Thursday, November 2, 2017

Book Review: An American Sickness

If there is one book you should read in the coming months, it is Elisabeth Rosenthal’s An American Sickness: How Healthcare Became Big Business and How You Can Take It Back. Rosenthal is a medical doctor who became a reporter for the New York Times and is now chief of Kaiser Health News, an independent journalism newsroom focusing on health and health policy. She has an MD from Harvard Medical School and has worked as an ER physician. She speaks from both experience and from an impressive array of research.
In his book The Revolt of the Elites and the Betrayal of Democracy, historian and social critic Christopher Lasch made this astute observation: “The market notoriously tends to universalize itself. It does not easily coexist with institutions that operate according to principles antithetical to itself: schools and universities, newspapers and magazines, charities, families. Sooner or later the market tends to absorb them all. It puts an almost irresistible pressure on every activity to justify itself in the only terms it recognizes: to become a business proposition, to pay its own way, to show black ink on the bottom line. It turns news into entertainment, scholarship into professional careerism, social work into the scientific management of poverty. Inexorably it remodels every institution in its own image.”
Lasch did not specifically mention health care, perhaps because he was writing before the market absorbed health care, but his observation certainly applies. In the past twenty years or so, health care has morphed from a service-oriented industry focused on patient care to a big business focused primarily on making a profit. I have argued in a recent Deseret News op-ed piece that health care is not a product or a collection of related products; it is a public good, similar in many ways to education, and when we treat it as a commodity, we unleash the sorts of problems that are on full display in the United States. The primary problem is the profit motive. And Rosenthal spells out in great detail why and how the voracious market has absorbed and remodeled health care.
The first thing to understand about health care is that it is not a typical industry. It does not behave according to traditional “laws” of economics. And this explains why Republicans cannot come up with a workable health-care plan. A common sentiment among conservatives is that getting government out of health care and turning market forces loose would solve our problems. But this solution is like pouring gasoline on a fire. The problem in many ways is the market.
The simplistic comparison between shopping for cars or clothing and for appendectomies or angioplasty certainly holds true, but the reasons why health care doesn’t react normally to market forces are myriad and complex. Rosenthal examines these in detail.
At the beginning of her book, she lists ten “economic rules of the dysfunctional medical market”:
1. More treatment is always better. Default to the most expensive option.
2. A lifetime of treatment is preferable to a cure.
3. Amenities and marketing matter more than good care.
4. As technologies age, prices can rise rather than fall.
5. There is no free choice. Patients are stuck. And they’re stuck buying American.
6. More competitors vying for business doesn’t mean better prices; it can drive prices up, not down.
7. Economies of scale don’t translate to lower prices. With their market power, big providers can simply demand more.
8. There is no such thing as a fixed price for a procedure or test. And the uninsured pay the highest prices of all.
9. There are no standards for billing. There’s money to be made for anything and everything.
10. Prices will rise to whatever the market will bear.
Rosenthal illustrates these rules with scores of stories about people like you and me, with health issues that are very familiar. You may think that some of these rules couldn’t possibly be accurate, but after you read the stories and the analysis of how various parts of the system work, you won’t find them so outlandish. And she covers all her bases: insurance, hospitals, physicians, pharmaceuticals, medical devices, testing and ancillary services, contractors, research and charity, monopolies and conglomerates. She examines the Affordable Care Act and where it falls short and explains how various components of the health-care industry work very hard to get around well-intentioned legislation and regulation, including a bill written by Utah’s Orrin Hatch that is now causing serious problems instead of solving them. But just because industry is ingenious and amoral doesn’t mean we should simply throw up our hands and assume government can do nothing. Our elected leaders need to be informed in order to stay one step ahead of conniving profit seekers.
As Rosenthal compares the mess in the U.S. with the relatively inexpensive and high-quality care offered through a variety of systems in foreign countries, it becomes obvious that the reason they succeed where we fail is that they use government effectively to restrain the profit motive and turn health care into a public good rather than a commodity. We could learn from these countries, if we had the political will, but the Republicans are so addicted to their simplistic free-market ideology and pathetic sloganeering that they cannot even see why government involvement is the only sane path out of our increasingly expensive and chaotic health-care crisis.
While the solution to most of the abuses we see in health care is indeed more (and more informed) government action, Rosenthal doesn’t ignore the fact that government can’t do everything. In the second part of her book, she offers suggestions to you and me about what we can do to prevent profit-minded providers from treating us unethically and robbing us blind. Her advice is spot-on—from demanding itemized bills to making sure hospitals don’t assign out-of-network physicians or anesthesiologists to treat us without our written permission.
This book could be a game-changer if more Americans read it. It would be especially influential if more politicians did.

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