{"id":15226,"date":"2023-07-07T04:09:35","date_gmt":"2023-07-07T09:09:35","guid":{"rendered":"https:\/\/ustower.net\/?p=15226"},"modified":"2023-07-07T04:09:41","modified_gmt":"2023-07-07T09:09:41","slug":"one-economists-plan-to-blow-up-americas-health-insurance-system","status":"publish","type":"post","link":"https:\/\/ustower.net\/?p=15226","title":{"rendered":"One Economist\u2019s Plan to Blow Up America\u2019s Health Insurance System"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Economist Amy Finkelstein has studied America\u2019s patchwork of health insurance policies for more than 20 years. In a&nbsp;<a href=\"https:\/\/www.penguinrandomhouse.com\/books\/690632\/weve-got-you-covered-by-liran-einav-and-amy-finkelstein\/\">forthcoming book<\/a>&nbsp;she concludes it\u2019s time to tear the whole system down.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Scroll down to listen to the full episode, read the transcript and get more information.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">If you want more deep dives into health policy research, check out our&nbsp;<a href=\"https:\/\/tradeoffs.org\/research-corner\/\">Research Corner<\/a>&nbsp;and subscribe to our&nbsp;<a href=\"https:\/\/tradeoffs.us3.list-manage.com\/subscribe?u=6ab1fc39a0b1b15521551487c&amp;id=89c5edcb93&amp;utm_source=twitter-newsletter-signup&amp;utm_medium=twitter\">weekly newsletters<\/a>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode!&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Dan Gorenstein:&nbsp;<\/strong>Amy Finkelstein has studied America\u2019s health insurance system for more than 20 years. She\u2019s conducted some of the most rigorous, most complex research on the topic \u2014 and she\u2019s come to one very simple conclusion.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Amy Finkelstein:&nbsp;<\/strong>It\u2019s just not a system that can work.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>DG:&nbsp;<\/strong>Today, why one of the country\u2019s leading economists says it\u2019s time for a total overhaul \u2014&nbsp;and what she believes we should build in its place.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">From the studio at the Leonard Davis Institute at the University of Pennsylvania, I\u2019m Dan Gorenstein. This is Tradeoffs.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">***<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Amy Finkelstein is a professor of economics at MIT. She\u2019s won a MacArthur genius award and authored some of the most important health economics papers in the last 15 years.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Later this month, she\u2019s publishing a short book called&nbsp;<a href=\"https:\/\/www.penguinrandomhouse.com\/books\/690632\/weve-got-you-covered-by-liran-einav-and-amy-finkelstein\/\">\u201cWe\u2019ve Got You Covered\u201d<\/a>&nbsp;cowritten with Stanford economist Liran Einav.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">So first of all, Amy, this book we\u2019re talking about today is actually, I believe, the second book you published already this year on insurance. Is that right? And do you need some suggestions for hobbies?&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>AF:<\/strong>&nbsp;Yes, I\u2019m a self-proclaimed insurance geek, but this is my last book on insurance this year, so I\u2019m weaning myself off the habit.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>DG:<\/strong>&nbsp;You said this year\u2026<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>AF:&nbsp;<\/strong>You\u2019re quick. You caught me.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>DG:&nbsp;<\/strong>So Amy, I\u2019m not sure I know anyone more allergic to anecdotes than you. You\u2019re all about the data. And one number jumped out at me early in your book.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Many of us know&nbsp;<a href=\"https:\/\/www.census.gov\/library\/publications\/2022\/demo\/p60-278.html\">about\u200210% of Americans<\/a>&nbsp;\u2014 or 30 million people \u2014 are uninsured right now.&nbsp;But the number I\u2019d never seen before is your estimate that over a two year period,&nbsp;<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/37094163\/\">25% of Americans<\/a>&nbsp;under 65&nbsp;\u2014 one in four of us \u2014 will go without coverage at some point in that window.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">What does that number tell you about the&nbsp;health&nbsp;of our insurance system?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>AF:&nbsp;<\/strong>That\u2019s really just crazy if you think about it.&nbsp;The entire purpose of health insurance is to provide some modicum of stability in an unstable and uncertain world. And yet, perversely, health insurance coverage, what is supposed to provide that stability is itself highly uncertain. So right when you fall ill and need insurance most you can find yourself suddenly and unexpectedly uninsured.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>DG:&nbsp;<\/strong>So for tens of millions of Americans, you\u2019re saying Amy, health insurance is fundamentally broken. It\u2019s failing to serve its basic purpose.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>AF:<\/strong>&nbsp;Exactly. And those who are insured, even if they don\u2019t lose their coverage, may find that coverage extremely inadequate when they actually get sick. There\u2019s an enormous amount of&nbsp;<a href=\"https:\/\/tradeoffs.org\/2022\/11\/03\/medical-debt\/\">medical debt<\/a>&nbsp;in the United States. But something like three-fifths of that medical debt is incurred by people who have health insurance.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>DG:&nbsp;<\/strong>And you make it clear from the start, you think the era of incremental improvements to our health insurance policies should end. You write that quote, \u201cIt\u2019s time to build a new house from scratch.\u201d In just a couple of sentences, sketch out your blueprint for that new house.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>AF:&nbsp;<\/strong>That\u2019s the easy part. It can almost fit on a bumper sticker. It\u2019s free, automatic basic health coverage for all with the option for people who can afford and want to to buy extra insurance. That\u2019s it. Now, obviously, the devil is in the details there but at a high level, that\u2019s the idea.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>DG:&nbsp;<\/strong>When we hear these sorts of big ideas \u2014 blowing up the system, universal coverage \u2014 we\u2019re looking for Bernie Sanders, not an MIT economist.&nbsp;But since you are an economist I\u2019d like you to walk us through some of the evidence behind this bumper sticker solution that you\u2019re proposing. Free, basic coverage for everyone with the option to buy more if you can afford it.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Let\u2019s kick off with this idea of universal coverage \u2014 that everyone should be automatically enrolled in the same basic thing. What data convinced you that\u2019s the right move?&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>AF:&nbsp;<\/strong>So one startling fact is that about&nbsp;<a href=\"https:\/\/www.kff.org\/policy-watch\/millions-of-uninsured-americans-are-eligible-for-free-aca-health-insurance\/\">six out of 10<\/a>&nbsp;of the currently uninsured individuals are actually already eligible for free or heavily discounted health insurance. They\u2019re just not enrolled. Even making everyone eligible for free coverage \u2014 if it\u2019s through a patchwork of programs like our current system \u2014 where there\u2019s one program if you\u2019re poor and one program if you\u2019re disabled, people are always going to be unsure about which program they\u2019re eligible for and people will slip through those gaps in the seams.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>DG:&nbsp;<\/strong>You\u2019ve talked about this patchwork for years and it seems like you really dug into its history in the book. You catalog how policymakers have continued to add new patches, new programs for people with COVID, postpartum moms on Medicaid low-income people with HIV\u2026<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">And Amy, when you zoom out, what you see is a picture of a country that is actually trying \u2014 in a kind of super inefficient and ultimately inadequate way \u2014 to meet everybody\u2019s basic medical needs.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>AF:&nbsp;<\/strong>You know you still get a lot of care when you\u2019re uninsured and you\u2019re paying for only about 20 to 30 cents on the dollar. The rest is paid by some combination of the state or federal government or through unpaid medical debt from hospitals. But I hadn\u2019t sort of put it together to realize, oh my goodness, that means like, we\u2019ve kind of backed ourselves into attempting to do universal coverage. Now, of course, anyone familiar with the many problems in the U.S. health care system may say, \u201cOh, come on, we\u2019re doing a terrible job,\u201d and I think we are, but that illustrates our failure to live up to those commitments \u2014 not their absence.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>DG:&nbsp;<\/strong>So your point is basically, look, we\u2019re already basically providing universal coverage. We don\u2019t call it that. We don\u2019t quite think of it that way, but it\u2019s already there. So if we\u2019re gonna do it, let\u2019s do it well.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>AF:<\/strong>&nbsp;Right, we\u2019re trying to make sure that people don\u2019t die in the streets, that everyone has access to essential medical care. We\u2019re not succeeding. And once you realize that\u2019s what we\u2019re doing then it\u2019s kind of obvious, you know, you do what every other high income country does and you give automatic, universal basic coverage.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>DG:<\/strong>&nbsp;Do you feel like you\u2019re the first academics to sort of connect these dots like this?&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>AF:&nbsp;<\/strong>&nbsp;Oh, I\u2019m sure we\u2019re not. I mean, in some sense, I think the worst and the best thing you could say about our book is \u201cduh,\u201d right?&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>DG:&nbsp;<\/strong>[Laughter] Okay, so Amy not only are you saying and again, I\u2019m still looking for the Bernie Sanders hair coming out of your ears or whatever. Not only are you saying that everyone should get coverage, but you\u2019re also saying that it should be free. Do they take away your economics card when you start talking like this?&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>AF:<\/strong>&nbsp;[Laughter] Yeah, this is the point where we get kicked out of the academy. I mean, this is as close to \u2014 I\u2019m not sure it\u2019s going to be, you know, burned at the stake like Galileo \u2014 but this is as close to heresy as one comes in the economics profession.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>DG:<\/strong>&nbsp;And to this joke about being burned at the stake, right, like health economists have talked for years about the essential role that cost sharing these copays that we all have place this kind of like really important check on patients. Cost sharing stops people from getting too much care that they really don\u2019t need. Your proposal flies in the face of this economic orthodoxy.&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>AF:<\/strong>&nbsp;Yeah. And let me just double down on that and say Liran and I have been out there, you know, not only preaching that orthodoxy to generations of students, but contributing evidence to it. There is a huge body of evidence that shows incontrovertibly that if you make people pay something for their health care they use less medical care. And it makes sense, you know, when you make things less expensive, people buy more of it. The research was correct in terms of what it found. It\u2019s the implication that we drew from it was wrong \u2014 at least when it comes in the context of universal coverage.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>DG:&nbsp;<\/strong>So if copays work \u2014 get some waste out of the system \u2014 why wouldn\u2019t you include them in your plan? What\u2019s the problem with them?&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>AF:&nbsp;<\/strong>The problem with copays is there will always be people who can\u2019t manage even a $5 copay for a prescription drug. And that\u2019s what we see in country after country \u2014 policymakers scrambling to create all kinds of exceptions for situations when even small copays are prohibitive. And so we have copays and then we have exceptions for the copays and then we have people having to know which exception they qualify for, and with all the complexity and the administrative costs, they end up saving almost no money and just creating a lot of headache and hassle.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>DG:&nbsp;<\/strong>And for people who need help with their copays but can\u2019t figure out how to get it, studies show that can have real, even deadly health consequences. They don\u2019t just cut back on wasteful care but also on life saving stuff like drugs that prevent strokes and heart attacks.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">After the break, Amy defends letting rich patients buy better access to care \u2014 and eats a slice of humble pie.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/tradeoffs.org\/2023\/07\/06\/universal-coverage-health-insurance-finkelstein\/\">Tradeoffs<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Economist Amy Finkelstein has studied America\u2019s patchwork of health insurance policies for more than 20 years. In a&nbsp;forthcoming book&nbsp;she concludes it\u2019s time to tear the whole system down. Scroll down to listen to the full episode, read the transcript and get more information. If you want more deep dives into health policy research, check out [&hellip;]<\/p>\n","protected":false},"author":7,"featured_media":15227,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1154],"tags":[9599,9600,7134,9598,1198],"class_list":["post-15226","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-trending","tag-aca","tag-health-disparities","tag-health-insurance","tag-political-issues","tag-america"],"_links":{"self":[{"href":"https:\/\/ustower.net\/index.php?rest_route=\/wp\/v2\/posts\/15226","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/ustower.net\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/ustower.net\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/ustower.net\/index.php?rest_route=\/wp\/v2\/users\/7"}],"replies":[{"embeddable":true,"href":"https:\/\/ustower.net\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=15226"}],"version-history":[{"count":1,"href":"https:\/\/ustower.net\/index.php?rest_route=\/wp\/v2\/posts\/15226\/revisions"}],"predecessor-version":[{"id":15228,"href":"https:\/\/ustower.net\/index.php?rest_route=\/wp\/v2\/posts\/15226\/revisions\/15228"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/ustower.net\/index.php?rest_route=\/wp\/v2\/media\/15227"}],"wp:attachment":[{"href":"https:\/\/ustower.net\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=15226"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/ustower.net\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=15226"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/ustower.net\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=15226"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}