Dean for Research and Innovation and Professor of Law at the University of Arizona. He is also an Academic Fellow Alumnus of the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School. His scholarship is well known to most of you including publications in leading law reviews and outlets such as the New England Journal of Medicine. He is routinely featured in national media, such as the Wall Street Journal and the Washington Post, and on NBC News and National Public Radio. His latest book is Exposed, published this month by Harvard University Press.

The Week in Health Law Podcast from Nicolas Terry is a commuting-length discussion about some of the more thorny issues in health law and policy. Subscribe at Apple Podcasts or Google Play, listen at Stitcher Radio, SpotifyTunein or Podbean.

Show notes and more are at If you have comments, an idea for a show or a topic to discuss you can find me on Twitter @nicolasterry or @WeekInHealthLaw.

The post New TWIHL with Christopher Robertson appeared first on Bill of Health.

02/10/2020 - 10:29am

by Alexandre A. Martins, Ph.D.

Imagine an effective and efficient universal health care system that delivers care to low-income families. Now imagine dismantling that program to further marginalize those same families. This scenario raises questions of global health disparities that threatens justice. Removing access to care for low-income families is a problem in the U.S. where Medicare work requirements restrict access and where efforts to undermine the Affordable Care Act mean fewer people can sign for insurance. Globally, the same problem is occurring in Brazil with implementation of neoliberal policies that foster the expansion of a private healthcare market where health becomes a privilege, similar to the failing U.S.…

02/10/2020 - 9:25am

Two children (Kent and Brandon Schaible) have died of
treatable pneumonia and dehydration because their parents (Herbert and
Catherine Schaible) resorted to prayer instead of medical care.  In another particularly egregious case,
members of the Faith Assembly Church denied medical care to a 4-year-old with
an eye tumor the size of the child’s head. 
Law enforcement officials found blood trails along the walls of the
girl’s home where she, nearly blind, used the walls to support her head while
navigating from room to room.  Seth Asser
and Rita Swan have documented 172 cases of child deaths from preventable
medical complication between 1975-1995.  The
report does not include seventy-eight faith healing deaths reported in Oregon
from 1955-1998, or the twelve deaths in Idaho from 1980-1998.  As recently as 2013, five child deaths in
Idaho were reported from families whose religious beliefs prevented them from
seeking medical treatment.  What sort of
religious beliefs might possess a parent to refuse medical treatment for their

Christian Scientists base their
refusal on the religious belief that medicine is fundamentally mistaken in
thinking the ultimate cause of disease is biological, seeing the real source of
disease as spiritual disorder; and a spiritual problem calls for a spiritual
solution.  The reality of sickness is not
denied (e.g., you really do have pneumonia), however, the ultimate cause of
that pneumonia is a result of spiritual disorder that can only be properly
cured by spiritual interventions. 
Because medicine is preoccupied with the biological level, it is unable
to bring about change at the spiritual level where real healing occurs.  Sometimes specific scriptures will be cited
and interpreted as encouraging the practice of faith-healing (e.g., Epistle of
James 5:14-15, Mark 16:18){Campbell,
2010 #836}.  Believers see an obligation to act as an
exemplary witness in the presence of illness by appealing to prayer, anointing,
and vigils alone for healing.  Some
scriptures are even interpreted as seeing recourse to medicine as an act of rebellion
against God (2 Chronicles 16:12, Luke 8:43-48). 
Others make more straightforward empirical claims by arguing that faith
healing is simply more effective than modern medicine by citing the high number
of annual iatrogenic deaths in hospitals (200,000-225,000 by some estimates).

Currently, most states offer legal
shield from child abuse and neglect statutes for parents who refuse medical
treatment for children on religious grounds (see:  Prior to 1974, it was considered child abuse
to fail to seek medical care for a child on religious grounds.  However, a national movement was sparked by
the Christian Science Church to have religious exemptions to child abuse and
neglect statutes after a member of the church was convicted of manslaughter for
failing to seek medical care for their child. 
These efforts succeeded in 1974 with the passage of the Child Abuse
Prevention and Treatment Act.  Several revisions
have subsequently been made to the act, which now defers to states to decide
whether to include religious exemptions to child abuse statutes. 

These legal exemptions ought to be
overturned and secular clinical ethicists ought to continue recommending the
override of religiously motivated medical refusals for children.  A growing consensus in clinical ethics cites
the harm principle as the proper justification for overriding these refusals in
pediatrics.  However, debate continues
over how to interpret the harm principle in such cases.  Aside from locating a proper physical
threshold of harm (some suffering, significant suffering, permanent disability,
death), ethicists have also considered whether non-physical forms of harm ought
to be taken into consideration.  For
example, does a parent refusing requested puberty-blocking therapy for a
trans-adolescent cross a psychological or dignitary harm threshold that should
also trigger state action?  These are the
sorts of questions that continue to engender lively debate in clinical

02/10/2020 - 8:57am

Tinslee Lewis, a critically ill 1-year-old girl born with a rare heart defect and severe lung disease, has spent her entire life in the intensive care unit at Cook Children’s Hospital in Texas and undergone multiple surgeries in attempts to save her life. Tinslee’s care team has determined that she has no chance for any meaningful survival and that ongoing intensive care is harmful and causing her undue suffering. They recommend withdrawal of life-sustaining treatment, against the parent’s wishes. Tinslee’s fate is being debated in court.

The post Deciding When Enough is Enough in Caring for a Child appeared first on The Hastings Center.

02/10/2020 - 3:00am

For decades, scores of courts have observed that "the truly ideal solution" for medical treatment disputes is for parties to "resolve their differences privately, on their own, with the aid of medical and clerical advice, and not have to resort to expe...