Brill's Bitter Pill: Accurate Diagnosis, Inadequate Treatment

On October 26, 2013, Marylanders from across the state marched for the human right to healthcare. (Photo: United Workers / Flickr Creative Commons)

Brill's Bitter Pill: Accurate Diagnosis, Inadequate Treatment

A review of Stephen Brill’s damning indictment of our market-based health care system

Steven Brill, author of the well-known 2013 Special Report, "Why Medical Bills Are Killing Us," in Time magazine has just released his new book, America's Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System. Based upon in-depth reporting of interviews with more than 240 people involved in various ways across our health care industry, he gives us an inside look at how the Affordable Care Act was written, passed, implemented and changed over the last five years.

The result is an honest, damning indictment of our market-based system, with all its profiteering and run away costs. He concludes that the ACA, despite the hype of some of its architects and supporters, will fail to contain costs:

There's nothing in the legislation that brings down the cost of healthcare... The bad news is that the taxpayers are paying for it and they're paying the same exorbitant prices that make the system so unworkable... The drug companies are making more money, the hospitals are making more money, the medical device makers are making more money, and everybody is happy except the taxpayer.

Brill's description of the flaws of our profit-driven system are further amplified by his own personal experience with open-heart surgery for an aortic aneurism. After an eight-day hospitalization, his medical bills came to $197,000. Some time later, even Stephen Hemsley, president and CEO of UnitedHealth Group, his health insurance company, could not explain the medical bills and explanation of benefits.

Brill's meticulous and well documented reporting of our system problems falls apart when it comes to fixing these problems. There is somehow a striking disconnect between his objectivity in the first part of the book and the proposals he puts forward toward the end. Yes, he is very well informed, is a graduate of Yale Law School, and has had personal experience as a patient, but that does not make him a health policy expert, as many of his readers now expect. He says in his book, as he was recovering from surgery, he began to frame his "unusual idea" of how to go beyond the Affordable Care Act, which he believes is unsustainable because of costs, and to fix U.S. health care:

At first, pieces of it came in the form of seemingly random thoughts that popped up during the extra time I had to read and watch television. But they soon began to come together.

These are the components of his seven-part proposal for regulating our health care system:

1. Require that any market have at least two big, fully integrated provider-insurance companies (e.g. Kaiser); large markets could have more.

2. Cap the operating profits of what would be those now-allowed dominant market players, or oligopolies, at perhaps 8 percent, compared to the current average of about 12 percent.

3. Cap the salaries and bonuses of hospital employees (including the CEOs) who do not practice medicine full-time at 60 times the amount paid to the lowest paid full-time physician, typically a first-year resident.

4. Establish ombudsman's offices in each oligopoly to streamline the appeals process for patients who believe they have received inadequate care, and for physicians who feel they have been pressured to limit care.

5. Any government-sanctioned, oligopoly-designated integrated system should have a physician with practice experience as its top executive.

6. Require any sanctioned, oligopoly provider to insure a certain percentage of Medicaid patients at a stipulated discount.

7. Require these regulated oligopolies to charge any uninsured patients no more than they charge any competing insurance companies whose insurance they accept, or a price based on their regulated profit margin if they don't accept other insurance.

While there may be merit in some of these proposals, Brill's brief prediction of how they would reform our system is unpersuasive and comes across as only wishful thinking, uninformed by evidence. His "plan" would just add another layer to our flawed system, based especially on getting some of its providers bigger yet somehow more accountable. There are many problems with his proposals. For example, what would they do for people in many parts of the country, including rural areas, and why is "bigger is better" a solution to our already consolidating system?

For some reason, Brill ignores mountains of experience and evidence that there are more logical and proven ways to rein in our out-of-control system. For example, he recognizes in his first chapter that the U.S. spends more ($3 trillion in 2014) than the next 10 biggest spenders on health care combined: Japan, Germany, France, China, the United Kingdom, Italy, Canada, Brazil, Spain, and Australia. But then he shows no interest in finding out how these countries can spend so much less on health care than we do while also providing better access and usually better outcomes of care. Recent years have seen a growing information base of how they do it, including T. R. Reid's excellent 2009 book The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, in which he notes, after study of the experience in France, Germany, Japan, the UK, and Canada, that:

The American system does well when it comes to providing medical care, but has a rotten system for financing that care... All the other rich countries have found financing models that cover everybody and they still spend much less than we do. We've ignored those foreign models, partly because of "American exceptionalism"--the notion that the United States has nothing to learn from the rest of the world.

Brill also ignores long-standing efforts in this country to enact universal coverage through a single-payer system, improved Medicare for all, as embodied in John Conyers' bill in the House, H. R. 676. He cavalierly dismisses this alternative in these words: [My proposed regulations are] certainly more realistic than pining away for a public single-payer system that is never going to happen.

Good as Brill's book is (and I strongly recommend it) in the diagnosis of our health care problems--the toxicity of our profiteer-dominated system-- his proposed treatment is speculative and uninformed by evidence. At best, if implemented, his proposals would just tinker around the edges of our problems.

We still need to ask more fundamental questions before we can see how to go forward with real health care reform, such as: who is the health care system for? (our current answer is the profiteering, mostly corporate stakeholders, not patients and their families); should health care be just another commodity for sale on an open market?; and is health care a personal right (as it is in most advanced countries), or a privilege based on ability to pay?

Brill and I agree on one reality--the ACA is unsustainable because of its inefficiency, increasing bureaucracy, and unaffordable costs to taxpayers as well as patients and families. As all this becomes more clear, he asks, as we all should, what should follow the ACA? My just released book, How Obamacare Is Unsustainable: Why We Need a Single Payer Solution for All Americans, describes and supports the single-payer solution, improved Medicare for all, as a public financing system costing less than the ACA, coupled with a more accountable private delivery system. I hope that readers will read both books and compare their merits based on evidence and experience.

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