Nina's Reading Blog

Comments on books I am reading/listening to

America’s Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System

Posted by nliakos on October 7, 2017

by Steven Brill (Random House 2015)

Did you think I had given up books because I had not posted in a while? Actually, I was slogging through this 455-page look at the Affordable Care Act, aka ObamaCare–how it came into being, the fight to pass the bill, the disastrous launch, and all the pros and cons. It wasn’t an easy read by any means, but I came away with a better understanding of some basic truths.

First, America got off on the wrong foot with healthcare  in the 1940s, when the National War Labor Board’s ruling that benefits (including health insurance) were not subject to wage controls encouraged employers to offer workers health insurance, letting the government off the hook for either insuring or providing healthcare to its citizens. The fact that health benefits were not taxed exacerbated the effect of this ruling, which “would forever change the course of healthcare in the United States.”

Second, the ACA became law only because people made a lot of compromises that included giving up some of the most crucial aspects of the original plan, like including a public option. Some of these sacrificed items constituted broken promises to people, companies and industries that gave their support to reform.

Third, random events like Democratic candidate Martha Coakley’s vacation, which ostensibly cost her the election (for Ted Kennedy’s Senate seat), jeopardized the passage of the bill and necessitated still more compromises to appease reluctant Members of Congress and induce them to vote for it. Much of what transpired was due to pure chance.

Fourth, the ACA was designed to expand coverage to the uninsured, not to improve coverage for the majority who already had it. The framers of the ACA made a conscious decision not to tackle the obscene cost of healthcare in the United States compared with other developed countries. Their bill purported only to solve the problem of the millions of Americans who had no health insurance; it did not address the related problem of soaring costs. In this (increasing coverage) it has been fairly successful, but because costs continue to skyrocket, premiums are bound to reflect that. Provisions within the ACA ensured that billions of dollars in new business would accrue to the hospital industry, the pharmaceutical industry, and the medical devices industry. Meanwhile, doctors and insurance companies (yes! because they, like the patients, have to pay the bills) were squeezed.

Fifth, the disastrous launch of the ACA, following years of delay writing the regulations needed to implement the law, could have been averted if the administration had managed the website build better, by making one person responsible for its success, by hiring more competent professionals to build it, and by thoroughly testing it prior to the actual launch (duh)–as the state of Kentucky did with its kynect exchange, which worked as expected because the extensive testing had uncovered the glitches before the launch, leaving time to fix them. As it was, when a group of Silicon Valley stars was brought in to rescue the federal exchange, they had to correct almost every detail of the website. It was embarrassing to read about how incompetent everyone else was.

In the final chapter, Brill proposes a way to fix the mess we are in by encouraging giant hospital chains to become insurers (or giant insurers to buy hospital chains). He points out that what at first glance seems like putting the fox in charge of the henhouse would actually work better because doctors and hospitals would be motivated to keep patients healthy, and not to over-treat them or order needless expensive tests. In fact, this was exactly why I loved Kaiser Permanente so much when I was a member. I trusted them to do the right thing because it was in their interest to do the right thing. This was especially true when I was pregnant, at a time when C-sections were becoming almost routine. I didn’t want a C-section, and I felt confident that my Kaiser doctor wouldn’t advise me to have one unless there was really no good alternative. Kaiser didn’t have its own hospital in the Washington, D.C. region (as it does in northern California, and as  does the University of Pittsburgh Medical Center [UPMC], which insures its own patients–this was the example Brill provides of how his suggestion might play out), but as everyone probably knows, Kaiser doctors and nurse practitioners provide the vast majority of care that its members receive outside of a true hospital setting, in Kaiser centers around the region.

I think Brill’s view of the ACA is pretty balanced. He describes the good, the bad, and the ugly (and there is a lot of bad and ugly) objectively and fairly. The reader who makes it through to the end will come away with a much better understanding of how we got into this mess in the first place and why the ACA has met with such resistance. It’s a pretty depressing read, but it’s an important topic that we should all understand better.

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