About Aobo Dong

Aobo is a Student Fellow at Petrie-Flom. He is studying religion, ethics and politics at Harvard Divinity School and also a junior fellow at the Science, Religion, and Culture (SRC) program. His research interests involve the intersections between religion, sexuality, human rights, and health law.

The Illusion of Choice in Health Care Consumerism

The rhetoric of “choice” has been pervasive in U.S. health care reforms and the consumerist health care culture for a long time. The idea is that giving patients more choices over doctors and insurance plans would increase competition in the industry and consequently improve the quality of health care patients receive. However, Allison Hoffman made a convincing case debunking this seemingly intuitive idea in this week’s HLS health law workshop. She argued that reform efforts aimed at increasing consumer choice often fail to empower patients to make better health care choices, and instead, create a wasteful market bureaucracy that is anathema to free market ideals. Her argument reminds me of one of my earlier blog posts on U.S. drug prices, where I compared insurance companies to the Central Planner in a socialist economy. Indeed, there are ironically many institutions and features in the so-called market-driven U.S. health care system that resemble authoritarian and technocratic practices that are directly against the principles of a laissez-faire health care economy.

I will expand Professor Hoffman’s argument by making a few additional points. First, her presentation discusses a number of revealing ways in which the market-based competition creates a false sense of choice in health care. Even Obamacare, which is supposed to offer patients more choices in the Exchange, fails to transcend the falsity of consumer choice. Most patients do not make the best available choice, even when they’re “nudged” by experts in the decision-making process. I’d like to also point out that even if consumers are capable of making the best choice for themselves, whether by thinking with perfect rationality or by accepting “expert opinions,” the choice they ultimately make could still be suboptimal or even disastrous. To understand why this might be the case, it is important to realize that the target population for Obamacare is the minority of people who do not have adequate employer-sponsored plans. Thus, many people enrolled in Obamacare may not have stable jobs and income levels. Nonetheless, the mechanism that determines how much premium for which one qualifies is predicated on an estimation of that individual’s projected annul earnings – a number that is hard to know in advance for those without stable income levels. Hence, a person who made the “right choice” by selecting a silver plan with only $100 monthly premium after receiving a $900 subsidy to cover a $1,000 plan at the beginning of a year may find herself owing the federal government thousands of dollars at the end of the tax year, if she happens to end up with a much higher income level. Had she known the future outcome, she would have chosen a less expensive plan to begin with, but either choice would be a gamble for her. This arbitrariness must be attended to in future health reforms.

Second, the “moral hazard” rationale – that patients would engage in behaviors that undermine their own health if they are insured or that they would abuse their insurance during sickness – could actually influence consumer behaviors. To counter moral hazard, many advocate increasing patients’ cost-sharing obligations so that they would be less likely to abuse their insurance. While it is true that no one is likely to deliberately hurt themselves just because they have insurance to cover losses, some moral hazard based insurance policy may actually cause patients to behave differently or prevent people with “unhealthy” behaviors from joining. In my own research on HCSMs – alternative “non-insurance” cost-sharing ministries run by evangelical Christians “bearing each other’s medical costs” – have strict eligibility requirements and reimbursement restrictions on lifestyle choices. For example, medical costs resulting from tobacco or alcohol would not be reimbursed. Thus, if someone has tobacco-induced lung cancer, no cost sharing might be available. Additionally, STDs caused by sexual activities outside of heterosexual marriage would not be covered. These “moral hazard” policies could have a large deterrence effect on individual behaviors – making them strong “arbiters of morality.” Thus, under HCSMs, the costs to build a censoring mechanism based on moral hazard turn out to be saving these ministries a significant amount of money. Yet, the autocratic element of such measures remains strongly inconsistent with free market ideas.

Lastly, I’d like to suggest a rather radical idea that may be too far-fetched to even think about in our current political environment. I wonder whether the fact that market competition fails to produce good health care outcomes has more to do with the market itself than the principle of competition. In other words, could competition work better if a competitor with significant competitive edge enters the deadlocked American health care marketplace? What if, hypothetically, insurance companies from Canada and Mexico start contracting with American providers and provide appealing, low cost choices for consumers? Or, these transnational insurance companies could even create border-crossing incentives for American patients to use foreign providers at a significantly cheaper cost? Since drug prices and medical expanses are significantly lower in other developed countries, allowing transnational health care access might create competitions that would not be possible for any American insurance company. I know that many Taiwanese Americans seek healthcare back in Taiwan, where high-quality universal health care is the norm. If such transnational health-seeking endeavors could be happening much more frequently and closer to American borders, it might be able to disrupt existing norms in the U.S. market and potentially drive health care costs down. Similarly, a radically cheaper federal-insurance option or single-payer system might also create such disruptions and norm-shifting competitions. Nonetheless, these conversations can never happen unless there is enough political will to seriously question some fundamental assumptions our current health care system relies on.

Elderly Care in the Age of Machine and Automation

By Aobo Dong

Would you be willing to accept a professional care-giving robot as a replacement to a human companion when your loved ones are far away from you? During last week’s HLS Health Law Workshop, Professor Belinda Bennett provided a great overview on the imminent age of machine and automation and the legal and ethical challenges the new era entails, especially in health care law and bioethics. After discussing three areas of potential health law complications, Professor Bennett argued that the field of health law is undergoing a transition from the “bio” to the “digital” or “auto,” and that instead of playing a catching-up game with rapidly evolving technologies, more focus should be placed on learning from past and existing laws and regulations in order to meet new demands from the “second machine age.” However, I wish to propose a closely-related but alternative paradigm, that is, using the issues raised by new technologies as a vehicle for improving existing laws and reshaping social norms that once made existing laws inadequate or flawed. I will elaborate on my point through the author’s own example of elderly care.

Despite the fact that the author advocates a revisionist approach for thinking about health law and technology, her paradigm is still about laws serving the needs and solving concerns of the tech industry intersected with health care. I wonder whether it would be productive to view the issue from the opposite direction, that is, how could new technologies and the challenges they raise inform us about existing laws (revealing blind spots or providing opportunity to improve unjust/unfair/discriminatory laws). Viewed this way, we could not only strengthen connections between past laws and future technologies, but also be guided by a clearer sense of how future legal reforms and regulations could redress past neglect and meet new challenges. Continue reading

From Westworld to U.S. Prisons: Reframing the Debate on the Right to Health

Is there a “Right to Health?” For many countries in the world, including Latin American countries like Brazil, the answer is easily in the affirmative. Similarly, in the hit HBO show Westworld, the “hosts” (androids on the verge of discovering consciousness) also possess a right to health. How so? Despite atrocious cruelty the human “guests” constantly inflict upon them, the company that runs Westworld maintains a highly extensive, functional “universal health care system” that employs the latest medical technologies for androids to take care of any health problems of all damaged hosts. The efficiency of the system is breathtaking: a cowboy host with 20 bullet wounds and a broken arm could be fully restored overnight; when the sun rises the next morning, the host returns to the simulated reality as if nothing happened.

Of course, the right to health in Westworld is not a result of democratic deliberations or judicial activism that invokes the UDHR or related treaty obligations. Instead, it originates in the sheer necessity of running a seamless alternate reality that requires good maintenance of the hosts, whom the Board depend on to please the guests and maximize the company’s profits. In other words, the physical wellbeing of the hosts is intrinsically tied to the functioning of the entire Westworld machinery and its profitability. Fixing them quickly and adequately allows them to return to their respective, pre-determined roles in a complex narrative with countless plots and subplot twists meticulously designed by their human masters. Continue reading

The U.S. Drug Price Catastrophe and the Central Planner

By Aobo Dong

If you are fortunate enough to have an insurance plan with extensive coverage and low co-pays for prescription drugs, chances are you may not be overly concerned with the U.S. drug price catastrophe. For millions of Americans without such a plan, getting the much-needed prescribed medicine often involves frustrating multi-player exchanges between the pharmacy, the insurance company, and the doctor, due to complications such as drug pricing and pre-authorization.

The NYT recently launched an investigation into a simple question: “Why Are Drug Prices So High?” One surprising revelation from the study is that deep drug pricing problems may have been contributing to the ongoing opioid crisis, as insurers restrict patient access to less addictive alternatives. For instance, UnitedHealthcare stopped covering Butrans – a drug that had successfully helped Alisa Erkes to ease her excruciating abdominal pain for two years – just to lower its own expenses. Instead, Alisa’s doctor had to put her on long-acting morphine – a drug in a higher category for risk of abuse and dependence than Butrans. However, since it costs the insurance company only $29 a month, UnitedHealthcare covered it with no questions asked. Continue reading

Is Your Medical Bill “Eligible for Sharing?” New research on Christian Health Care Sharing Ministries (HCSMs)

By Aobo Dong

As the future of Affordable Care Act (ACA) hangs in the balance amid political deadlock in Washington, more Americans are signing up for Christian health care sharing ministries (HCSMs) – a growing alternative to traditional health insurance. Instead of paying a monthly premium to insurance companies, most members of HCSMs write monthly checks directly to other members in need. If you are on the receiving end, chances are you may be surprised with a wave of letters, flowers, and prayer cards wishing you well. However, not all medical bills are “eligible for sharing.” Most HCSMs exclude pre-existing conditions, as well as any conditions or medical expenses caused by “unbiblical lifestyle” involving using drugs/alcohol or having sex outside of heterosexual marriage. Also, if you are an adopted child with disabilities or an undocumented immigrant, some ministries explicitly exclude you from participating at all. Continue reading