I put off reading Steven Brill’s new book for much the same reason I procrastinate when it’s time to clean the gutters on my house. I was sure it would be a boring chore that would leave me yearning for a shower. A previous encounter with this writer’s work in a 2013 edition of Time suggested that this tome would contain a catalogue of canards about U.S. health care, a tendentious account of the tawdry political process that produced Obamacare, and some hare-brained theory on how to fix our medical delivery system once and for all.
My forebodings were well founded. Brill’s first chapter begins, “I usually keep myself out of the stories I write,” then launches into a lengthy anecdote about his own health problems, complete with scary dreams: “I was having open-heart surgery to fix something called an aortic aneurysm …” Brill tells us this tedious personal tale to demonstrate that the health care market is rendered dysfunctional by the fear experienced by the customer at the point of sale, fear that is exploited by the avaricious and heartless robber barons of the medical industry.
Brill does admit that his perspective changed to some degree when those robber barons were saving his life. He realized that the doctors, nurses, and technicians who worked on him “achieve amazing things.” The MRI machine he had dubbed “a symbol of profligate American healthcare” became a “miraculous lifesaver that had found and taken a crystal clear picture of the bomb hiding in my chest.” Once safely back home, however, Brill had an ideological relapse. He began, once again, to fret about “the healthcare industrial complex.”
He began brooding, for example, about the salary earned by the CEO of the hospital where his life was saved, and how much that facility paid the manufacturer of the sternum saw used to open up his chest. He wondered about the deal the pharmaceutical company has with the hospital for providing the drugs required to keep him alive during surgery and from dying a few days later due to some bacterial infection. Once he had recovered, in other words, Brill decided that the hospital had charged far too much to keep him out of Forest Lawn.
And Brill’s ideological recidivism colors every word in America’s Bitter Pill. Thus, the hopelessly dysfunctional Rube Goldberg contraption whose supporters still call the “Affordable Care Act” isn’t the product of sleazy politicians determined to take over a sixth of the U.S. economy and gain control over the most intimate decisions Americans make about their lives. It is rather the result of pressure put on those well-meaning public servants by “the hospital lobby” and the other special interest groups that control U.S. health care.
Brill’s description of Obamacare’s conception and passage, like all good works of fiction, contains victims, sympathetic good guys, and irredeemable villains. But they are not the people most Americans would assign to those roles. One of his victims, for example, is Harry Reid. I kid you not. Brill represents the then Majority Leader as a man besieged by greedy medical industry lobbyists, blackmailed by members of his own caucus, and thwarted at every turn by relentlessly obstructionist Republicans determined to throttle “reform” in the cradle.
Predictably, another of Brill’s good guys is then House Speaker Nancy Pelosi. And, as incredible as it may seem to most readers, he even defends Pelosi’s infamous claim that Congress had to “pass the bill so that you can find out what is in it.” Brill actually has the crust to tell us that this bizarre assertion was taken out of context: “In fact, Pelosi was simply promoting what she thought were the bill’s benefits, which, in her view, had not been discussed enough because the political fight over passing it was dominating the cable news networks.”
The hero of the tale is, of course, the President. But Brill’s Obama is a complex character. He isn’t the messiah of hope and change whom the voters were sold in 2008. Nor is he the serial prevaricator who earned PolitiFact’s “Lie of the Year” award for 2013. He hovers above petty politics, farms out the hard work of building a health care package to Congress, and only condescends to join the fray when the troops become dispirited and need an inspirational speech. He is “the president who refused to lose the fight for broad reform.”
But no work of fiction is complete without an unrepentant bad guy. Brill gives that role to the health care industrial complex, the people and organizations responsible for defusing what he calls “the bomb hiding in my chest.” He does his best to insulate the “caregivers” from the other people and organizations whom he indicts as “profiteers,” but most intelligent readers will see that for what it is—a cheap rhetorical trick that allows him to trash the U.S. health care system without insulting the specific individuals responsible for saving his life.
Yet Brill needs to trash the health care industry because he knows Obamacare is never going to live up to the promises made on its behalf, and his plot line doesn’t permit him to say why. He can admit that a procurement system “that rewards an insular group of Beltway contractors” caused the Healthcare.gov debacle. He can write that health costs will continue to rise “at the same or greater pace that they did in the years leading up to Obamacare.” But he can’t say that government will never do health care as well as the private sector.
And Brill has to say something good about PPACA. So, he perpetuates the access myth: “Obamacare provided more coverage.… Now everyone has access to insurance.” The reality is that Medicaid accounts for the vast majority of the newly insured patients signed up under PPACA, and that program doesn’t provide coverage in any meaningful sense. Those patients won’t get decent primary care because PPACA cut physician payments by 43 percent on January 1, 2015. People “covered” by Medicaid will continue to clog the nation’s ERs.
Still, like all good fiction, Brill’s story must contain enough of the truth to give it verisimilitude. So, he rehabilitates one of his villains, the CEO of “the supposedly nonprofit hospital” where he had his surgery. Brill initially indicts Steven Corwin for the crime of earning $3.58 million a year, but has a long discussion with this “profiteer” after recovery. Oddly enough, this gave Brill his “idea for how to fix Obamacare.… Let these guys loose.” One can imagine Corwin reading those words and thinking, “Glad you thought of that, Brill.”
But, before you free market types celebrate, it’s important to understand that Brill’s stroke of genius has nothing to do with the free market. His idea is to “Let the foxes run the henhouse—with conditions.” Brill imagines a series of highly regulated health care “oligopolies” that would serve both as insurer and medical provider for huge regional markets. “There would be no middleman. No third-party insurance company.” If this model sounds familiar, that’s because it has already been tried, unsuccessfully, by Kaiser Permanente.
What Steven Corwin would no doubt suggest is that the government should really let him and other CEOs loose by deregulating the health care market. But Brill’s book is a work of fiction. He doesn’t expect anyone to act on his idea. He’s just trying to sell books. The only way to fix Obamacare is for the GOP and a few honest Democrats to force repeal down the President’s throat, just as he shoved the law down our throats five years ago.