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.”
“Superb . . . Brill has achieved the seemingly impossible—written an exciting book about the American health system.”
—The New York Review of Books
“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.”
“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.”
“A landmark study, filled with brilliant reporting and insights, that shows how government really works—or fails to work.”
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.”
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.”
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.
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.