popular America's new arrival Bitter Pill: Money, Politics, Backroom Deals, and the Fight sale to Fix Our Broken Healthcare System online sale

popular America's new arrival Bitter Pill: Money, Politics, Backroom Deals, and the Fight sale to Fix Our Broken Healthcare System online sale

popular America's new arrival Bitter Pill: Money, Politics, Backroom Deals, and the Fight sale to Fix Our Broken Healthcare System online sale
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NEW YORK TIMES BESTSELLER • A NEW YORK TIMES NOTABLE BOOK • “A tour de force . . . a comprehensive and suitably furious guide to the political landscape of American healthcare . . . persuasive, shocking.”The New York Times 

America’s Bitter Pill is Steven Brill’s acclaimed book on how the Affordable Care Act, or Obamacare, was written, how it is being implemented, and, most important, how it is changing—and failing to change—the rampant abuses in the healthcare industry. It’s a fly-on-the-wall account of the titanic fight to pass a 961-page law aimed at fixing America’s largest, most dysfunctional industry. It’s a penetrating chronicle of how the profiteering that Brill first identified in his trailblazing Time magazine cover story continues, despite Obamacare. And it is the first complete, inside account of how President Obama persevered to push through the law, but then failed to deal with the staff incompetence and turf wars that crippled its implementation.
 
But by chance America’s Bitter Pill ends up being much more—because as Brill was completing this book, he had to undergo urgent open-heart surgery. Thus, this also becomes the story of how one patient who thinks he knows everything about healthcare “policy” rethinks it from a hospital gurney—and combines that insight with his brilliant reporting. The result: a surprising new vision of how we can fix American healthcare so that it stops draining the bank accounts of our families and our businesses, and the federal treasury.
 
Praise for America’s Bitter Pill
 
“An energetic, picaresque, narrative explanation of much of what has happened in the last seven years of health policy . . . [Brill] has pulled off something extraordinary.” —The New York Times Book Review
 
“A thunderous indictment of what Brill refers to as the ‘toxicity of our profiteer-dominated healthcare system.’ ” Los Angeles Times
 
“A sweeping and spirited new book [that] chronicles the surprisingly juicy tale of reform.” The Daily Beast
 
“One of the most important books of our time.” —Walter Isaacson
 
“Superb . . . Brill has achieved the seemingly impossible—written an exciting book about the American health system.” The New York Review of Books

Review

“A tour de force . . . a comprehensive and suitably furious guide to the political landscape of American healthcare . . . persuasive, shocking.” The New York Times

“An energetic, picaresque, narrative explanation of much of what has happened in the last seven years of health policy . . . [Steven Brill] has pulled off something extraordinary—a thriller about market structure, government organization and billing practices.” The New York Times Book Review
 
“A thunderous indictment of what Brill refers to as the ‘toxicity of our profiteer-dominated healthcare system’ . . . For its insights into our nation’s fiscal, psychological and corporeal health—and for our own long-term social well-being—it is a book that deserves to be read and discussed widely by anyone interested in the politics and policy of healthcare.” Los Angeles Times

“A sweeping and spirited new book [that] chronicles the surprisingly juicy tale of reform . . . [Brill’s] book brims with unconventional insight delivered in prose completely uninfected by the worn out tropes and tired lingo of the Sunday shows.” The Daily Beast
 
“This is one of the most important books of our time. Through revealing personal stories, dogged political reporting, and clear analysis, it makes the battle over Obama’s healthcare plan come alive and shows why it matters. It should be required reading for anyone who cares about our healthcare system.” —Walter Isaacson
 
“Superb . . . Brill has achieved the seemingly impossible—written an exciting book about the American health system.” The New York Review of Books

“[An] ambitious new history of the Affordable Care Act.” —Malcolm Gladwell, The New Yorker

“Steven Brill’s new book about the process of passing the Affordable Care Act is so meticulously reported, I found myself surprised by many details of a process I myself was deeply involved in. . . . Brill has written an outstanding book about the administration’s efforts to pass Obamacare. Now it is up to the administration to prove him wrong about what the legislation does to the trajectory of health-care costs.” —Peter R. Orszag, Bloomberg View
 
“Brill’s book performs an admirable job of getting behind the scenes. . . . [A] state-of-the-nation account of the broken U.S. healthcare system and Obama’s partially successful attempt to heal it.” The National

“A landmark study, filled with brilliant reporting and insights, that shows how government really works—or fails to work.” —Bob Woodward
 
America’s Bitter Pill is deeply impressive, an important diagnosis of what America needs to know if we’re ever to develop a healthcare system that is fair, efficient, and effective.” —Tom Brokaw
 
“In America’s Bitter Pill, Steven Brill brilliantly ties together not only the saga of Obamacare, but also the larger story of our dysfunctional healthcare system and its disastrous impact on both businesses and ordinary Americans. In a gripping narrative, his thorough reporting is made all the more powerful by his own scary experience looking up from a gurney.” —Arianna Huffington

About the Author

Steven Brill has written for The New Yorker, Time, and The New York Times Magazine. A graduate of Yale College and Yale Law School, he also founded and ran Court TV, The American Lawyer magazine, ten regional legal newspapers, and Brill’s Content magazine. Brill was the author of Time’s March 4, 2013, Special Report “Bitter Pill: Why Medical Bills Are Killing Us,” for which he won the 2014 National Magazine Award for Public Service. Brill also teaches journalism at Yale, where he founded the Yale Journalism Initiative to encourage and enable talented young people to become journalists. He is married, with three adult children, and lives in New York.

Excerpt. © Reprinted by permission. All rights reserved.

Chapter 1
Looking Up from the Gurney

I usually keep myself out of the stories I write, but the only way to tell this one is to start with the dream I had on the night of April 3, 2014.
Actually, I should start with the three hours before the dream, when I tried to fall asleep but couldn’t because of what I thought was my exploding heart.
THUMP. THUMP. THUMP.  If I lay on my stomach it seemed to be pushing down through the mattress. If I turned over, it seemed to want to burst out of my chest.
When I pushed the button for the nurse, she told me there was nothing wrong. She even showed me how to read the screen of the machine monitoring my heart so I could see for myself that all was normal. But she said she understood. A lot of patients in my situation imagined something was going haywire with their hearts when it wasn’t. Everything was fine, she promised, and then gave me a sedative.
All might have looked normal on that monitor, but there was nothing fine about my heart. It had a time bomb appended to it. It could explode at any moment—-tonight or three years from tonight—-and kill me almost instantly. No heart attack. No stroke. I’d just be gone, having bled to death.
That’s what had brought me to the fourth--floor cardiac surgery unit at New York–-Presbyterian Hospital. The next morning I was having open--heart surgery to fix something called an aortic aneurysm.
It’s a condition I had never heard of until a week before, when a routine checkup by my extraordinarily careful doctor had found it.
And that’s when everything changed.
Until then, my family and I had enjoyed great health. I hadn’t missed a day of work for illness in years. Instead, my view of the world of healthcare was pretty much centered on a special issue I had written for Time magazine a year before about the astronomical cost of care in the United States and the dysfunctions and abuses in our system that generated and protected those high prices.
For me, an MRI had been a symbol of profligate American
healthcare—-a high--tech profit machine that had become a bonanza for manufacturers such as General Electric and Siemens and for the hospitals and doctors who billed billions to patients for MRIs they might not have needed.
But now the MRI was the miraculous lifesaver that had found and taken a crystal clear picture of the bomb hiding in my chest. Now a surgeon was going to use that MRI blueprint to save my life.
Because of the reporting I had done for the Time article, until a week before, I had been like Dustin Hoffman’s savant character in Rain Man—-able and eager to recite all varieties of stats on how screwed up and avaricious the American healthcare system was.
We spend $17 billion a year on artificial knees and hips, which is 55 percent more than Hollywood takes in at the box office.
America’s total healthcare bill for 2014 is $3 trillion. That’s more than the next ten biggest spenders combined: Japan, Germany, France, China, the United Kingdom, Italy, Canada, Brazil, Spain, and Australia. All that extra money produces no better, and in many cases worse, results.
There are 31.5 MRI machines per million people in the United States but just 5.9 per million in England.
Another favorite: We spend $85.9 billion trying to treat back pain, which is as much as we spend on all of the country’s state, city, county, and town police forces. And experts say that as much as half of that is unnecessary.
We’ve created a system with 1.5 million people working in the health insurance industry but with barely half as many doctors providing the actual care. And most do not ride the healthcare gravy train the way hospital administrators, drug company bosses, and imaging equipment salesmen do.
I liked to point out that Medtronic, which makes all varieties of medical devices—-from surgical tools to pacemakers—-is so able to charge sky--high prices that it enjoys nearly double the gross profit margin of Apple, considered to be the jewel of American high--tech companies.
And all of those high--tech advances—-pacemakers, MRIs, 3--D mammograms—-have produced an irony that epitomized how upside--down the healthcare marketplace is: This is the only industry where technology advances have increased costs instead of lowering them. When it comes to medical care, cutting--edge products are irresistible; they are used—-and priced—-accordingly.
And because we don’t control the prices of prescription drugs the way every other developed country does, we typically spend 50 percent more on them than what people or governments everywhere else spend. Meanwhile, nine of the ten largest pharmaceutical companies in the world have signed settlement agreements with federal prosecutors, paying millions or even billions in criminal and civil penalties for violating laws involving kickbacks and illegal marketing of their products. Nine out of ten.
To prove how healthcare had become an alternative--universe economy amid a country struggling with frozen incomes and crushing deficits (much of it from healthcare spending), I could recite from memory how the incomes of drug and medical device industry executives had continued to skyrocket even during the recession and how much more the president of the Yale New Haven Health System made than the president of Yale University.
I even knew the outsized salary of the guy who ran the supposedly nonprofit hospital where I was struggling to fall asleep: $3.58 million.
Which brings me to the dream I had when I finally got to sleep.
As I am being wheeled toward the operating room, a man in a finely tailored suit stands in front of the gurney, puts his hand up, and orders the nurses to stop. It’s the hospital’s CEO, the $3.58-million--a-year Steven Corwin. He, too, had read the much--publicized Time piece, only he hadn’t liked it nearly as much as Jon Stewart, who had had me on his Daily Show to talk about it.
“We know who you are,” he says. “And we are worried about whether this is some kind of undercover stunt. Why don’t you go to another hospital?” I don’t try to argue with him about gluttonous profits or salaries, or the back pain money, or the possibility that he was overusing his MRI or CT scan equipment. Instead, I swear to him that my surgery is for real and that I would never say anything bad about his hospital.
Remembering a bait and switch billing trick common at some
hospitals that I had written about (though not this one, as far as the nondreaming me knew), I even blurt out, “I don’t care if the anesthesiologist isn’t in [my insurance] network. Just please let me go in.”
A week before, I could have given hospital bosses like him the sweats, making them answer questions about the dysfunctional healthcare system they prospered from. Their salaries. The operating profits enjoyed by their nonprofit, non--tax--paying institutions. And most of all, the outrageous charges—-$77 for a box of gauze pads or hundreds of dollars for a routine blood test—-that could be found on what they called their “chargemaster,” which was the menu of list prices they used to soak patients who did not have Medicare or private insurance. How could they explain those prices, I loved to ask, let alone explain charging them only to the poor and others without insurance, who could least afford to pay?
But now I am the one sweating. I beg Corwin to let me into his operating room so I can get one of his chargemasters. If one of the nurses peering over me as he stopped me at the door had suggested it, I’d have bought a year’s supply of those $77 gauze pads.
I didn’t care about the cost of the anesthesiologist, who the afternoon before had told me that her job was to keep my brain supplied with blood and oxygen during the three or four hours that they were going to stop my heart. Stop my heart? No one had told me about that.
In the next part of the dream, the gurney and I are about to go through the doors to the operating room when off to the left side I
see two cheerful women at a card table under a sign that proclaims
“Obama-care Enrollment Center. Sign Up Now Before It’s Too Late. Preexisting Conditions Not a Problem.”
Actually, on April 4, 2014, the morning of my surgery, it was already four days too late to sign up for insurance under the Affordable Care Act, or Obamacare. Besides, I already had decent insurance. But at least that dream was more on point with what was happening in my real life. The day I found out about the time bomb in my chest, I was finishing reporting for a book about Obama-care and the fight over how to fix America’s healthcare system.
In fact, on March 31, 2014, the day I was told about my aneurysm, I was awaiting the results of the final push by the Obama administration to get people to enroll in the insurance exchanges established under Obamacare.
What follows is the roller--coaster story of how Obamacare happened, what it means, what it will fix, what it won’t fix, and what it means to people like me on that gurney consuming the most personal, most fear--inducing products—-the ones meant to keep us alive.
From its historical roots, to the mind--numbing complexity of the furiously lobbied final text of the legislation, to its stumbling implementation, to the bitter fights over it that persist to this day—-the story of Obamacare embodies the dilemma of America’s longest running economic sinkhole and political struggle.
It’s about money: Healthcare is America’s largest industry by far, employing a sixth of the country’s workforce. And it is the average American family’s largest single expense, whether paid out of their pockets or through taxes and insurance premiums.
It’s about politics and ideology: In a country that treasures the marketplace, how much of those market forces do we want to tame when trying to cure the sick? And in the cradle of democracy, or swampland, known as Washington, how much taming can we do when the healthcare industry spends four times as much on lobbying as the number two Beltway spender, the much--feared military--industrial complex?
It’s about the people who determine what comes out of Washington—-from drug industry lobbyists to union activists; from senators tweaking a few paragraphs to save billions for a home state industry to Tea Party organizers fighting to upend the Washington status quo; from turf--obsessed procurement bureaucrats who fumbled the government’s most ambitious Internet project ever to the selfless high--tech whiz kids who rescued it; and from White House staffers fighting over which faction among them would shape and then implement the law while their president floated above the fray to a governor’s staff in Kentucky determined to launch the signature program of a president reviled in their state.
But late in working on this book, on the night of that dream and in the scary days that followed, I learned that when it comes to healthcare, all of that political intrigue and special interest jockeying plays out on a stage enveloped in something else: emotion, particularly fear.
Fear of illness. Or pain. Or death. And wanting to do something, anything, to avoid that for yourself or a loved one.
When thrown into the mix, fear became the element that brought a chronically dysfunctional Washington to its knees. Politicians know that they mess with people’s healthcare at their peril.
It’s the fear I felt on that gurney, not only in my dream, but for real the morning after the dream, when I really was on the gurney on the way into the operating room.
It’s the fear that continued to consume me the next day, when I was recovering from a successful defusing of the bomb. The recovery was routine. Routinely horrible.
After all, my chest had just been split open with what, according to the website of Stryker, the Michigan--based company that makes it, was a “Large Bone Battery Power / Heavy Duty” sternum saw, which “has increased cutting speed for a more aggressive cut.” And then my heart had been stopped and machines turned on to keep my lungs and brain going.
It’s about the fear of a simple cough. The worst, though routine, thing that can happen in the days following surgery like mine, I found out, was to cough. Coughing was torture because of how it assaulted my chest wounds.
I developed a cough that was so painful that I blacked out. Not for a long time; there was a two--two count on Derek Jeter just before one of the episodes, and when I came to Jeter was about to take ball four. However, because I could feel it coming but could do nothing about it, it was terrifying to me and to my wife and kids, who watched me seize up and pass out more than once.
In that moment of terror, I was anything but the well--informed, tough customer with lots of options that a robust free market counts on. I was a puddle.
There were occasions during those days in the hospital when the non--drug--addled part of my brain wondered, when nurses came in for a blood test twice a day, whether once might have been enough. Sometimes, I imagined what those chargemaster charges might look like, or wondered whether the cheerful guy with the wheel--around scale who came to weigh me once a day—-and who told me he owned a second home as an investment—-was part of the healthcare gravy train.
But most of the time the other part of my brain took over, the part that remembered my terror during those blackouts and the overriding fear, reprised in dreams that persisted for weeks, that lingered in someone whose chest had been sawed open and whose heart had been stopped. And as far as I was concerned they could have tested my blood ten times a day and weighed me every hour if they thought that was best. They could have paid as much as they wanted to that nurse’s aide with the scale or to the woman who flawlessly, without even a sting, took my blood. And the doctor who had given me an angiogram the afternoon before the surgery and then came in the following week to check me out became just a nice guy who cared, not someone who might be trying to add on an extra consult bill.
In the days that I was on my back, to have asked that nurse how much this or that test was going to cost, let alone to have grilled my surgeon—-a guy I had researched and found was the master of aortic aneurysms—-what he was going to charge seemed beside the point. It was like asking Mrs. Lincoln what she had thought of the play.
When you’re staring up at someone from the gurney, you have no inclination to be a savvy consumer. You have no power. Only hope. And relief and appreciation when things turn out right. And you certainly don’t want politicians messing around with some cost--cutting schemes that might interfere with that result.
New York–-Presbyterian’s marketing slogan is “Amazing Things Are Happening Here.” I’ll drink to that (although part of me did wonder why they need a marketing budget and how much it is). To me, it was, indeed, amazing that eight weeks after my bad dream I was back working out aerobically and with weights, just as I had before they had discovered the time bomb. That was more important to me than the hospital’s amazing salaries or chargemaster.
That is what makes healthcare and dealing with healthcare costs so different, so hard. It’s what makes the Obamacare story so full of twists and turns—-so dramatic—-because the politics are so treacherous. People care about their health a lot more than they care about healthcare policies or economics. That’s what I learned the night I was terrified by my own heartbeat and in the days after when I would have paid anything for a cough suppressant to avoid those blackouts.
It’s not that this makes prices and policies allowing—-indeed, encouraging—-runaway costs unimportant. Hardly. My time on the gurney notwithstanding, I believe everything I have written and will write about the toxicity of our profiteer--dominated healthcare system.
But now I also understand, firsthand, the meaning of what the caregivers who work in that system do every day. They do achieve amazing things, and when it’s your life or your child’s life or your mother’s life on the receiving end of those amazing things, there is no such thing as a runaway cost. You’ll pay anything, and if you don’t have the money, you’ll borrow at any mortgage rate or from any payday lender to come up with the cash. Which is why 60 percent of the nearly one million personal bankruptcies filed in the United States last year resulted from medical bills.
Even when it’s not an emergency, even those who would otherwise be the toughest customers lose their leverage.
“When I went in for knee surgery, I couldn’t have cared less about healthcare policy or cost containment,” Marna Bargstrom, the CEO of the giant Yale New Haven Health System told me. “I was just scared.”
That is the perspective that anyone’s encounter with a scalpel provides—-the “How can I think about the cost at a time like this?” element.
Most of the politicians, lobbyists, congressional staffers, and others who collectively wrote the story of Obamacare had some kind of experience like that, either themselves or vicariously with a friend or loved one. Who hasn’t?
Montana’s Max Baucus, the chairman of the all--important Senate Finance Committee, had a picture on his desk of a constituent he had befriended who had died after a long fight against a disease stemming from an industrial pollution disaster, the court settlement of which, Baucus believed, had not sufficiently provided for his medical care.
Billy Tauzin, the top lobbyist for the drug industry had, he said, “a cancer where they told me I had a one percent chance of living, until a drug saved my life.”
The staffer who was more personally responsible than anyone for the drafting of what became Obamacare had a mother who, in the year before the staffer wrote that draft, had to take an $8.50 an hour job as a nightshift gate agent at the Las Vegas airport. She worked every night not because she needed the $8.50—-her semiretired husband was himself a doctor—-but because a preexisting condition precluded her from buying health insurance on the individual market. That meant she needed a job, any job, with a large employer. Her daughter’s draft of the new law prohibited insurers from stopping people with preexisting conditions from buying insurance on the individual market.
And then there was Senator Edward Kennedy, for fifty years the champion of extending healthcare to all Americans. Beyond his brothers’ tragic visits to two hospital emergency rooms, Ted Kennedy’s firsthand experience with healthcare began with a sister’s severe mental disabilities, extended to a three--month stay in a western Massachusetts hospital following a near--fatal 1964 plane crash, and continued through his son’s long battle with cancer.
Although their solutions varied, these four—-as well as most of the dozens of other Obamacare players, who to some degree had these kinds of personal stories—-saw and understood healthcare as an issue not only more urgent and more emotionally charged than any other, but also bedeviled by one core question: How do you pay for giving millions of new customers the means to participate in a marketplace with inflated prices—and with a damn--the--torpedoes attitude about those prices when they’re looking up from the gurney? Is that possible? Or must the marketplace be tamed or tossed aside? Or must costs be pushed aside, to deal with another day?
As we’ll see, even the seemingly coldest fish among politicians—-the cerebral, “no--drama” Barack Obama—-drew on his encounters with people who desperately needed healthcare to frame, and ultimately fuel, his push for a plan.
“Everywhere I went on that first campaign, I heard directly from Americans about what a broken health care system meant to them—the bankruptcies, putting off care until it was too late, not being able to get coverage because of a pre-existing condition,” Obama would later tell me.
But as Obama’s campaign began, he had not yet met many of those Americans victimized by the broken healthcare system. And it showed.

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Top reviews from the United States

Anne Mills
5.0 out of 5 starsVerified Purchase
A Tough Read, But The Best I Have Read on US Healthcare in Years
Reviewed in the United States on February 5, 2015
For any one who is seriously interested in healthcare, it is critical reading, if sometimes heavy going reading. Brill focusses on the history of Obamacare, and in doing so makes it clear that the root of the U.S. health care problem is political. Healthcare now accounts... See more
For any one who is seriously interested in healthcare, it is critical reading, if sometimes heavy going reading. Brill focusses on the history of Obamacare, and in doing so makes it clear that the root of the U.S. health care problem is political. Healthcare now accounts for one sixth of the US economy, and that means that the money and influence t that can be rallied against any change are formidable. This made the enactment of Obamacare so torturous a process, and explains why the result is a U.S. system that still has profound problems.

Another reviewer refers to Bismark''s dictum that one should not watch either laws or sausages being made, and the first half of Brill''s book demonstrates that -- exhaustively and and times exhaustingly. He shows how it was that, even with a Democratic majority in both houses, lobbyists for special interests (the drug companies, the insurers, the hospitals, the device makers, the patient''s groups, and on and on and on) were able to force those in favor of reform to water down proposals, compromise, buy off, and on and on an on. In so doing, I learned a lot about the economics and the power structure of the U.S. health care system, but I also learned more than I probably wanted to know about a few too many individuals. I also learned (or was confirmed in my belief) that within the Obama administration there were major divisions of opinion and major shortages of communication.

The second part of the book, on what happened after the legislation was passed, was more interesting -- or perhaps more accurately less exhausting. First, in this part, Brill intersperses the political narrative with stories of individuals who ran into financial catastrophe through illness, and looks at what varioius institutions (mostly hospitals) did to bring these individuals close to financial ruin. Second, his narrative of the failed launch of the Obamacare website is eyeopening -- the launch failed because the project was badly run from its inception, and that reflected bad management by the administration, all the way up to the top. That, however, is followed by the livliest part of the book, in which a "Geek Squad" of mostly private sector techies saves the day. There is a lot in this section to gratify anti-Obama types and anti-govenment types, but only if you read it in isolation from the context. That context is one of "non profit" hospitals with CEO''s who earn millions a year, drug companies whose devotion to research is far exceeded by their devotion to their profit margins, and an overall situation in which the consumer of healthcare comes in last.

At the end of the book, Brill argues that there is no way that the U.S. healthcare system can be rebuilt from the ground up in a way that would minimize costs and maximize outcomes. That would mean single payer, it would mean Medicare drug price negotiation if not drug price regulation, it would mean serious research on comparative outcomes and costs, and it would mean a whole lot of other violent change to one-sixth of the U.S. economy. That sixth has a very powerful interest in resisting change, while the five-sixths of the economy that would benefit has a more diffuse interest. Granted that, he proposes that perhaps we should consider making the institutions that directly provide more and more U.S, medical care --the hospitals -- into insurers as well as providers. It''s an interesting idea that sounds a little like handing the whole henhouse over to the fox, but it bears discussion. As to Obamacare, Brill concludes that it was a major accomplishment, in that it brought healthcare into the reach of many more Americans. Still, Brill argues that it was essentially tinkering with the jalopy, not putting in a new engine.

This book is the best overall summary of the U.S. healthcare situation that I have read in years, which is why five stars. It could have been a better book, better organized and more readable. Still, I think it is one of those books you should read even if it takes effort.
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alanhouston
4.0 out of 5 starsVerified Purchase
A Hard Look At How Big Insurance Companies and Big Drug Companies Make Billiions While Bankrupting America.
Reviewed in the United States on March 7, 2016
Brill has always been a writer who asks the hard questions. The basic question he asks in "Bitter Pill" is: how does extending private health insurance to millions of Americans solve the most basic problems of our broken health care system: price gouging where a... See more
Brill has always been a writer who asks the hard questions. The basic question he asks in "Bitter Pill" is: how does extending private health insurance to millions of Americans solve the most basic problems of our broken health care system: price gouging where a hospital can charge $50 for a box of Kleenix, $30 for one band-aide, or $20 for one aspirin? How does MORE insured people solve the problem of insurance companies refusing to pay for treatment or drugs that doctors say are essential? How does having more insured people solve the problem of Medicare Part D paying 400% more than the price Costco charges for prescription drugs, and the price of drugs in Detroit (in the USA) being ten times higher than the same drugs one mile south in Windsor Canada?

The Affordable Health Act, just like the Medicare Part D Prescription Drug law, transfers billions of dollars of taxpayer money to insurance companies, drug companies, and hospitals, yet for most people, the co-pays for medical treatment and drugs for a serious illness, such as HIV or cancer, remain bankrupting.

England, Canada, and Australia found an easy way to provide health care to 100% of their citizens: get rid of insurance companies. Drug companies and hospitals are paid quickly and fairly for services rendered. The result is every single person gets health care, and at HALF the cost per person as in America''s broken system.
20 people found this helpful
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MJ
5.0 out of 5 starsVerified Purchase
All Americans Should Read This Important Book!
Reviewed in the United States on June 24, 2017
Will healthcare back in the forefront of the political discussion, anyone that wants to be well informed on the issue should pick up a copy of this book. I would love to see one updated for the latest attempt to "fix" the system (more like rolling back the few... See more
Will healthcare back in the forefront of the political discussion, anyone that wants to be well informed on the issue should pick up a copy of this book. I would love to see one updated for the latest attempt to "fix" the system (more like rolling back the few improvements that HAVE been made and increasing the speed at which it will completely go off the rails), but Brill does a great job of explaining things like 1. how we got here in the first place with a crazy system that NO other country would end up copying (much like our nutty electoral college), 2. how many different ways the current system is broken and is rapidly getting worse 3. how Obamacare attempted to improve it but was bound to fail by making too many compromises to keep all the big healthcare lobbies happy, etc. It''s a fairly non-partisan book with an incredible amount of research behind it and dispels a lot of myths most people have (such as insurance companies being the main drivers of cost, and raking in big profits). And for a topic that would seem boring, he manages to make it quite a fascinating read at the same time.
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Stephen D McLeod
4.0 out of 5 starsVerified Purchase
We Can Have Better Health Care at Lower Cost
Reviewed in the United States on April 19, 2019
I’ve followed this story for many years now in various periodicals such as The New Republic Magazine. An enormous amount of research went into this history of Obama Care. This is a classic example of the sausage making in a legislature to get to something useful and... See more
I’ve followed this story for many years now in various periodicals such as The New Republic Magazine. An enormous amount of research went into this history of Obama Care. This is a classic example of the sausage making in a legislature to get to something useful and acceptable to enough of the stake holders to get past the post. Historically, profound change in a political economy usually follows a terrible disaster such as an economic collapse or a lost war. The Affordable Care Act is not a profound change, but an accommodation to many stake holders. Profound change requires breaking many rice bowls. People and organizations whose source of income is tied to the status quo are going to fight to the death to keep their rice bowl intact and filled.
Steven Brill mentions the World War II ruling that health insurance is not wages. This a good example of unintended consequences. In the 19th century Americans joined clubs that contracted with a local doctor to supply medical services to their members. The doctor was paid a retainer by the club for each member who in return would provide all medical services required by club members. The American Medical Association formed near the beginning of the 20th century to vet and license doctors. The AMA also prohibited the practice of doctors accepting retainers. Blue Cross and Blue Shield insurance was the doctor and hospital answer to replacing the retainers. While these were the only source of insurance, they could set a flat fee and take everyone who wanted to sign up. This worked until the free market intervened with for profit insurance companies taking away the young and healthy with lower rates. The non-profit Blues were driven to bankruptcy. This is where we were before the ACA. The ACA has helped, but not cured.
I was particularly interested in the healthcare.gov fiasco. I worked for the company that CGI purchased and likely knew some of the people at CGI who worked on healthcare.gov. I’ve worked for a number of years in acquisition in a couple of three letter government agencies. My cynical conclusion is that government cannot contract for computer systems development with any hope of success. Mr. Brill outlined some of the issues. Basically only businesses that are experienced and expert at treading through the minefield of government procurement can get a contract. They can subcontract the work to a more nimble company, but can make a lot more money trying to execute the contract themselves. The ad hoc team that saved healthcare.gov is a good example of how to do this right, but it broke every rule of acquisition that not even a Ferengi could understand.
I have seen a collection of successes and failures in system development. The failures tend, like healthcare.gov, to be mainly management failure. The most frequent of these is a failure to manage expectations, both that of the client and the development team. Technical issues as a reason for failure tend to be almost non-existent. I worked on one project at that CGI predecessor that was a technical and management success. So it can be done. I also witnessed several disasters that eventually ended that company’s existence with the government division being sold to CGI. That was the second large systems company I’ve worked for that no longer exists. Have you ever heard of Control Data Corporation? They once had 62,000 employees.
I think Mr. Brill is onto something with his cure described in Part 4. It is almost inevitable that hospital and doctor practices will merge until a small number of very large organizations will survive. Having both provider and insurer within the same corporate umbrella seems the best answer to the economic dilemmas in medical care delivery. My opinion is that there are no positive economic incentives in medical care. All economic incentives produce bad and increasingly expensive results. This makes the British NHS look good. I once worked as a marketing rep. We had a six page fine print marketing plan or contract that defined precisely what we each had to do to get our commissions. This is a great example of managing incentives to get the results management wanted. Regulation of medical practice is no different. As shown in several European countries, a highly regulated private insurance and medical delivery system can work well and keep a nation healthy.
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LF
5.0 out of 5 starsVerified Purchase
wow! if you read one book this year on healthcare this is the one
Reviewed in the United States on January 16, 2015
Mr. Brill does an incredible job in two areas. First he is able to explain some very complicated concepts in very simple layman terms. Secondly he tells the story of Obamacare with a pace and intrigue you would expect from a great mystery writer. Even though we all know... See more
Mr. Brill does an incredible job in two areas. First he is able to explain some very complicated concepts in very simple layman terms. Secondly he tells the story of Obamacare with a pace and intrigue you would expect from a great mystery writer. Even though we all know how it turned out eventually Mr. Brill is able to make the story very suspenseful. In terms of politics he seems to play the ball straight down the middle to use a golf analogy. For that reason I think even if you feel strongly one,way of the other about Obamacare you will come away with new insights that may just soften your position slightly.
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C. Gaspero
5.0 out of 5 starsVerified Purchase
Health Coverage Not the Problem its The Costs Stupid
Reviewed in the United States on March 20, 2017
As Brill details, much of the dysfunction in healthcare can be traced to a single regulatory deficiency: largely because of the influence of the pharmaceutical, hospital and medical device lobbies, the United States does not engage in wholesale rate-setting in the... See more
As Brill details, much of the dysfunction in healthcare can be traced to a single regulatory deficiency: largely because of the influence of the pharmaceutical, hospital and medical device lobbies, the United States does not engage in wholesale rate-setting in the healthcare market (although it does so in a limited fashion for those enrolled in Medicare and Medicaid). Through a price list known as a chargemaster, American hospitals engage in unconscionable gouging — marking up even the most basic products like Tylenol by 100% the retail cost. In some cases, hospitals inflate the price for cancer drugs by 400%. These markups are passed on to insurance companies and, ultimately, to patients.
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Interested customer
5.0 out of 5 starsVerified Purchase
Required reading for any course in Civics.
Reviewed in the United States on February 22, 2015
A must read. Brill is an excellent writer who has done his usual fine job of research and writing. And, as noted in the heading, a devastating look at the reality of our political process. Before my review, a confession of bias. If I have a terminal condition... See more
A must read. Brill is an excellent writer who has done his usual fine job of research and writing. And, as noted in the heading, a devastating look at the reality of our political process.

Before my review, a confession of bias. If I have a terminal condition of some sort, I don''t want the government or some insurer to pay lots of money to "care providers" to keep me alive a little bit longer. Especially not if those few days or weeks will be spent in any pain or discomfort. After all, we all have to die of something someday. I would much rather they just gave the money to me, so I could give it to my heirs, or spend it on a fortnight of riotous living. If, though, we are to have such a system, I have reluctantly concluded that a "single payer" system is far superior to the present non-system. If nothing else it will force the government into the "bad guy" role of trying to minimize costs by rationing care and cutting reimbursements to the providers. As Brill notes several; times, the providers have succeeded in shifting all of the blame for the excessive costs of medical care onto the insurers, leaving such enormous pockets of high profit as the medical device industry untouched.

Having said which, I am apparently in a minority, so this review:

The tragedy of ObamaCare, or ACA, proves once again the remark attributed to Bismarck about making laws and sausage. As observed frequently through the book, Obamacare''s proponents early gave up any hope of controlling medical costs, and began the process of "buying" support of its likely opponents by promising them more customers and more profits, meanwhile engaging in extensive backroom dealing with Congressmen to get a bill, any bill, through Congress; and "explaining" all his to the public sometimes with deliberate and knowing falsehoods. The result was a bill that according to one report was just short of 1,000 pages long; and to some other reports even longer, plus regulations of an as yet unknown length, but lots longer. But the Bill accomplished the one result that was paramount to its supporters--get some version of universal health care into the law, and it will immediately become an entitlement which can never be eliminated. Facts on the ground sure beat theoretical arguments.

The result was what could have been expected. The ACA has been rescued by the Supreme Court once by characterizing the mandate as a "tax", although the Administration had gone to great lengths to avoid that term. Now it is again before the Court, which is being asked to ignore the plain language of the law to salvage it. Distressing, but having drafted lots of agreements far shorter than this law, I am well aware that errors are bound to creep into any document, and the longer it is, the greater the probability of an error. That''s what careful review of a proposed law is supposed to prevent; and that''s what wasn''t provided for this Bill, governing an industry that is reported to be one-sixth of our economy. . Given its gestation it would be unduly optimistic to think that no other unexpected problems lurk within this monstrous Bill..

But now we have the law, and it must await the test of time, and a second presentation to the Supreme Court to see whether at least 5 Justices are willing to salvage the Bill by ignoring its quite explicit language, or will just apply the law as written, which will, we are assured, create chaos.

Perhaps the best reason for reading this book is that ACA is a striking example of what happens when everything is ignored except getting a Bill passed. Over the next few years we will see whether that is a good strategy, or a recipe for disaster. This book will make the observer of the passing show better informed, and better able to evaluate the costs and the benefit of what was done.
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Pamela R Winnick
5.0 out of 5 starsVerified Purchase
A must read!
Reviewed in the United States on March 18, 2015
Whether or not you support Obama Care, you must read this book. A brilliant author and reporter, Brill carefully documents how various lobby groups interfered with the legislative process during the drafting of the Affordable Health Care Act. He also discusses his personal... See more
Whether or not you support Obama Care, you must read this book. A brilliant author and reporter, Brill carefully documents how various lobby groups interfered with the legislative process during the drafting of the Affordable Health Care Act. He also discusses his personal medical experiences.

The problem with modern health care, the author suggests, is not that "liberals'' are trying to socialize health care. Most involved in the legislation appear to have genuinely desired health care for all. But the devil is in the details. As is, Obama Care cannot work.

The real issue is cost. How can we adequately insure all Americans when medical costs are skyrocketing? When so-called "nonprofit" hospital reek in billions in profits? When pharmaceutical companies will not make price concessions for groups? When manufacturers of medical devices earn obscene profits? When providers duplicate each others equipment?

Here in Pittsburgh, the dominant (and dominating) healthcare provider is UPMC. Its CEO earns $7 million a year. In just six months profits rose by $65 million. In the meantime, even those with Obama care policies either cannot afford the premiums or face enormous co-pays and deductibles. Something must be done.
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Top reviews from other countries

RMF
5.0 out of 5 starsVerified Purchase
Brill''s TIME article expanded and balanced
Reviewed in the United Kingdom on January 24, 2015
You hear Steve Brill''s intelligent voice, his thought process throughout this fascinating and highly informative book. It is not only about the ramshackle and over-costed U.S. Health care industry and the actual degree of impact of Obamacare. He also makes it clear why the...See more
You hear Steve Brill''s intelligent voice, his thought process throughout this fascinating and highly informative book. It is not only about the ramshackle and over-costed U.S. Health care industry and the actual degree of impact of Obamacare. He also makes it clear why the Affordable Care Act struggled so hard to come into being and why anything value-adding, wise, or efficient so rarely, if ever, can emerge from Washington.
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Gordon Ritchie
4.0 out of 5 starsVerified Purchase
Brill is perhaps the best writer on the byzantine world of American health care ...
Reviewed in Canada on February 23, 2015
Brill is perhaps the best writer on the byzantine world of American health care today. This is a must-read account for anyone interest in understanding the real stories of Obamacare, stripped bare of much of the partisan hype on both sides. The main thrust, corroborated by...See more
Brill is perhaps the best writer on the byzantine world of American health care today. This is a must-read account for anyone interest in understanding the real stories of Obamacare, stripped bare of much of the partisan hype on both sides. The main thrust, corroborated by multiple other accounts, is that the deeply dysfunctional American political system, awash with money and special interests that control the legislative processes, forced the Obama team to make the fumbling attempt to cobble together a "rube goldberg" mishmash of policy fixes. They were obliged to forego the tried and tested methods of other systems throughout the rest of the developed world---with their state run core provision of universal health care with a single payer---systems which produce consistent better health outcomes at much less cost. Instead, the combined effort of the White House and Administration team plus a congressional team led by Senator Baucus, was focused on obtaining bi-partisan and special interest support for the extension of coverage to at least some of the vast pool of uninsured Americans. The result failed for many reasons: at the end of the day, it was politically impossible for any Republican legislator to sign on to any Democratic proposal; the special interests, led by the pharmaceutical and insurance companies diverted the reforms to ensure their own very considerable profit; and the policy gurus in the Administration acted as though it were beneath their dignity to pay any attention to the little matter of execution, which was monumentally botched. The result, in Brill''s judgment, is a terribly complicated overlay which should, indeed, somewhat extend coverage but at a tremendous cost in government subsidies going ultimately to the pharma and insurance sharks. Recommended ready for anyone interested in going beyond the rhetoric.
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