Anatomy of a Health Care Mess
Never sign up for a tour of the sausage factory, not if you want to keep eating sausage. In the case of health care, unfortunately, no one gets to abstain. Journalists and legislators, doctors and nurses, reformers and reformed alike, all eventually land on the conveyor belt that feeds those grinding gears.
Is it better to go through the machinery with some understanding of how it works (or doesn’t)? Individual preferences will vary. For those who believe forewarned is forearmed, the veteran journalist Steven Brill has put together a comprehensive and suitably furious guide to the political landscape of American health care circa 2014 — a tour de force inspection of both sausage and factory.
Mr. Brill began his muckraking early in the rollout of the Affordable Care Act, with a comprehensive indictment of American health care costs that occupied an entire issue of Time magazine in early 2013. He continued to comment in the pages of Time on the disastrous debut of the act’s health insurance marketplaces that fall and the widespread repair work that still continues.
All this reporting reappears in the book, sometimes verbatim, reframed by several new sections. At the beginning comes a long back story detailing the years of politicking that created the new legislation. At the end, Mr. Brill offers a series of personal insights provoked in large part by his recent, unexpected detour from reporter to patient, and suggestions for how it might all be fixed.
Full disclosure here: It became clear early in the creation of the Affordable Care Act that my definition of the word “reform” differed substantially from that of our political leaders. After that, I stopped paying a lot of attention to the political Kabuki — a disgraceful if all too common reaction among us beleaguered sausage-makers.
Hence, I cannot assess the accuracy of Mr. Brill’s account of the negotiations that created Obamacare, but I found it persuasive, shocking and very sad. It is not an easy story to follow, a little like plowing through a long description of every can of paint flung onto a Jackson Pollock canvas. Still, the difficulty and occasional tedium of the narrative themselves inform the subject.
As Mr. Brill tells it, the legislation was from the very beginning all about profit, with all the relevant industries, from insurers to drug makers to hospitals, methodically seduced aboard with promises of big returns. The politicos spoke of broader insurance coverage, but what they actually meant was more health care dollars to spread around. The nonprofit “public option” never had a chance, and vanished.
The final legislation was a truly remarkable triumph of fiscal diplomacy. No wonder the act’s political parents were so exhausted by its creation that implementation took second place. The initial result: a deeply flawed federal enrollment website and phone banks of confused people diligently dispensing misinformation. Mr. Brill details these mishaps in full, along with the months of mopping up required.
He revisits the sick people he came to know across the country to examine the legislation’s effects. In Kentucky, a state with a great deal of chronic illness and a seriously underinsured population, the new insurance options were deployed smoothly, and have clearly improved life for many residents. Elsewhere, confusion reigns on.
For unintentional comic relief, Mr. Brill also details the 2013 creation of a cool New York insurer, Oscar, named after the great-grandfather of one of its founders. Devised by hipsters for their peers, Oscar aced all the start-up tasks that bedeviled the feds, with smoothly functioning technology and appealing branding. Its young proprietors were jazzed when the premiums started pouring in, then more than a little taken aback when they actually had to start paying some gigantic medical bills.
That’s the health business for you — totally awesome till someone goes and gets sick. Mr. Brill’s own perspective took a similar lurch when in the spring of 2014 he underwent repair of an aortic aneurysm, an expensive and complicated procedure. As a patient, he writes, “I was anything but the well-informed, tough consumer with lots of options that a robust free market counts on. I was a puddle.”
That is the fatal flaw in market-based medical care: Patients and their relatives simply cannot be savvy shoppers. Their attentions are elsewhere.
Mr. Brill’s solution is born in large part from his gratitude that his surgery at one of New York’s premier teaching hospitals went very well. He suggests: Why not allow these giant academic medical centers, most of them smoothly run by physician-executives, to insure themselves, sweeping up smaller nearby facilities into networks of care? The plan would cut out some middlemen, reduce some bureaucratic expense, and the medical background of those in charge would ensure a patient-centered ethos. These would be “regulated oligopolies,” in Mr. Brill’s phrase, with heart and soul.
His idea has some precedent in nonacademic insurer-provider organizations like California’s Kaiser Permanente. Some large teaching centers are already headed in this direction. Whether a more humane, less pricey marketplace will result remains to be seen, one obvious caveat being that, for all of Mr. Brill’s illusions, physician-executives are hardly immune to corruption, hubris and greed.
As for that other definition of the word “reform,” the one that would transform American health care into a tightly controlled nonprofit commodity funded by a single payer, Mr. Brill emphatically sounds its knell, providing 500 pages of convincing evidence that it is never going to happen.