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4.5
I’m wary of hyperboles and blanket statements. Having said that, every American should read this book.There’s an old saying about Washington—the shocking thing isn’t how much lawbreaking goes on, the shocking thing is what’s legal. And what this book depicts, beyond just a messy fight to bring some fairness to a bloated and corrupt system, is the dysfunction at the heart of American politics. We freely criticize politicians, but this book makes it all too clear that they’re not in charge—the money is. Every industry or interest group that turns a decent profit has lobbyists in place to flatten any piece of legislation that threatens to derail their gravy train. Republican or Democrat, it doesn’t matter—your campaign contributions will rise or fall based on what you support or oppose. So unless you’re in a completely safe seat ideologically—the reddest of the red, or the bluest of the blue—you will need to pay attention to the lobbyists.Since our healthcare industry comprises one sixth of the richest economy in the world, it should be no surprise that it has some tremendously effective lobbyists. Thus the problems with Obamacare are the same as the problems with George W. Bush’s prescription drug benefits for seniors: while both are ostensibly aimed at alleviating the financial medical pain of the American consumer, neither made a serious effort to reign in the primary source of that pain. And as Brill’s book makes clear, the source of that pain, oddly enough, isn’t so much the insurance companies that are squeezing us for larger and larger premiums every year—it’s the pharmaceutical companies and medical device manufacturers that are squeezing the insurance companies. (Not that the insurance companies aren’t turning a profit, but as Brill makes clear, they, too, are consumers, paying prices that are suspiciously arbitrary and even, like the $1000-per-pill cost of Sovaldi.) (A quick aside: conservatives are quick to point out that you have to pay for other things that keep you alive, like food, so why not healthcare, too? But it’s a flawed analogy. Food is an industry with a tremendous range of options, and low barriers to entry, so it’s very easy for new providers to enter the market at a low price point. And no one meal keeps you alive, so skimping or splurging here and there doesn’t make much of a difference. So the free market works far more efficiently for food than it does for medicine—there are innumerable ways to feed a hunger, but far fewer ways to clear a blocked artery or treat hepatitis C.)Granted, nobody ever thinks they’re the bogeyman. So, too, in healthcare. The pharmaceutical industry’s lobby, led by former Republican congressman Billy Tauzin, is convinced that they are the world’s engine of medical innovation; they’re clearly entranced by the righteousness of the cause that’s earning them so much money. (Tauzin even has his own wonderful I-beat-cancer-thanks-to-big-Pharma story, pretty much the medical equivalent of “Not only am I president of the Hair Club For Men, I’m also a satisfied member.”) But the great strength of this book is Brill’s ability to get behind everyone’s story and crunch the real numbers—he looks at Amgen’s financials for 2013, for instance, which seem to show that the company’s advertising and marketing expenses are substantially higher than its research and development costs, or its production costs.It’s understandable, to some extent—having been in business myself, I know that you can make the greatest product in the world, but if nobody knows about it, it’ll never sell. But our situation in the U.S. is different from Canada and Europe, in that drug makers can market these products directly to patients (who can then ask doctors if such-and-such a pill is right for them) rather than only advertising to doctors, who might be slightly more knowledgeable about the effectiveness of said pill. As the book makes clear, the industry very effectively fought to water down a provision in Obamacare to measure the effectiveness of various drugs and treatments and pay accordingly. (The pharmaceutical industry has also legally protected its prices with its largest consumer, Medicare. Rather than, say, using its power as a consumer to negotiate lower rates, the way Wal-Mart or Amazon might do with its suppliers, Brill tells how the government is legally handcuffed to an arbitrary percentage [106%] of the fair-market-value for a given drug—a value that has little clear relation to what it costs the drug companies to produce and sell the drug, and no clear relation to its effectiveness relative to other drugs.) So you have a well-entrenched lobby for a group that performs a valuable service resisting any efforts at accountability for how well they provide that service—it’s like a teacher’s union on steroids.This is not to say that corporations are villians, or that government is blameless and noble in all of this. Indeed, as Brill makes clear, there have been problems all around, both in the status quo ante-Obamacare, and in the Obama administration’s flawed implementation of a flawed law, and in the relentlessly ideological opposition to that law. One salient point Brill makes: Obama’s team made much the same decision when implementing Obamacare that Romney’s team made when implementing Romneycare—to work on universal coverage first, rather than tackling costs. (Politics, they say, is the art of the possible, and nobody apparently believes it’s even possible to rein in the pharmaceutical industry.) He also rightly calls the Obama administration out for slow-pedaling the implementation of its own signature law, especially in the run-up to the 2012 election—delays which seem like they were mostly motivated by fear. And he does a great job of sorting through the chaotic launch of the Healthcare.gov website, sorting through the tangled org charts and email chains that led to the well-publicized botched launch. (Having been part of a botched website launch in the private sector, I can assure you that the government has no monopoly on incompetence in such matters.) Even given that it was a government project, it didn’t need to be that way; along the way, he helpfully contrasts the initial Healthcare.gov efforts with the smooth and efficient launch of Kentucky’s Obamacare website, and he shows, too, how the ferocious efforts of a tiger team of industry veterans eventually brought order out of chaos on the federal site.There are a few quibbles with the book: Brill ends up spending a decent amount of time writing his own prescriptions, althought it might have been worthwhile to simply have a thorough diagnosis instead. And while he does make clear how reluctant the Democrats are to take on their own pet lobbies, such as the trial lawyers, it’s tough to tell how much they’re to blame for out-of-control-costs, relative to Big Pharma and the others. Lastly, it’s difficult to keep some of the names and personalities straight, particularly when he’s discussing the Healthcare.gov launch. (In fairness to Brill, it was a very confusing project initially; everyone was responsible, so no one was. And he does a great job with some of the more outsized personalities, thanks in part to having the journalist’s ear for the telling quote, the one that captures a personality and a worldview. [In discussing Billy Tauzin’s desire to be involved in meetings where large decisions were being made, for instance, he cites one of the former congressman’s favorite dictums: “If you’re not at the table, you’re on the menu.” It’s an earthy and endearing maxim, one that humanizes a man who could just as easily be demonized.])Still, Brill’s performed a valuable public service in sorting through this tangled mess. And rather than discussing all of it from an icy journalistic distance, Brill adds some worthwhile personal discussions while mentioning a health problem of his own, an aortic anyeurism which hospitalized him and forced him to undergo possibly life-saving surgery.And here Brill gets at why it’s really so profoundly difficult to fix our health care. Our bodies are as flawed as any physical object, and all are doomed to break eventually, but nobody wants to skimp on fixes when it’s their health at stake. (As he puts it, nobody wants to do a cost-benefit analysis on their own health—they just want to maximize the benefit.) So in a sense, WE are to blame, as much as any industry or group of lobbyists. We are the ones who fall prey to the incessant marketing from hospitals and insurers and makers of little purple pills; we are the ones staring at ad after ad for Prilosec and Levitra, and then wondering why our insurance costs are so high. We are the ones less concerned with diet and exercise, and more concerned with paying someone else to fix us. America, heal thyself.
