- Series: A Columbia / SSRC Book (Privatization of Risk)
- Paperback: 139 pages
- Publisher: Columbia University Press; 1 edition (November 6, 2008)
- Language: English
- ISBN-10: 0231146035
- ISBN-13: 978-0231146036
- Product Dimensions: 5.5 x 0.5 x 8.2 inches
- Shipping Weight: 7 ounces (View shipping rates and policies)
- Average Customer Review: 5 customer reviews
- Amazon Best Sellers Rank: #2,738,680 in Books (See Top 100 in Books)
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Health at Risk: America's Ailing Health System―and How to Heal It (A Columbia/SSRC Book (Privatization of Risk)) 1st Edition
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A great resource for understanding the development, problems, and possible solutions to health care in the US. (Choice)
About the Author
Jacob Hacker is professor of political science at the University of California at Berkeley, where he heads the Center on Health and Economic Security at the Boalt Law School. A frequent media commentator and author of numerous scholarly and popular articles, he is the author of four books, most recently The Great Risk Shift: The New Economic Insecurity and the Decline of the American Dream. Contributors: Jacob Hacker: "Health Insecurity and the Middle Class"; Elizabeth McGlynn and David Meltzer: "Health Quality"; Brandon McKelvey and Jill Quadagno: "The Transformation of American Health Insurance"; Katherine Swartz: "The Uninsured and Underinsured"; Elizabeth Warren: "Medical Bankruptcy"
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"Health at Risk" is also a part of a larger project on the part of its sponsoring organization, the Social Science Research Council (SSRC), to consider the ways in which economic risk in the United States has changed in recent years. It is thus not merely a stand-alone volume providing a map of the health care crises, but a book relating that crises to wider shifts in the economic landscape. Hacker is a particularly good candidate to edit such a text. He cogently describes the privatization of risk as "the contemporary celebration of the private sector as the first and best means for dealing with problems of all kinds." Allegiance to private sector solutions has transferred responsibility for dealing with problems from the government and employers onto individuals and their families, a change which he dubs "the great risk shift" and sees as "a defining economic and political transformation of our times." Thus, the chapters brought together in this book are united by a dual set of factors: their commitment to grappling with questions about what we know about health reform and what that research suggest, and the thematic preoccupation with economic risk.
In the service of sorting out the jumble, the chapters proceed with a logical orderliness rare to the health care debate. In a chapter entitled, "The Transformation of American Health Insurance," Jill Quadagno and Brandon McKelvey begin the book by laying a foundation about medical risk and how its handling has changed. Noting the high recent numbers of uninsured, they explain the way in which American insurers have moved from a "community rating" system, in which populations were evaluated for their collective health risks and everyone charged the same fee, to "experience rating," whereby individual subscribers are charged according to their own expected medical costs. Lowering fees for low-risk individuals attracts healthier, less expensive people to the pool, but it also stratifies the group such that disabled and elderly members encounter higher premiums than many could afford. The change in ideology from the collective to the personal is an effort to solve rising health care costs by promoting personal responsibility, but has carried difficult consequences for many.
In "Uninsured in America," the book's second chapter, Harvard economist Katherine Swartz explores the implications of the inability of so many Americans to afford insurance, tracing the effects that non-insurance has on the health and on the pocketbooks of individuals. Surveys indicate that many avoid preventive treatment and diagnostic tests, resulting in the costly development of advanced conditions. In her objective measurement, Swartz finds that, "All in all, being uninsured is dangerous for one's health," and devotes the latter portion of the chapter to evaluating strategies toward universal health care.
Chapter three, "Get Sick, Go Broke," turns away from the examination of the healthcare have-nots and explores the financial experience of the insurance "haves," for whom health services can be startlingly pricey. Elizabeth Warren and Deborah Thorne evaluate the official data on medical bankruptcies, which they find to be misleadingly conservative. "For every family filing for bankruptcy," they note, "economic experts estimate that another sixteen are in serious enough trouble to benefit from bankruptcy -- if only they were willing to file." The authors outline which medical services tend to be most financially perilous, and the bogs of debt and credit scams that can follow the bills for denied claims. Warren and Thorne are up front about the lens through which they address the issues. "We approach the health care debates from a single perspective: maintaining the financial stability of families confronting illness or injury," they write. "People should not be gouged for getting sick."
Neither should they receive sub-optimal care, regardless of what they pay. In their chapter, "Just how good is American Health Care?" Jacob Hacker, David Meltzer, Elizabeth McGlynn deliver some disconcerting measurements about the quality of American health care in reply to the question, "Won't reform hurt the best medical care in the world?" Their answer - implied or stated - is no, because American patients tend to be undertreated, receiving approximately half of recommended care.
In the final chapter, "The New Push for American Health Security," Hacker examines the likelihood of major action to address the costs of care and access. To do so, he poses the fundamental question: Why is the United States the only rich democracy without guaranteed coverage for all (or virtually all)? And answers it with a brief but insightful review of American political history. American political parties, for starters, have always differed on what role the federal government should take in the lives of its citizens. In the early to mid 20th century, private institutions received a boost from public policy to serve as a bulwark against federal intervention. And so on. The chapter covers a vast amount of territory, concluding with some of the most concrete suggestions for reform posed within the volume.
All told, "Health at Risk does" an excellent job of meeting its stated purpose to make issues of the health care debate accessible to non-experts in an even-handed form. "The contributors to this volume have not checked their opinions at the door," warns Hacker, but he assures us - truthfully - that they have grounded their arguments in empirical evidence. One aspect of that honesty is that no author in the book assigns full responsibility to any one influence or party. One chapter explains the problems of public finance for health care, another demonstrates the private ones - demonstrating that the problem is spread as much across public coffers as private ones. An attentive reader will find herself forced to consider the ways in which economic spheres work in tandem. There is no single solution to this problem - as Hacker eloquently explains in the final chapter, outlining the three-pronged approach that seems most likely to work in the current political moment.
But while Hacker's book is satisfying in many respects, it is worth asking whether the reach of the presented facts extends quite far enough. Several important stones may remain unturned in this publication. The book takes for granted, for instance, the prevalent hysteria that the ills of health care spending are related to "over consumption" of medical services. But does the economic model on which this critique is based even provide a relevant `fit' for the decision making and spending pertinent to health care?
Insurers and some policymakers raise the prospect of "moral hazard," a situation in which patients who are shielded from the actual costs of health care will incur greater (and unnecessary) expenses. The specter of moral hazard in health care rests of a free-market model in which patients are equated with "consumers," and as such are assumed to be rational decision makers whose choices will bring them the most value for their money. They are understood to have clear-cut preferences and face budget constraints, and they are expected to make comparisons of satisfaction with costs. Health care is not an elastic good like a refrigerator or a book or any other luxury commodity whose price responds to the laws of supply and demand. Instead, health care is an inelastic good, like food or water, a need essential to human survival. Much of the health care debate engaged by Health at Risk is premised on the assumption that policy restrictions against the "over-utilization" of care will significantly curb medical spending, making "necessary" care more affordable.
To reduce the astronomical costs of care, we might do better to refocus attention from the assumed moral hazards of patients to the temptations of the provider. Where, precisely, are our health care dollars going? A review of the money trail provides pieces of clarity that are glaringly omitted from most books - including this one.
In a 1980 article in the "New England Journal of Medicine," Dr. Arnold Relman famously coined the term "the medical industrial complex" (MIC) to describe an industry that had come to be dominated by private, profit-seeking companies. Further investigation of the MIC demonstrates that the holdings of this industry are tightly intertwined, with common stock ownership, frequent joint ventures, and internal transactions forming a mosaic of portfolios so complicated that the destinations of their profits are almost impossible to track. Such conditions provide the perfect basis for the formation of cartels, whereby companies cooperate to keep prices artificially high. As early as 1982, the $118 billion garnered in corporate profits equated to 37% of the nation's total healthcare spending. To motivated scholars and policymakers, the stunning profit margins in evidence in the health care industry should be as open to interrogation as the bills incurred by health care "consumers." In a volume as thorough and well-planned as Health at Risk, it is somewhat disappointing not to see an examination of these economic orthodoxies.
In chapter one, Quadagno and McKelvey present two ideologically different solutions for transforming the American health insurance - social insurance model on which Medicare and Medicaid are based and consumer-directed healthcare which is operationalized through health savings accounts. Explanation of the underlying principles of the two models, including the adverse risk selection, moral hazard, and difficulties with shifting estimation of health risks to individuals are particularly useful in understanding the pros and the cons of the each model in reforming the current health insurance system.
In chapter two, Swartz discusses the impact of health insurance on health outcomes. Further, she describes the major population groups that comprise the 47 million uninsured Americans and the main reasons for the lack of insurance in these groups. She also examines plausible paths for securing universal health insurance and the associated costs. Swartz illuminates the importance of carefully considering the many faces of the uninsured as well as what a basic health plan should include in order to devise effective solutions for reaching the goal of ensuring all Americans.
In chapters three and four sobering statistics are presented indicating that "about a half of all families filing for bankruptcy do so as a result of a serious medical problem" and that U.S. spends most per capita on medical care in the world but, contrary to the public belief, fails to consistently provide best quality of medical care. In these two chapters Hacker and colleagues expose the flaws of the current health insurance system that can lead even the middle class and working class Americans who have health insurance to file for bankruptcy due to medical costs. Further, they point to a number of solutions for improving the quality of medical care, including, for example, standardization of healthcare delivery and increased utilization of technology. The authors, however, neglect to discuss the vital role that registered nurses, nurse practitioners and other allied health providers play in ensuring quality patient care.
In the final chapter, Hacker offers a historical overview of the failed attempts for health care reform and an analysis of the familiar and the new obstacles facing the health care reformers as they approach another "major national debate about health care." Hacker suggests that a shift in mindset is necessary for the healthcare reform to occur. This book is sure to inspire the necessary change in thinking on what the most viable solutions for the ailing healthcare system may be.