A Review of An American Sickness: How Healthcare Became Big Business and How You Can Take It Back
I am a consumer of health care, a practitioner and educator in general internal medicine for over fifty years, and a lifelong advocate for health care reform–single payer, a national health care service, and health care for all. In college, my sophomore term paper was a history of the AMA’s role in defeating Truman’s proposal for a national health service for America.
Critiques of the American medical system have been with us for decades but more recently, as our system becomes more and more dysfunctional, the level and volume of critique has accelerated. The system is too big, too bureaucratic, user-unfriendly, exploitative, bad for our health, inaccessible, and too costly. These are some of the recurring themes that one encounters in the explosion of commentary in books, articles, political polls and in my favorites, television shows, such as New Amsterdam, and the Resident, that are chronicling the faults in our system that make it so impenetrable to both consumers and practitioners.
I was an avid reader of this literature until there were just too many articles and books to keep up with. I am grateful that I was introduced to Elisabeth Rosenthal’s An American Sickness through Politics for the People as I might have dismissed it as just another critique that I already knew what it was going to say. Even for the jaded and cynical, Rosenthal grabs your attention. I was totally engaged with the first part of the book, How Health Care Became Big Business. She brings her talents and experience as a doctor, social critic, and journalist to her writing, producing a devastating analysis of how the patient, aka the consumer, is caught in a web of confounding business operations designed to maximally exploit them and their illnesses. The book is filled with clinical vignettes that are case studies in patient exploitation, such as the shell game of adding expensive testing, medical equipment and ancillary services to the hospital bill, the charging for the extra anesthesiologist, the moving of procedures to ancillary sites where extra facility fees can be collected as providers form LLCs to increase profit. It is the patient who is left alone with the financial impact of an unregulated drug market, lack of transparency in anticipating hospital and procedure costs, and an insurance market that simply passes on the costs of this exploitative care to the consumer in the form of higher and higher premiums.
Coming away from the book one is left with a strong sense of outrage, and a much better grasp of the complexities and deceptions of the system. I have been in treatment for breast cancer for over six years and continue to be confounded by my monthly bills that quote the charge for the service as one amount, the amount the plan pays as another and the copay as another inexplicable amount and none of it adds up. Rosenthal gives us some way of understanding how these unfathomable charges have landed on our health care bills.
I was somewhat disappointed in the second half of the book “How you can take it back.” Rosenthal provides some invaluable tools in the form of apps and sources of information and organizations that support us to become more astute consumers of health care as we shop around for the best hospitals, compare drug prices, and question the charges on our hospital bills. She exhorts us to speak up and push back; something that is not so easy to do as individual operators in a system so big and opaque as ours.
What I found most lacking was some recognition of how politicized our health care system is. The three-trillion-dollar American medical machine did not just happen to become the profit center for insurers, hospitals, doctors, manufacturers, politicians, regulators, charities, banks, real estate, and tech—or any of the many other entities that have no connection to health or health care. Much of this giveaway was accomplished through the compliance of our representatives, who vote on the legislation that has facilitated the turnover of medical care to private industry. Medicare and Medicaid were established in 1965 under Lyndon Johnson, a master of the deal. Steven Brills’s book, America’s Bitter Pill, is the sad story of the making of the Affordable Care Act, a political-mash up of deal-making and trade-offs that is the best that our partisan and divided Congress could offer the American people. I am not critical of Rosenthal for not including an analysis of the politics of health care in America in the book, and I would have liked to have some recognition of what we are being asked to push back against in challenging big business health care. I have learned in my many years as a health care activist that I could not impact the flawed nature of our health care system without engaging in changing the way politics is conducted in our country. Health care reform, like educational reform and other major reforms, is not a single-issue item. It is embedded in everything we do.
Where does one look for hope, a way out of this mass of corruption and deception that health care in the US has become? For me, one has to get out of the system and look elsewhere to a number of grassroots, community-based, and patient-initiated efforts to take control of their own health care. A few examples of this are: Patient run self help organizations such as SHARE that provide support, education and empowerment to women affected by breast or ovarian cancer; Gilda’s Club, a community organization for people with cancer, their families and friends; Project Open Notes, an international movement advocating change in the way visit notes are managed by providing access to patient and families of their medical records; The Maven Project that is leveraging medical school alumni to connect experienced volunteer physicians with safety net clinics across the US to augment and meet unmet health care needs in underserved and uninsured patient populations; The Beryl Institute, a global community of practice dedicated to improving the patient experience through collaboration and shared knowledge, as well as my own efforts to help patients to self-organize health teams that perform as collective, social units for health and healing that is amplifying the patient’s voice in taking control of their own health care.
In An American Sickness Rosenthal eloquently chronicles how dreadfully sick our health care system is. It made me think about the advice that All Stars Project and East Side Institute founder Fred Newman gave at the Performing the World conference in 2007. In speaking about the despair and chaos of our world, Newman says, “We have to perform the world again—and we are all involved in this—because this one stinks.”
I take this to mean that if we are going to create our way out of the three-trillion-dollar morass that health care in the US has become, it is we the people who will have to do it.
Susan Massad is a retired primary care physician educator who is on the faculty of the East Side Institute where she leads workshops/conversations exploring what it means for people to grow and develop in the face of serious illness, aging or memory loss. Susan is a long time independent activist with Independent Voting.