Do Not Resuscitate: Why the Health Insurance Industry is Dying, and How We Must Replace It (review)

The book Do Not Resuscitate: Why the Health Insurance Industry is Dying, and How We Must Replace It, by John Geyman, MD, is another in the author's series of critical books on health care system. The main point of the book is to identify the routine problems that plague the current health care system. Centrally, Geyman argues that he way the health insurance companies control the market does not favor the people that need insurance coverage the most. He walks us through the problems step by step to show what the problems are, and why and how so-called health care reform has not come about after being debated for over three decades. He also argues that significant fundamental reform has become mandatory to get the health insurance industry on the right track.

The introduction reviews the historical transformation of the health insurance industry that took place in the twentieth century. At their advent, premiums, prepayment, and employer-sponsored insurance seemed to be sound developments. Dr. Geyman then traces the history that led them to have widespread negative effects on the health care system. In doing so he compares government run public programs with the reimbursement system run by the private health insurance policies. Commercialization and privatization of the public programs revolutionized the health insurance industry and transformed it into a profitable and lucrative business. However, avoiding risk for profit rather than spreading the risk became central to the industry's profitability, a practice that has not served enrollees well. The level and amount of care provided has declined as premiums have increased. Geyman also discusses the recent uncontrolled hikes of cost of health care, decreasing insurance benefits sponsored by employers, uncertain access to care, and ever-increasing politics and bureaucracy.

Geyman argues that the for-profit industry, investor ownership, and managed care coupled with limited regulatory oversight have deprived the enrollees of the care they deserve. The phrase, consumer-directed health care (CDHC), with its suggestion of beneficial focus on the consumer, blankets an actual decrease in covered care: "The industry has welcomed this new trend by rolling out a variety of stripped-down limited benefit plans. Insurers are carving out profitable new niches in the market, targeted at healthier enrollees. Examples include high-deductible health insurance (HDHI) plans with deductibles up to $10,000, and short-term policies which exclude any pre-existing condition and offer no continuing protection, and policies with capped benefits" (p. 16).

Continuing his indictment of U.S. health insurance economics, Geyman discusses the fact that market economies often dictate the mergers of insurance companies, with resulting risks that the industry will be controlled by a monopoly. Furthermore, the expectations of the shareholders and the sensitivity of investors and financial analysts to the profits and medical loss ratios force the insurance companies to enact deceptive marketing strategies with inadequate or improper disclosure. Actual coverage becomes blurred in fine print, and individualized plans that are supposedly increasing one's scope for choices in fact further restricting access to care. Often, after mergers, insurance companies end up with more enrollees but giving less coverage, and charging higher deductibles. Such practice makes health insurance less affordable for many. Other problems with the industry that Geyman discusses include hidden conflicts of interest, improper dealings with physicians, profiteering through insider stock trades, and outright fraud (pp. 53–4).

Ineffective state and federal regulations and growing economic insecurity and hardship (even for the insured) also affect the system. When fragmented attempts are made to regulate the insurance industry, Geyman argues, without reducing the cost of care just to ensure more affordable premiums "people with greater health care needs are excluded from coverage and more financial barriers are placed before individuals and families seeking care" (p. 114).

Incremental reform strategies (such as tax credits, chronic disease management, and pay-for-performance...