The most incisive guide to issues facing the American family today . . . An invaluable resource for anyone wishing to stay on the cutting edge of research on family trends.
-W. Bradford Wilcox
Associate Professor of Sociology, University of Virginia
Anyone who has ever been to see the doctor and subsequently received one of those mysterious documents called an “EOB” or “Explanation of Benefits” will appreciate the central tenet of Steven Brill’s tome on the American health-care system: American medicine is overcomplicated and overpriced when compared to that of other nations, for an inferior product. Brill explores this theme by delving into the tortuously complicated tale of the Affordable Care Act, a story of political maneuvering, lobbying, unfortunate compromising, inept leadership, and head-spinning amounts of money.
Brill—a lawyer, journalist and entrepreneur (founder of Court TV and the monthly The American Lawyer, among others)—sandwiches his 450 pages of thorough investigative reporting between an account of his own time spent “looking up from the gurney.” Brill’s experience with emergency open-heart surgery to remove an aortic aneurism makes him highly sensitive to the fear that drives medical decision-making. Who, after all, will dispute charges when awaiting life-saving surgery? And who is willing to settle for a cardiac surgeon who ranks in the 85th percentile, even if he or she is in a less expensive network, when one in the 95th percentile is just down the street? When it comes to health care, Americans aren’t willing to cut corners.
Brill begins at the beginning—FDR’s National War Labor Board’s decision in 1943 that health insurance was not subject to wage controls. An employer seeking to lure an employee could offer as much in insurance benefits as necessary. As Brill points out, “The decision released much of the political pressure for reform by allowing a large swathe of the population to start getting protected from healthcare bills, while motivating the unions to oppose government intervention.” This decision was exacerbated in 1954 when the IRS ruled that insurance benefits were not wages and thus could not be taxed as such, so creating “America’s most gaping tax loophole.” Consequently, labor unions began pushing for insurance coverage in their negotiations with employers, increasing unions’ power by giving them one more thing they could offer to members. Union support for this regime imperiled any desire or attempt by government either to provide insurance (the “single-payer system”) or to take over health care completely, which were the models eventually followed in most developed nations.
Few have even attempted to address the stranglehold that corporate interests have had on health care since then (America is one of the only countries in the world with no price controls on health-related industries). Even Barack Obama was not at first prepared in his campaign to deal with the issue that had clearly become a massive problem. At the time of the first Obama campaign, America was spending a greater percent of its GDP on health care than any other developed nation, and yet we were nowhere near the top in results. Furthermore, the out-of-control costs were putting an ever-greater pressure on middle-class American families and employers, who were spending more and more on health care to the detriment of, for example, raises. All this in the middle of the greatest economic crisis we had seen in years.
Obama quickly got into the health care game, however, declaring that he wanted to be the President who fixed the problem. So was launched a years-long project, beginning with Max Baucus’s Senate Finance Committee and spiraling to include literally hundreds if not thousands of committees, offices, centers, politicians, staffers, aides, lobbyists, industry “experts,” tech people, web people, PR people, polling people, etc.
Two things stand out in the narrative of the legislation’s drafting. First, the sheer amount of bureaucracy involved highlights why Washington is the place that it is. Major and minor characters alike rotate in and out of Brill’s book in the revolving doors of the political process, and the reader would do well to take notes or keep a chart handy. The bureaucracy explains what perhaps lingers in most Americans’ minds more than any other feature of the ACA: the utter failure, for months, of HealthCare.gov. As Brill discovered in researching the debacle, there was no single person in charge of the website’s construction. So although there had been murmurings for months about concerns over the website, followed by weeks of frantic emails before its launch on October 1 of 2012, those concerns never seem to have reached the highest offices. Brill rightly calls out the amazing lack of governance on the part of our leaders, the President especially.
A second part of the story that stands out is the role of special interests. The pharmaceutical, hospital, and medical device industries wielded especially heavy influence because of their huge financial contributions to various congressional campaigns. As a result, one glaring omission in the 1,000-page bill is any attempt to control the outrageous charges these industries levy. These include, for example, $40,000 for the bed on which Steven Brill underwent surgery, or $1,000 per pill for a cancer drug requiring 85 doses. The markups can range anywhere from 100% to 400% of the cost of producing the drug or device in question.
Amidst the necessary, though sometimes dry, coverage of political maneuvering and debating, Brill weaves in other stories: the hip start-up insurance company in New York that wanted to change the way the industry functions, the efficient offices in Kentucky who launched their state’s exchange with barely a hitch and managed to insure more than half of Kentucky’s previously uninsured, the family that had to set up its own “death panel” to determine how much they could afford for the father’s extra month or two of life, the Google executive who flew in and worked nonstop to salvage HealthCare.gov, the bus driver who fell in her backyard and accrued years of medical bills for a basic procedure in the ER because her relatively inexpensive insurance didn’t really insure against much. In stories like these, Brill gives the reader the “big picture” of health-care reform, both good and bad.
The narrative is at times complicated, but it must be so to keep pace with a complicated subject. Nonetheless, the book is well written and successful at Brill’s goal of uncovering exactly how we got to where we are today. Many reviewers have criticized Brill’s proposed solution, that hospitals continue to consolidate into larger networks and become their own insurance companies, as overly simplistic. Brill gives several examples of networks where this has already happened. Admittedly, it may be too easy of a fix, but it seems to be an elegant solution. Hospitals would have incentive to reduce costs instead of seeking extra excuses to bill insurance companies, and patients would have less paperwork and access to a broader network of medical professionals. Part of Brill’s solution is that the CEOs of these networks are themselves doctors with a minimum required number of years in practice. Doctors, Brill points out, are the group that has benefited the least from rising medical costs and suffered from increasing paperwork, monitoring, and other bureaucratic requirements. Brill rightly predicts that if change does not come, the result will be, in the not-too-distant future, that medicine, like Washington, will fail to attract America’s best and brightest.
Advocates for the family will find specific numbers on what our bloated health-care system means for real families and real people, including how much on average families spend in various states on health care as a percentage of income. What Brill—or anyone else—does not spend any time on is the way in which the breakdown of the family unit continues to place higher burdens on the public sector, including when it comes to health care. Indeed, even the more controversial family-policy-related topics of abortion or contraception receive only passing reference in the book, as when a priest tells Obama at an event that he is going to have a tough time winning over the papacy on anything that pays for birth control. The book provides good context of the background against which the average American family must operate, but nothing more direct than that.
Nonetheless, America’s Bitter Pill is a must-read for anyone seeking a better understanding of the complicated mess we have got ourselves into, and a good start at beginning to dig ourselves out.
Nicole M. King is Managing Editor of The Family in America.