Getting "Madder and Madder" About Health Care is Not Enough

“Bitter Pill” author Steven Brill on the “The Daily Show”

By Rajiv Mehta
CEO & Founder of Unfrazzle

As I watched Jon Stewart interview Steven Brill on “The Daily Show” last Thursday evening, I identified with one of Jon Stewart’s comments. He said that as he read Brill’s epic article “Bitter Pill” in TIME magazine he got “madder and madder each page.” 

That was my reaction exactly. In fact, I had to put the article down several times just to regain my composure.

And I still can’t quite absorb it.

I was already aware of the terrible economics of our health care system and the fact it is anything but a free market. The insurance companies, as much as it is easy to dislike them, are not in fact the primary “bad guys.”  The doctors also are generally not the ones getting rich, though they have been primarily responsible historically for getting us into this mess as laid out by Paul Starr is his Pulitzer Prize-winning The Social Transformation of American Medicine

Brill is correct, the hospitals, private and especially “nonprofit” are the real culprits. His analysis is spot-on. How can anyone defend the price mark-ups that Brill found?

And yet, as Brill notes, these executives and their hospitals are held in high esteem in their communities.  When forced to respond, these executives can and will defend their business practices as being good business, as creating jobs, as being good for their communities, as creating the “best hospitals” for their regions in the ways “best” is currently defined.

What frustrated me the most about “Bitter Pill” are Brill’s suggested solutions at the end. They’re technocratic solutions, not likely to be adopted because they won’t inspire the public to demand them and will be strongly lobbied against by the industry, and would unlikely have much impact anyway.

What do we actually want?

I wish Brill had gone further, and forced us to ask basic questions of what we actually want from our healthcare system.

One of the leading health economists, Princeton professor Uwe Reinhardt, put his finger on the basic problem in a 1997 essay “Wanted: A Clearly Articulated Social Ethic for American Health Care,” in which he said:

“Throughout the past 3 decades, Americans have been locked in a tenacious ideological debate whose essence can be distilled into the following pointed question: As a matter of national policy, and to the extent that a nation’s health system can make it possible, should the child of a poor American family have the same chance of avoiding preventable illness or of being cured from a given illness as does the child of a rich American family?

The ‘yeas’ in all other industrialized nations have won that debate hands down decades ago, and these nations have worked hard to put in place health insurance and health care systems to match the predominant sentiment. In the United States, on the other hand, the ‘nays’ so far have carried the day.”

To put it starkly, Reinhardt is basically pointing out that we as a people fundamentally don’t care if the poor, if “someone else”, can’t afford good healthcare. We have regular bouts of public agonizing about the consequences of our crazy healthcare system, but we also don’t want to address the fundamental problem.

A faithful reflection

A decade later, Reinhardt was asked by New Jersey Governor Jon Corzine to lead a commission to recommend what the state could do to rationalize its health care resources. They came up with various suggestions, but Reinhardt added a long personal letter to preface their final report. The letter concluded:

“In short … the extraordinarily expensive, often excellent and just as often dysfunctional, confused and confusing American health system is a faithful reflection of the minds and souls making up America’s body politic. … Alas, no Commission can provide a complete blueprint for a truly rational health system … until the citizens of this country reach a politically dominant consensus on a more logically consistent set of preferences for their health system … Until that happens, any attempt at ‘health reform’ will always degenerate into mere tinkering at the margin …”

If we as a people reach the same conclusion as the rest of the civilized world — that every single one of us deserves good care — then it is already well known (by people like Professors Reinhardt and Starr) what we need to do.  The “right solution” comes in many flavors but boils down to these items:

  • Everyone physically inside the U.S. should have access to healthcare services with only modest fees.
  • This insurance should be run as a cost-plus business with 90-95% passed through to pay for actual treatment, the remaining to pay all insurance overhead and expenses, including salaries.
  • There should be a universal price list for all treatments, drugs, procedures, etc., and it should be transparent. No need to shop around, no haggling over prices, no surprises.
Every other advanced country has such a system. Beyond these three issues the systems vary considerably — some totally run the government, some almost completely private (private insurance companies, private hospitals, private doctors) — tailored that country’s mindset and historic circumstances. 

A great and very readable tour of the many different system employed in other countries is describe in T. R. Reid in The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care.Each of the players in our system feels he’s doing the right thing — it makes “good business sense”, it’s not illegal, etc. — though the net result is awful.

So, I wish Brill had put more passion into helping people envision a better future, something we can really put our energies into. His meticulous presentation of the problem was wonderful, but it is not enough. 

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