On Wednesday, January 15, the Jaharis Health Law Institute hosted Christopher Robinson, Associate Dean for Research and Innovation and Professor of Law at the University of Arizona, for a lecture and signing of his new book, Exposed: Why Our Health Insurance is Incomplete and What Can Be Done About It.

In front of a small crowd consisting of DePaul health law students, faculty members, and Barnes & Noble shoppers, Professor Robinson discussed the central theme of his book, cost exposure in the health insurance system. Cost exposure, he explained, is the amount that people, including insured people, have to pay in the course of seeking care in the United States health care system.

Unsurprisingly, Professor Robinson explained that the United States has the highest levels of cost exposure among developed nations with advanced health care systems. Insured people usually must pay a deductible before their insurance will cover any medical expenses, and covered treatment usually comes with some form of copay. These costs and their effects on patients and our healthcare system are the subject of the book.

Cost-sharing measures work to displace the risk of insuring individuals from the insurance companies onto policyholders. Higher cost exposure, in effect, means higher out-of-pocket costs for health care consumers.

Professor Robinson suggested in his lecture that the Affordable Care Act, while working to increase the total number of Americans with health insurance, has not brought meaningful relief to American families. He noted that adverse effects on debt on health, and posited that a health care system must take debt into account in order to be comprehensive.

“Price exposure is a policy choice,” and therefore can be changed. Professor Robinson argues in his book that current system of extensive cost exposure throughout the insured population is unsustainable, and exacerbates bad outcomes as it squeezes the most economically vulnerable populations. To this end, he offers a variety of prescriptive solutions.

Among these would be to tinker with the prevailing cost-sharing regime. These changes would entail a preference for lower-cost procedures, while promoting empirically-guided insurance schemes. This would mean means testing cost-sharing, so that people without significant resources can still affordably seek care. Professor Robinson cautions, however, that these sorts of interventions only amount to small modifications without structural change to the overall system, and therefore their net impact may be limited.

With that in mind, Professor Robinson suggests that the United States could adopt a health care system that severely limits or eliminates patients’ cost-exposure. Implementing this new regime, Professor Robinson notes, would entail a complete overhaul of our health care delivery systems, and would likely only be practical under a single-payer regime, like Medicare-for-All.

Eliminating or severely limiting cost-sharing would run counter to the dominant way health insurance has been managed in the United States, in part because it requires insurers to bear a greater portion of the pool’s risk. The most common counterargument against a cost-sharing-free environment is that without some level of cost-sharing, patients will seek more health care than they actually need, a phenomenon called moral hazard.

Professor Robinson suggests that this could be a feature, not a bug, of a cost-exposure-free system. In this way Professor Robinson rejects the premise of the counter argument. He explained that with high levels of cost-sharing, people forgo care that they need, and that the downstream effects of having free-at-the-point-of-service health care could exceed the supposed value lost to moral hazard.

Professor Robinson also collaborates on research with Professor Wendy Netter Epstein, Director of the Jaharis Health Law Institute. Professor Robinson’s book Exposed: Why Our Health Insurance is Incomplete and What Can be Done About It is available for purchase at the DePaul Center’s Barnes & Noble.