Health Care at Risk

A Critique of the Consumer-Driven Movement

Health Care at Risk

Book Pages: 288 Illustrations: Published: August 2007

Author: Timothy Jost

Law, Medicine and Health > Public Health and Health Policy, Politics > Public Policy

In Health Care at Risk Timothy Stoltzfus Jost, a leading expert in health law, weighs in on consumer-driven health care (CDHC), which many policymakers and analysts are promoting as the answer to the severe access, cost, and quality problems afflicting the American health care system. The idea behind CDHC is simple: consumers should be encouraged to save for medical care with health savings accounts, rely on these accounts to cover routine medical expenses, and turn to insurance only to cover catastrophic medical events. Advocates of consumer-driven health care believe that if consumers are spending their own money on medical care, they will purchase only services with real value to them. Jost contends that supporters of CDHC rely on oversimplified ideas about health care, health care systems, economics, and human nature.

In this concise, straightforward analysis, Jost challenges the historical and theoretical assumptions on which the consumer-driven health care movement is based and reexamines the empirical evidence that it claims as support. He traces the histories of both private health insurance in the United States and the CDHC movement. The idea animating the drive for consumer-driven health care is that the fundamental problem with the American health care system is what economists call “moral hazard,” the risk that consumers overuse services for which they do not bear the cost. Jost reveals moral hazard as an inadequate explanation of the complex problems plaguing the American health care system, and he points to troubling legal and ethical issues raised by CDHC. He describes how other countries have achieved universal access to high-quality health care at lower cost, without relying extensively on cost sharing, and he concludes with a proposal for how the United States might do the same, incorporating aspects of CDHC while recognizing its limitations.


Health Care at Risk should be of great interest to two groups of readers. Anyone who teaches health policy and politics should read it for its arguments about history and economics and its account of current ideas, and I suspect many who read it will consider adopting it for their courses. This book is a superb introduction to a large part of health policy. Yet it should be read more widely because it is the best work I have seen about one of the basic policy conflicts in American politics today.” — Joseph White, Perspectives on Politics

“[A]n analytic tour de force, comprehensive in scope, scrupulous in scholarship, balanced in approach, and incisive in its policy recommendations. . . . Health Care at Risk is a fine piece of work that should be of interest to policy makers, policy researchers, and many physicians. It would also be an excellent supplementary text for an introductory course in health policy and management. Name an issue that is germane to the current health policy debate and you are likely to find it discussed here. The references and footnotes are comprehensive and meticulous. Most of the major modern contributors to health care organization and finance are not only cited, but their ideas are transmitted with high fidelity and clarity.” — Richard L. Kravitz, JAMA

“[A]nyone who wants to learn what the movement is all about should read this insightful book by the nation’s foremost expert on the subject.” — Jill Quadagno, Health Affairs

“Jost has written an insightful and very informative book on the strengths and limits of the CDHC approach to meeting the health care needs of the US. In a very readable and compelling style, Jost lays out the problems in the current health care system, defines the primary issues one must consider in building a health care financing system, and explores the history and solutions that CDHC offers . . . .The book is extensively referenced. It will be valuable as Americans search for a health care solution. Recommended.” — R. L. Jones, Choice

“Jost’s arguments are fair, thorough, and convincing; his book is well written and well researched.” — Library Journal

“This book is much more than an attack on the particulars of CDHC theory and policy, however. It is a broad-based critique of market theory and ideology generally. . . . Many of this book’s both broad and focused points of attack are already familiar to academic health policy audiences (e.g., adverse selection, favoring the rich and healthy), but several of Jost’s arguments and uncovered sources of evidence are novel or are exceptionally well stated and documented. Several chapters constitute important new contributions to the health policy literature, and the book as a whole is very well researched, written, and argued.” — Mark A. Hall, Journal of Health Politics, Policy and Law

“Timothy Stoltzfus Jost has prepared an interesting and very readable book on a topic of widespread interest to policymakers, employers, health care providers, and academic researchers. . . .” — Anthony T. Lo Sasso, Inquiry

Health Care at Risk is the first intelligent and intelligible discussion of a new fad in American health policy, the so-called ‘consumer-directed’ movement. This topic is quite important, and Timothy Stoltzfus Jost knows what he is talking about.” — Theodore R. Marmor, author of Fads, Fallacies, and Foolishness in Medical Care Management and Policy

Health Care at Risk offers a scholarly and insightful assessment of the origins, theoretical underpinnings, and key elements of the modern consumerism movement in health care financing and its implications for health care access and quality. Clear, unbiased, and thought-provoking, Timothy Stoltzfus Jost’s book is essential reading for anyone concerned about the future of the American health care system.” — Sara Rosenbaum, Chair of the Department of Health Policy and Harold and Jane Hirsh Professor of Health Law and Policy, George Washington University School of Public Health and Health Services

“A well-timed, compelling study, written for experts but also, thankfully, understandable by ‘consumers.’ Timothy Stoltzfus Jost shows why leaving health care decisions to a free market cannot work, even in the United States, while also emphasizing the importance of consumer choice in future policy decisions. Erudite, clearly argued, engaging, and fair.” — Rosemary A. Stevens, author of The Public-Private Health Care State

“In Health Care at Risk, Timothy Stoltzfus Jost has written a compelling and yet balanced critique of the so-called ‘consumer-driven health care movement,’ a movement that is gaining force not just in the United States, but around the world. Students of international health policy, and indeed supporters and opponents of the CDHC movement, would benefit from reading Jost’s account.” — Adam Oliver, Editor in Chief, Health Economics, Policy and Law


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Author/Editor Bios Back to Top

Timothy Stoltzfus Jost is the Robert L. Willett Family Professor of Law at the Washington and Lee University School of Law. He is the author of Health Care Coverage Determinations: An International Comparative Study and Disentitlement? The Threats Facing Our Public Health-Care Programs and a Rights-Based Response. He is the editor of Readings in Comparative Health Law and Bioethics and a coauthor of Health Law: Cases, Materials, and Problems, now in its fifth edition.

Table of Contents Back to Top
Preface ix

1. Our Broken American Health Care System 1

2. The Consumer-Driven Prescription 17

3. Consumer-Driven Health Care Advocates: Who They Are and What They Believe 27

4. Consumer-Driven Health Care the First Time Around 42

5. The Nonaccidental System 54

6. The Origins of Consumer-Driven Health Care: A Short History of American Health Economics

7. The Theoretical Foundations of Consumer-Driven Health Care 86

8. But Does It Work? The Evidence for and against Consumer-Driven Health Care 119

9. Legal, Ethical, and Regulatory Issues Presented by Consumer-Driven Health Care 150

10. Are Consumers Our Only Hope? How Other Countries Organize Their Health Care Systems 166

11. How to Fix Our Broken Health Care System: Where Do We Start? 189

Notes 205

Bibliography 225

Index 253
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Additional InformationBack to Top
Paper ISBN: 978-0-8223-4124-6 / Cloth ISBN: 978-0-8223-4101-7
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