Ideology Meets Reality: What Works and What Doesn't in Patient Exposure to Health Care Costs

Abstract

U.S. policymakers, scholars, and advocates have long displayed an ideological commitment to exposing insured patients to substantial out-of-pocket expenses. These commitments derive from both overt political ideologies, which favor individual responsibility and oppose redistribution of wealth and risks, as well as more-subtle ideological commitments of academic economists, which link observed patterns of consumption to value-claims about welfare. In this symposium contribution, we document those ideological commitments and juxtapose them with a review of the scientific evidence about the actual effects of patient cost-sharing. We find, as economic theory predicts, that patients exposed to healthcare costs consume less healthcare. However, a fair review of the evidence — including the effects on health outcomes, access to care, and financial insecurity — makes it very hard to conclude that substantial and untailored cost-sharing exposure — as we have seen in actual application — is good social policy. We suggest directions for future study and reform.

Keywords: health insurance, out-of-pocket expenses, cost-sharing, underinsurance, health outcomes, access to care, financial insecurity, ACA, deductibles, copays