[ Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System ]
Book Review by Teachout Zephyr
Posted January 18, 2015.
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Steven Brill is not easily intimidated. The founder of Court TV and Brill’s Content, among many other ventures, Brill likes to dive deeply and quickly into complicated national policy issues — public education, health care — that he, by his own admission, knows relatively little about when he begins. This is his great appeal and can be a great frustration. It makes him vulnerable to the charisma of his sources, as was apparent in his 2011 book, “Class Warfare,” in which he seemed dazzled by individuals involved in privatizing public education, while he largely ignored the existing research.
But in Brill’s new book, “America’s Bitter Pill,” his fresh, outsider curiosity makes him a superb guide to the maze of issues in American health care and health care reform. He breaks down insider language, asks fundamental and surprising questions, and leaves the reader — at least this one — full of more questions yet with a much clearer map of the lines of debate. You may not be persuaded by his conclusions, but you’ll emerge with a broader understanding of the characters and questions shaping our health care system.
“America’s Bitter Pill” is an energetic, picaresque, narrative explanation of much of what has happened in the last seven years of health policy. It is full of insights, contradictions, apologias, flashes of anger, tidbits of history, extended stories of awe, compassion, some glibness and moments of brilliance. Above all, it includes fascinating reporting on how crucial decisions were made involving the drafting and implementation of the Affordable Care Act.
What is this book about? Well, everything. It reminded me of a Bruegel painting, so full of minor characters that I made a chart to keep track. It is about the conflicts between President Obama’s economic policy team and his health care policy team. It is about the initial white paper from Senator Max Baucus that didn’t even include the “public option” of a government-run insurance plan.It is about the “chargemaster” system of American health care, whereby hospital administrators easily drive up costs because of their relative bargaining power over insurers and patients. It is about a woman openly talking about how she and her husband — insured, but underinsured — had to create their own family “death panel” to weigh the cost of medical treatments that might keep him alive for another month. It is about Brill’s own open-heart surgery and how it affects his understanding of costs, and repeated visits to a group of well-funded entrepreneurs trying to create a “cool” new insurance company. Following his 2013 Time magazine cover story that inspired the book, Brill introduces us to Americans with no coverage, as well as those with inadequate coverage, like the 61-year-old bus driver whose slip in her yard and busted nose led to six hours in the hospital, six stitches and six years of medical bills.
It is also about a Washington fight for power among five key forces: insurers, hospitals, patients, pharmaceutical companies and medical equipment suppliers, and the general public, including those who are supposed to represent them. In Brill’s account of the Affordable Care Act, the insurers got a fair shake, uninsured and underinsured patients truly benefited, hospitals and pharmaceutical companies and medical equipment companies were left free to charge exorbitant prices, while the general public was left with no real strategy for cost containment.
In other words, Brill is impressed with the expanded coverage provided by Obamacare, and depressed about the cost of care.
Despite the cynical title, this is a surprisingly triumphant book. A significant number of pages are dedicated to something extremely rare: three gripping stories of great government success.
First, there is the improbable story of passing any health care reform in the first place. Max Baucus, the Montana Democrat and chairman of the Senate Finance Committee, spends untold hours trying to court the Republican senators Charles Grassley and Olympia Snowe; Baucus’s initial bipartisan dream appears close enough to touch, and then it falls away. Edward Kennedy, an engine behind Obama’s focus on health care and a critical 60th vote, dies. Scott Brown, a Republican, wins Kennedy’s seat. Brown’s victory doesn’t end health care reform but severely circumscribes it, because House Democrats lose their negotiating power: They are forced to accept the Senate bill or face the prospect of no bill at all.
Then there is the inspiring story of Steve Beshear, Democratic governor of Kentucky, and Carrie Banahan, the civil servant who manages a near-flawless rollout of Kynect, Kentucky’s implementation of the Affordable Care Act that included a properly functioning website. (This led Senator Mitch McConnell of Kentucky, the Republican leader, to campaign comically both for and against the same thing, saying he was opposed to Obamacare but in favor of Kynect — which was, of course, Obamacare.)
Finally, there is the long story of the botched website debut. As Brill tells it, the website was almost overdetermined to fail. There was no one in charge — or too many people in charge — and the people who built it had never been involved in a project of this magnitude. At the same time, the White House wanted to stall on the regulations necessary to set up the insurance exchanges because, as Brill notes, “they did not want to make any waves before the election.” But after the embarrassing beginning, the White House quickly addressed problems of structure and personnel, and 7.1 million people signed up within six months, 100,000 more than the initial goal.
Brill finds Obama’s early failure to be more involved in the “nitty-gritty details” a “great unforced disappointment,” but he looks with enormous admiration at what the president was able to accomplish, calling it “a milestone toward erasing a national disgrace.”
“America’s Bitter Pill” presents a personality-driven view of historical change, including the temperaments and accidental moments that affect history, like the ill-timed December vacation of Martha Coakley, who was running against Scott Brown for Kennedy’s Senate seat. But two of the book’s more powerful insights have to do with matters of industrial or bureaucratic structure. The first involves the health delivery system. Many people tend to look with alarm at consolidation in the insurance industry, and they focus on insurance company lobbying power as the essential cause of rising prices. One of Brill’s critical insights is how consolidation in the hospital industry has actually decreased insurer power relative to provider power: Much of the rising cost of health care comes from overcharging by hospitals, not insurers.
Take the example of NewYork-Presbyterian Hospital. Because of its size and array of services, no insurance company in the New York City area can sell policies if it doesn’t include NewYork-Presbyterian — therefore none of them are able to bargain aggressively for lower prices. This is not unique to NewYork-Presbyterian, nor is it even the most extreme example: Consolidation is the norm in many markets around the country. The hospital sets the price, and the insurer jumps to it.
The second insight has to do with the structure of management within the government. Brill argues that the initial website rollout failed in significant part because the “Office” in charge was demoted to a “Center,” in order to protect it from Republican funding cuts. In a wonderful passage, he recalls taking the train to Washington and reviewing his notes, noticing that when he asked different people who was in charge of establishing the federal exchange, he got seven different answers.
The subtitle — money, politics, back-room deals — refers primarily to the role the pharmaceutical industry plays in gutting any chance for cost effectiveness or price controls. According to the Center for Responsive Politics, the trade group Pharmaceutical Research and Manufacturers of America (PhRMA) has spent a quarter of a billion dollars since 1998 on lobbying. Brill shows what that means in day-to-day negotiations. Billy Tauzin, a former congressman and, until 2010, the trade group’s president, is the voice of Big Pharma in the book.
Tauzin is everywhere in the negotiations. He does not so much haggle as dictate policy, identifying the precise amount the industry would be willing to give up and still support the bill. Tauzin successfully guts comparative effectiveness research under Obamacare — Big Pharma’s profits are threatened by studies comparing which drugs work effectively at lower costs. With projections showing that the pharmaceutical industry will make at least $200 billion more with expanded coverage, Tauzin and his group “kick in” what amounts to $80 billion in givebacks, in exchange for killing any chance of containing the costs of drugs. He agrees to spend $70 million in political action funds supporting reform, and when pressured to raise his industry’s contribution to $120 billion, he sits tight, confident that he can kill the bill. Describing Tauzin’s position, Brill is matter-of-fact: “He knew they could never get 60 votes in the Senate if the drug makers switched sides and began financing a different set of ads, and he said so.”
“Depending on one’s view,” Brill writes, “this secret deal between Obama political operatives, PhRMA, staffers from the Senate Finance Committee who had just brokered a multibillion-dollar deal with PhRMA, major unions and other liberal groups was proof that Washington was finally buckling down, coming together and getting the people’s business done; or it was Washington at its worst: liberal groups selling out to big business to accommodate all the groups’ special interests.”
Brill tells us what he thinks (the deals with Big Pharma were tragic but politically necessary); he becomes partisan when he wants to defend a subject he believes has been unfairly attacked; he fills a chapter with direct statements of conclusion. He brushes over some contentious issues, making a casual assumption that tort reform would keep medical costs down. (Texas has tort reform, but there is no evidence to show it has kept costs from escalating.) His glibness in these areas, along with a charming tendency to find some persuasive argument in almost everyone he interviews, led me to trust his reporting but to be more skeptical of his policy prescriptions.
Ultimately, Brill comes across as a fallible human trying to understand the politics and implications of health care on our behalf, and he has pulled off something extraordinary — a thriller about market structure, government organization and billing practices, by turns optimistic and pessimistic, by turns superficial and insightful, but always interesting, and deadly important.
You can view the 60 mns U-tube program: Stahl: Dissecting Obamacare 60 mns 2015
You can also get more information about fixing the broken health care system by going to: Fixing broken health care system
[ Facilitator Sorochan has added additional commentaries from other journalists below. ]
Roy Avik, "What '60 Minutes' Didn't Say: Hospitals Will Charge You More Under Obamacare," Forbes magazine, January 12, 2015. Roy: Brill shortcomings 2015
Stahl Leslie, "Dissecting Obamacare," CBS 60 minutes Transcript of "Obamacare" aired on Jan. 11, 2015. Stahl: Dissecting Obamacare 60 mns 2015
Sterbenz Christina, "The Daily Show' Nails Why Health Care Will Never Work As A Free Market," Business Insider, January 18, 2014. Sterbenz: Brill health care not free market 2015
Teachout Zephyr, AMERICA’S BITTER PILL by Steven Brill, Book Review, International New York Times, January 7, 2015; Book published by Random House, 2015, 512pp. [ Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System .] Teachout: America's Bitter Pill 2015