We've Got You Covered: Rebooting American Health Careby LiranEinav and AmyFinkelstein. Penguin, 2023, 304 pp., $29 (paperback).

The book We've Got You Covered proposes a tantalizingly simple solution to the vexing, often life-or-death shortcomings of healthcare coverage in the United States. Einav and Finkelstein argue that we should “tear down” our ramshackle edifice of public and private financing programs and replace it with an entirely new home: “universal coverage that is free and basic” (2023, p. 1; 2024, p. 956). Although no one would pay premiums or out of pocket for services, the authors hold out the possibility of financing this coverage without increased government spending on healthcare. Everyone would be allowed to buy supplemental private insurance for amenities like private hospital rooms, broader networks, extra services and coverage, and shorter waits. The authors estimate that about two thirds of Americans would buy this top-up coverage. The book's blueprint for achieving universal coverage has already been discussed in JPAM, in a “Point-Counterpoint” between the authors and Jacob Furman (2024). In that exchange, Furman expressed his preference for incremental reform instead of a teardown. He raised concerns about costs, especially when everything covered by the government plan would be free for everyone, and the danger of public backlash if the “basic” benefits proposed by Einav and Finkelstein were seen as too skimpy or eroded over time because of increasing costs. Nevertheless, Furman (2024) endorsed their policy approach, writing, “I would be perfectly happy if their proposal were adopted” (p. 962). We have written this book review to express more skepticism about the teardown and apparently simple, affordable plan for universal coverage proposed by Einav and Finkelstein. However, we also want to call attention to ways that the book contributes to discussions about whether and how to move towards universal coverage that were not emphasized in the Point-Counterpoint. We particularly appreciate the authors’ argument that Americans are strongly inclined to help people “who are desperately ill and unable to access essential medical care” (p. 48). The authors see this implicit social contract in the enactment of many coverage programs in the past, and it could sustain a move to universal coverage in the future. We conclude with suggestions for reworking the authors’ blueprint for fulfilling this social contract. This book is intended for a wide audience that we imagine will encompass legislative staff, health practitioners, and members of the public concerned about American health insurance. The book is especially suitable for health policy classrooms. It offers an extensive introduction to the current system of health coverage, and the authors’ efforts to “think outside the box” can stimulate lots of critical reflection, discussion, and debate. The book builds its arguments in a logical and understandable way, teeing up the failures of insurance in Part One, carefully articulating the goals of reform in Part Two, and then laying out the authors’ policy solution in Part Three. In Part One (“It's a Teardown”), Chapter 1 points to “the Achilles heel” of American health insurance as its complex terrain of eligibility rules across different sources of coverage. If someone loses their job, they lose their private coverage; if they get a job, they lose their public coverage. For someone with coverage, Chapter 2 describes the puzzles they face in identifying and navigating the providers, services, and expenses covered by their policy. As one engaging illustration, the authors invoke Walter White's momentous decision to make methamphetamine to pay for his out-of-network oncologist in the television show Breaking Bad. Chapter 3 describes how lawmakers, responding to public outcry about one particular hole in the system after another, have left ill-fitting coverage patches on coverage patches. Here one of the examples discussed by the authors is the federal waiver named after Katie Beckett, the child who inspired it. It protects long-term care for disabled children on Medicaid up to age 18 but offers nothing for those who survive to adulthood (pp. 39–40). In Part Two (“Form Follows Function”), the authors marshal evidence for Americans’ implicit social commitment to helping the desperately ill, argue that this function should dictate the form of tax-financed coverage, and explore implications for such a program's design. Chapter 4 describes how the uninsured can often access publicly funded care in charity clinics or emergency services in hospitals, despite their inability to pay. Chapter 5 explores how and why the public seems more committed to helping with “moral emergencies” like serious illness or natural disasters than ongoing deprivations like hunger or poverty. Harkening back to Alexander Hamilton's compulsory health insurance for seamen in the late 1700s, Chapter 6 argues for implementing an up-front, coherent public program that makes explicit both everyone's claim on mutual support in health crises and the shared obligation to pay for it. Chapter 7 argues that a public healthcare plan can meet the social commitment to provide all “essential” medical care without providing equal care, as long as it enables every person to participate in society to the full extent of their potential. Part 3 (“The Blue Print”) lays out the authors’ policy vision for universal free coverage (no premiums) and free care (no out-of-pocket expenses for covered services). Chapter 8 explains that the program can only be universal if the government automatically enrolls everyone, which is not feasible if premiums must be paid. Chapter 9 makes a strong case for free care, with no patient cost-sharing. The next two chapters deal with the problem of keeping free coverage and free care affordable within the social contract. Chapter 10 emphasizes that the care will be very basic—with multiple beds in hospital rooms, longer wait times for nonemergency care, gatekeeping for specialty care, and limited choices of providers in the basic network. Chapter 11 stipulates that all services needed by the desperately ill, as well as primary and preventive care, will be covered. Ways of prioritizing other covered services are then described. The budget discussion in Chapter 12 (subtitled “Relax, we can afford it”) suggests reassuringly that current public spending on healthcare, already half the national total, could cover such a basic plan without increasing taxes. After all, at 9% of GDP, government healthcare spending in the U.S. is comparable to government healthcare spending in countries with universal basic coverage like Germany, the UK, and Canada. However, the authors eschew price negotiations with providers and suppliers employed by those countries. They argue that, while lowering prices would save money, it would also reduce patient care as providers saw fewer patients and drug makers created fewer new drugs in response. The authors also downplay possibilities for cutting administrative expenses or unnecessary medical services as “cut-waste-quick” schemes. They argue that any cost cutting would come from an accumulation of small changes, the sum total of which would “scarcely make a dent” in annual spending (p. 157). Instead, they lean heavily on Congress to legislate and “insist” on a binding annual budget for the basic plan (p. 145). While the basic plan will cover major illnesses and preventive and primary care for everyone, Chapter 13 explains how everyone can (and many people will) purchase private supplemental insurance. More like Medicare Advantage than Medigap, supplemental insurance will both replace and augment the basic plan with enrollees paying only the incremental cost of the improved coverage. An obvious strength is the book's conversational tone and readability, with its many references to pop culture, individuals’ stories, and history. It is a book that can engage a wide audience in thinking and talking about what ought to be done about American health insurance. The introductory chapters paint a vivid picture of the complexity and fragmentation of coverage sources and access to providers, and the accompanying exposure to financial and health risk. Moreover, the authors insist on expanding the range of topics that serious policy and economics scholars can discuss, going beyond what can be done within current political constraints to what should be done. As already noted, the authors’ empirical examination of the extent and limitations of Americans’ apparent social commitment to healthcare for people with serious illnesses is thought-provoking and potentially very helpful in guiding policy discussions. Readers familiar with health economics will also appreciate the authors’ re-examination of some long-standing orthodoxies, on the economic necessity of cost-sharing and the negligible effect of coverage on physical health (heavily influenced by a randomized study in Oregon; Baicker et al., 2013). They conclude that cost-sharing substantial enough to noticeably reduce medical spending leaves too many people exposed to too much financial risk. Because the bulk of medical spending happens beyond the out-of-pocket maximum in many health insurance policies, where enrollees are no longer subject to cost-sharing, the most expensive care is wholly unaffected by cost-sharing requirements. As for the conclusion from the Oregon study that coverage does not matter for physical (as distinguished from mental) health, the authors call attention to the mortality-reducing effects of coverage that were evident in a more recent randomized study involving millions of tax filers (p. 17; Goldin et al., 2021). The book's big weakness is its questionable accounting. The book contends that we could implement a universal public plan, covering in-patient and outpatient services and everyone's primary and preventive care, without raising taxes. We doubt that the authors have identified enough savings, even with their vision for bare-bones coverage, to enact such a policy without rerouting a majority of healthcare spending that is currently privately financed through the new, tax-based system. For scale, consider that the top 5% of people with the costliest care in a given year consume half of the national total (Amin et al., 2024). That leaves no government funds to redistribute to the healthcare of the other 95% of Americans in a universal plan. To cover everyone for only the services explicitly listed in the book's budget chapter (roughly corresponding to hospital, physician, and clinical services in the National Health Expenditure Accounts) would require about 50% of the current national total (Centers for Medicare and Medicaid Innovation, 2024). Adding prescription coverage, certain to play some part in “essential” healthcare, would bring the plan's cost to over 60% of the NHE total. Adding in administrative expenses, which the authors argue are mostly useful and would not be meaningfully reduced (especially with extensive supplemental insurance), would push the plan above 70%. That still would not include other aspects of care, like durable medical equipment, mentioned by the authors in illustrating unacceptable holes in today's coverage (p. 22), nor other costly services like post-acute nursing facilities that seem essential. We think the offsetting savings proposed by the authors, mainly the bare-bones nature of the universal plan, are unlikely to meet the scale of the shortfall. For example, moving million-dollar heart transplant patients from ICUs to shared rooms for the rest of their hospitalizations will not do much to reduce the total cost of a heart transplant. Retrofitting hospitals nationally to create shared rooms would itself be costly. Furthermore, if the shortfall were covered with relatively expensive supplemental insurance, many Americans would probably want employment-based or individually-purchased supplements to maintain something close to their current level of private coverage and provider choice. Then, as individuals’ employment and/or incomes changed, churning in and out of supplemental insurance could lead to substantial disruption in healthcare, akin to what the U.S. has now: Walter White might not have much choice among oncologists without a pricey supplemental plan. Given the history of government shut-downs and Congressional dysfunction in passing appropriation bills, we do not share the authors’ faith that insisting on a binding budget for the universal public plan will restrain costs or yield well-reasoned decisions about spending priorities. For example, what if Congress limits spending growth in the universal plan to something close to the rate of general inflation, with no effective mechanisms for keeping medical price increases in line with inflation or finding efficiencies in care delivery? The medical services financed by the program would have to be cut every year. The authors compare this process to the budget discipline exercised by public schools that cut arts and athletics (p. 147), but—if we start with a very basic plan—where would that process take our healthcare system? Our reading of We've Got You Covered leaves us doubting that the social commitment identified by the authors could really be met without significantly increasing government spending and taxes. We see a universal public plan that is committed to providing all needed care—regardless of patient resources—as necessarily covering most of the very expensive, sophisticated care received by relatively few people in the population. Because that care accounts for such a large share of national healthcare spending, we do not see how the proposed plan could cover the essential healthcare needs of the rest of the population without more government funding. Although Einav and Finkelstein characterize their plan as “basic,” we think of it as a free, zero-deductible major-medical plan that includes a good deal of primary and preventive care. Seeing their plan in those terms suggests that the financing shortfall might be addressed by adding an income-related deductible, one that would be zero at low-income levels and would not apply to primary and preventive care. That change would still take care of everyone who cannot afford to pay for their own care, while requiring the rest of the population to bear more costs in a limited, relatively predictable fashion. Additionally, moving forward incrementally with that architecture in mind would not require all the risk, dislocation, and transitional costs of tearing down our current coverage “house” and erecting a new one. Private plans designed along these lines, with income-related limits on out-of-pocket expenses, are already subsidized in the health insurance exchanges created by the Affordable Care Act (American Academy of Actuaries, 2017). Medicaid already offers free essential care to those who cannot afford it (Rudowitz et al., 2024), and income limits on Medicaid could be further relaxed to the extent that states are willing. Current limits on the amount of care that Medicare covers could be eliminated and out-of-pocket expenses capped, which would reduce the need for beneficiaries to supplement Medicare. With most employers already providing plans with deductibles (Claxton et al., 2024), moving to a tax-financed plan with a similar structure would not be a huge departure from the health insurance currently held by large numbers of Americans with employment-based insurance. What will be needed are mechanisms to effectively control costs without degrading health outcomes. At this time, relying on Congress to thoughtfully weigh competing priorities and enforce fiscal discipline is unrealistic. We would particularly want the public plan to leverage its purchasing power to restrain payments to providers and suppliers, similarly to how traditional Medicare does now. Focusing on the price of care (where the U.S. is an outlier), rather than the quantity of care delivered (where the U.S. is already below median; Blumenthal et al., 2024) would control costs without directly impeding healthcare consumption. Furthermore, although the book's authors argue that it is not necessary to work on cost savings in the delivery of healthcare to change its financing, we would like to highlight the opportunities for leadership from federal and state agencies to organize cost-containment and quality improvements. This can help to structure and incentivize cost-containment efforts without undermining the social commitment to a decent quality of life and quality of opportunity for everyone that Einav and Finkelstein emphasize. As large and influential purchasers through Medicare and Medicaid, the federal government and the states are already deeply involved in encouraging delivery system innovations (Center for Medicare and Medicaid Innovation, 2024), often with changes in payment incentives going back as far as the introduction of Diagnosis Related Groups for hospital payment (Centers for Medicare and Medicaid Services, 2019). Like Einav and Finkelstein, we see universal public coverage as the best solution to the gaps, unhappy surprises, and sometimes life-threatening shortcomings of health insurance in the United State. Although we doubt that We've Got You Covered entirely lives up to the promise of its title, we are grateful to its authors for writing a book that is engaging and accessible enough to encourage non-academic audiences and students to keep talking and thinking about universal public coverage. By pointing out that most Americans, despite their political divisions, share a social commitment to assuring needed healthcare for everyone, Einav and Finkelstein have laid out a strong argument for universal coverage that could be used to build public support for its eventual enactment. Naomi Zewde is an Assistant Professor at the University of California, Los Angeles, 650 Charles E Young Dr S, Los Angeles, CA 90095 (email: [email protected]). Pamela Farley Short is a Professor Emerita in the Department of Health Policy and Administration at The Pennsylvania State University, 1758 Cambridge Drive, State College, PA 16803 (email: [email protected]).

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