Book Review - America's Bitter Pill

More than three hundred pages into Steven Brill's deeply sourced and wonderfully written book America's Bitter Pill, about the passage and implementation of the Affordable Care Act, he elliptically touches on the central frustration many of us who believe in universal health care as a right and not a privilege had about the ACA. As the countdown to the launch of healthcare.gov draws near, the bureaucrats and government officials note the irony of the avalanche of criticism and scare tactics utilized by Republicans against a law that was based on an idea hatched at the conservative think tank Heritage Foundation and implemented in Massachusetts by Mitt Romney. After all, the simpler fix, converting our entire health care system into a single payer model instead of maintaining the bifurcated system where some people receive "government health care" (the elderly, disabled, poor, and military/veterans) while the rest of us are left to the predations of the private market, was never more than a pipe dream. Instead, a Democratic President and Democratic Congress passed a Republican health care proposal and then got the shit kicked out of them by those same Republicans for doing it. 

Brill manages to balance the tick-tock of how the ACA was passed into law with the real world consequences of the inequities of our health care system. The book is itself a longer form meditation on a piece Brill did for TIME that focused on the vagaries of cost in our system - that obscure hospital administrators called "charge masters" can bill one amount for say, a CT scan if you are insured by Medicare, but an entirely different amount if you have private insurance or none at all. Other, even less savory elements of the pre-ACA world, of debt collectors who harass people after costly treatment is rendered but goes unpaid and consultants who literally require a credit card payment before you are treated in an emergency room, reinforced the predatory conduct against people at their most vulnerable. 

Brill's story introduces us to some unsung heroes, people like Liz Fowler, a senior staffer for Senator Max Baucus, who works tirelessly to get the ACA passed only to see her name dragged through the mud when she eventually leaves government to take a lucrative job at Johnson and Johnson; and other, less heroic profiles of people like Jeanne Lambrew and Nancy-Ann DeParle, senior staffers at HHS and the White House who seem more interested in winning bureaucratic turf fights than focusing on the nitty gritty of implementing the myriad regulations, rules, and yes, the website, that would form the backbone of the ACA. 

Along the way, Brill debunks a few Republican (and media) talking points - to wit, he reports that President Obama had eight one-on-one meetings with Senator Olympia Snowe in the lead-up to Senate votes on the ACA (media myth - Obama needs to reach out to Republicans more) and that more than 140 Republican amendments were ultimately included in the final bill (GOP talking point - the ACA was negotiated in private and "rammed through" Congress). He also levels fair criticism at the Obama team for its sometimes tin ear to the politics of the ACA  - not emphasizing the low cost of many plans after subsidies were included - and the poor management of the healthcare.gov website. On the other hand, Brill highlights the largely below-the-radar screen effort in blood red Kentucky to launch kynect, the state-run health care exchange and to gladly accept the Medicaid expansion offered under the ACA that, combined, allowed the state to significantly reduce the number of its uninsured and save the state hundreds of millions of dollars in the long run. 

Indeed, it is one of the central paradoxes of not just Brill's book, but the overall Republican reaction to the ACA, as to why an initiative that largely relied on the private sector for its success and would save states billions in health care costs was so widely reviled. Then-Governor Tim Pawlenty of Minnesota issued an executive order prohibiting any state agency from working with the federal government on the ACA and when Brill called one of Senator Ted Cruz's offices in Texas asking for information about the ACA, the staffer who took his call bluntly told Brill no assistance was forthcoming and he should contact HHS directly. These are just the one-off examples. The years-long litigation that resulted in the Supreme Court's ruling that upheld the ACA and follow-along lawsuits about contraception coverage and whether subsidies are available to those who got their coverage via the federal exchange instead of a state-run exchange are just so much clogging of the system and draining of resources that would have otherwise been dedicated to implementation of the law. The question of why so many were so opposed to people having access to health coverage is left largely unanswered. 

Brill also points out that the health care industry, in the main, has significantly profited from the Affordable Care Act. Health stocks have gone through the roof since the ACA was enacted and because lobbyists aggressively fought for tweaks in the law and the subsequent HHS regulations, their bottom lines have been largely protected with the added benefit of having millions of new customers who must now purchase insurance or face a tax penalty. Indeed, the sacrifice of cost controls at the altar of expanding coverage is the most significant flaw Brill identifies in the ACA. 

That costs, and estimates of future costs, have gone down more than the initial CBO estimate is simply a happy coincidence. On the other hand, he points to the hue and cry over a small tax on medical device makers as one of the great inequities of the ACA debate. That industry's profit margins are particularly high, yet the modest tax levied on those devices is inevitably raised as a target for repeal. The pharmaceutical industry, which already received protection from cost controls when Medicare Part D was passed, successfully protected its members (and their profits) by agreeing to offset some costs under the ACA while receiving gifts like extended patent protection for biologic products. 

It is these back room deal and lobbying efforts that Brill points to as eroding the value of the ACA. Another example is the so-called Medicare "doc fix," which was kept out of the ACA for fear it would negatively impact the law's overall impact on the budget (Democrats were fixated on getting the CBO to "score" the ACA as saving the government money at best or revenue neutral at worst) but passed without much fanfare just a few weeks ago while adding at least $141 billion to the long-term deficit. Was this idea horrible five years ago and suddenly great in 2015? Of course not. The only difference was in which party controlled Congress. Rest assured that had Democrats attempted to slip the "doc fix" into the ACA, Republicans would have howled in anger. Now that they are in control, Republicans can blithely add this bill to the government's credit card and not fear any political reprisal. 

Of course, the dirty little secret of the Affordable Care Act is that with all its complexity, the lockstep Republican opposition, and some of its stumbles, the law has been an enormous success, you just would never know it because the media only took the time to report on its missteps, not its triumphs. Perhaps no clearer example of this is the healthcare.gov website. While there is no question the development and roll-out were done poorly, the problems were entirely resolved within a few weeks. Indeed, the heroic work of a team of coders Brill discusses would be worthy of its own book. The only difference is that while the media provided wall-to-wall coverage of the failings, they largely shrugged their shoulders once the problem was fixed and millions of people successfully accessed the site to get covered. 

And that is truly too bad, because the story of the ACA's success deserves to be told. To Brill's credit, he does attempt to highlight some of the real world consequences for people like Tommy and Viola Brown, a Kentucky couple in their early 60s who live in a county that went for Romney over Obama 2:1 and who had a litany of illnesses (she is a diabetic, he had an untreated broken neck and 2 bouts with cancer!) and could not afford health insurance before the ACA, get it under the Medicaid expansion - a literal life saver. On the other end of the spectrum, Brill mentions Sean and Stephanie Recchi, small business owners who are struggling because of the cost of treating Sean's cancer, but skeptical that Obamacare can help them (spoiler alert - it does) because of all the negative things they heard about the law on TV.

Where Brill falls short is in the final section of the book, where he proposes to turn over the entire health care industry to oligopolies of hospitals cum insurance companies. The idea would make health care single payer to a large degree, except the payee would be a government approved oligopoly restrained (to some degree) by regulations like profit margin (limited to 8% annually) and strict billing oversight. Brill points to places like New York and Pittsburgh as cities where what he proposes is, to a certain degree, already happening, but it is unclear if his model would play as well in Peoria or other, more rural parts of the country that do not have ready access to world-leading medical care facilities. Why not just go single payer? Medicare is a low-overhead (3%, as compared to 25-30% in the private sector) insurance product that is able to significantly bargain down the exorbitant prices charged in the health care system and is incredibly popular. Plus, we already pay into it through our paychecks and would streamline what is a too complicated system. 

It is not surprising that the advocates of the law had difficulty "selling" it to the public - the primary beneficiaries of the ACA, those around the poverty line, and the random assortment of part-time workers, employees at companies where health care was not offered, and those denied coverage because of pre-existing conditions, are not a vocal or powerful voting bloc. They have no lobbyists trolling the halls of Congress to insert language into legislation that will save them millions in taxes or secure their financial bottom lines, but they are our fellow Americans and did not deserve to experience financial ruin or a preventable death because our health care system is ridiculous. 

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