Medical Necessity?

Medical Necessity: Health Care Access and the Politics of Decision Making, by Daniel Skinner (Minneapolis: University of Minnesota Press, 2019).

Reviewed by Elizabeth Durham, Princeton University

Medical Necessity is a thoughtful, crisply-written analysis of the political theater of US healthcare since the expansion of access to formal health insurance in the early twentieth century. Weaving across popular, clinical, and policy texts, Daniel Skinner traces how the idea of medical necessity has changed from a given provider’s assessment of the most appropriate treatment for a patient to become a dizzying bureaucracy in which multiple stakeholders assess the therapeutic, social, and economic justification for this treatment. Illustrating how this bureaucratic expansion has often failed the very people it is meant to serve—people seeking medical care—Skinner argues that the convoluted politics of US healthcare cannot be addressed by a better definition or stronger consensus as to what constitutes medical need. Rather, he suggests, “the problem is not the politicization of medical care, but the depoliticizing tendency to treat medical necessity decision making as a matter of facts to be found rather than a set of values to be defended.” This leads him to propose, as a solution, “a more inclusive and openly normative political process… a contest over the terms of discourse, where the result of such contests is, above all, the right to define” (p. 20).

Skinner marshals his call for a more explicit and engaged healthcare politics across four theoretically-inflected case studies that focus in turn on medical coding, medical marijuana, mental health, and the procedures of Caesarian delivery and abortion. While he has a deft hand for mobilizing theory, evident for example in his reading of coding through the lens of the Derridean archive, his call to enliven political debate on medical necessity beyond the binaries of medical/non-medical and necessary/non-necessary is most compelling when he pauses to consider its lived politics, such as a diabetic man mounting a medical defense after striking people with his car, or a hospital struggling to classify (and thus to treat and bill) a woman arriving at its doors in the throes of a breech birth (was she a mother? A pregnant woman? A woman in labor?). Of the four case studies Skinner presents, the chapter on mental health is perhaps the strongest. While his discussion of mental healthcare’s potential to (over)medicalize certain conditions of existence is not novel (nor does he claim it as such), this focus does help to emphasize how medical care itself cannot be reduced to a binary of first resort/last resort, and how overarching dynamics of necessity and care in the US clinic are so contingent on what insurance will cover. Skinner follows his case studies with a relatively brief examination of what he frames as three popular attempts—contracts, rights, and technology—to “escape medical necessity’s political dimensions” (p. 153) and ends by reiterating that the politics of US healthcare merit collective rethinking.

As a future-oriented embrace of an assertive, heterogenous brand of politics, Medical Necessity reads well; as a historical critique of depoliticization and its (im)possibilities, less so. Put another way, Skinner’s efforts to give center stage to the politics of medical necessity would have been strengthened had he more fully set the scene from which such politics emerge. At times, the differences between depoliticization and a more conventional form of politicization are unclear, as are the stakes of such differences for Skinner’s analysis, perhaps because he is writing against the imperative to easily or better define objects of political contestation in the first place. Nevertheless, the result is that Medical Necessity opens and ends with the intriguing provocation of the so-called depoliticizing tendency, but never wholly develops this in the intervening pages, nor clearly contrasts this tendency to what Skinner proposes by way of medical politics. Given that his interest in problematizing the boundaries between clinical facts and values is shared with many scholars in the medical humanities and social sciences, the absence of a more robust outline for a novel medical politics seems to indicate a missed opportunity to advance his claims in a more multifaceted way.

This missed opportunity—or what I, as a medical anthropologist, see as a missed opportunity—raises important questions about Skinner’s intended audience and also who can revitalize healthcare politics in the way that he proposes. Throughout the book, he frequently uses the first-person plural without specifying the readers he interpellates, which sometimes leads him to assume a preexisting political consensus of sorts between author and audience. To take a representative example, in his discussion of Foucault and power he writes that “as we read, we must also calibrate our expectations [of power such that] we should expect change to occur through the slow boring of holes and exploiting of cracks in knowledge” (p. 12). But should we? The answer necessarily depends on who “we” are: as readers, as medical stakeholders, as a political collective. My concern here is less with the particular stance itself and more with how the apparent incorporation of readers into this stance undermines Medical Necessity’s larger call for a more explicit, clamorous, and arguable politics of medical care. Indeed, this is a point Skinner eventually makes in a different vein in his conclusion, writing that “we are deciding along the way what we wish to include under the malleable and normative umbrella of necessity. The key political question, of course, is who this ‘we’ is… medical necessity is, from this perspective, a contested social text rather than a purely technical or clinical matter” (pp. 180-181; italics original). Medical Necessity is, from my perspective, an insightful text that Skinner could have made even more engaging by extending its contestability and sociality to readers themselves.