Robert Evans, the Canadian health economist, insightfully observed, “Every dollar of health-care expenditure is also a dollar of someone's income.” For decades citizens, health policy scholars, and public officials have lamented the inexorable rise of health costs, which now approach one of every five dollars within the American economy. Despite what appears to be a universal concern about growing costs, the problem persists. Cost control is difficult because the benefits of restraints are broadly distributed and not immediately noticed. Cost-control success threatens the income of a large swath of the American public, which includes not just physicians but nurses, salespeople, and facility middle managers.
There are two general approaches to explaining the problem. The macroapproach is exemplified by the National Health Expenditures Team annual report, which is a comprehensive and definitive analysis of national health spending each year. Annual comparisons allow us to understand macropatterns and percentage changes. For example, the report for 2015 stated that “health care spending increased 5.8 percent” (Martin 2017: 166). This macroperspective allows us to understand the trends in health spending. The Dartmouth studies use Medicare data to compare regional aggregate and procedure-specific costs. The Commonwealth Fund and the Organisation for Economic Co-operation and Development publish systematic comparisons of health spending among developed nations. Some will pinpoint individual communities, such as Gawande's New Yorker article about McAllen, Texas (Gawande 2009). The macroapproach uses aggregate statistical analysis to describe the problem.
The microperspective tells stories. Anyone who has run for office, lobbied legislators, or sought to build public support for a policy initiative understands the value of good stories. If the story features heroes and villains, it is even more compelling. A story is worth a thousand statistical graphs.
Elisabeth Rosenthal is a journalist and Harvard-trained physician who, near the end of her two-decade career with the New York Times, produced an award-winning eleven-part series, Paying Till It Hurts, which examined medical care costs. Her book, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, builds on that series of articles. She takes the microperspective to tell interesting stories about how the delivery of health care has transformed from a cottage industry into a bureaucratic big-business. The book is divided into two parts. The first, which occupies two-thirds of the whole, is organized by health sectors (hospitals, insurance providers, physicians, device makers, pharmaceutical companies, testing labs, and coding contractors) and tells how each has sought to game the system to their financial advantage. Individual stories illustrate the consequences of this system for real families. For example, Olga Baker's daughter visited the emergency room and was seen by a “consulting neurosurgeon” who recommended immediate surgery. Although she was diagnosed with a benign brain tumor, Baker's daughter was billed $97,000 because the surgeon was an out-of-network subcontractor.
The first part of the book offers stories of a patient or doctor battling the system to illustrate the general theme that health care has become a business bureaucracy, rather than the “noble profession” it was in the past. These are not tales of evil individual doctors or corrupt institutional administrators intentionally inflicting harm. Enough history is introduced to provide a sense of how business bureaucracies have pursued a narrow institutional advantage and have transformed the system from a focus on caregiving to a relentless emphasis on revenue maximization.
The approach and flow of the chapters will be familiar to any reader who followed Rosenthal's 2013–14 New York Times series, in which each article focused on a procedure, such as colonoscopy or joint replacement. One or two illustrative stories deftly frame the main theme in each chapter. Rosenthal provides many vivid examples of large drug price increases or excessive procedural charges. She must have a large Rolodex. Each chapter has at least several timely short quotes from doctors or health system managers, often lamenting the current system.
I have been a member of the Advocacy Committee of the National Multiple Sclerosis Society for several years. Rosenthal's depiction of Mary Chapman, a woman with multiple sclerosis who has struggled for two decades to pay for essential medications in order to function, is an excellent and relevant story about the emergence of effective but very expensive therapies. The lack of transparency in hospital pricing and the inherent conflicts with the physician ownership of facilities are familiar stories, cogently told. The chapters on medical devices and ancillary services cast new light on a world rarely covered in the typical treatment of rising health costs. In the chapter on conglomerates, Rosenthal laments the loss of smaller hospitals that have been absorbed into larger systems and challenges the notion that better bargaining leverage will reduce costs within integrated systems.
Rosenthal's knack for illustrating a point with a good story is less evident in her discussion of public policy. The chapter on the Affordable Care Act (ACA) emphasizes how various actors have undermined the intent of the law; for example, with insurers promoting high-deductible plans or physicians distinguishing between a colonoscopy as a free screening test or a costly procedure for the removal of a polyp. She faults the Obama administration for promising and then dropping the public option from the ACA. However, the removal of the public option in the Senate bill is in fact a complicated tale of needing sixty votes in the Senate, as well as the issue of a Massachusetts Senate race and a surprise GOP victory. The Obama administration was not prepared to risk the whole legislation in a fight over the public option. This is a minor point in the book, but it illustrates how the author's background as a physician and reporter fails to provide the deep understanding of public policy that many readers of the Journal of Health Politics, Policy and Law might wish.
In the second part of the book, “Diagnosis and Treatment,” Rosenthal issues a call to arms to fight back against the big business that health care has become. Throughout the book she references more efficient systems in other developed countries. Her solutions section begins with a cursory reference to fee schedules, single-payer systems, and market tools as approaches. The casual reference to single-payer systems in Canada and Great Britain as both having state ownership of hospitals glosses over the major differences between them. Subsequent chapters do not attempt to evaluate other health systems or suggest how to translate lessons into public policy changes to reverse the detrimental trend toward the corporatization of health care documented earlier in the book.
Rosenthal in this final third of the book devotes segments to doctor and hospital bills; insurance costs; and the prices of drugs, devices, and tests. The major remedy she proposes is to be an informed and aggressive consumer. Scrutinize bills when received, vet and quiz hospitals and doctors about their changes, and carefully study health insurance plans before selecting one. In each segment she usually includes a brief advocacy for policy change, such as more vigorous antitrust enforcement against hospital mergers, negotiable prices for drugs, and malpractice reform. The appendix includes references to health shopping websites, a medical bill glossary, and a set of protest letter templates that can be used to dispute bills that appear incorrect or just outrageous.
Will consumer activism, price transparency, and letters to your congressional representative achieve the systematic change that Rosenthal seeks? Political scientists reading the final chapters will probably find a coherent policy reform strategy missing. This book appears in the spring of 2017 as President Trump and the Republican majorities in Congress are preparing to repeal the ACA. As I write this review, there is no clear replacement that will cover those now insured through the public and private ACA approaches, nor is there any indication that policy changes will address the cost and transparency issues Rosenthal has described.
I have never liked to evaluate a publication by wishing the author had written a different one. Elisabeth Rosenthal was an emergency room physician who became a reporter for the Times. After assignments in Beijing and Rome, she returned to New York and reported on global environmental issues until 2012. She was out of the country and did not cover health policy issues during the decade leading up to the enactment of the ACA. Essentially, her recent work is investigative reporting into the details of health costs as experienced by individuals who require specialized procedures, such as joint replacement or expensive medications. This dive into the weeds of medical charges helps shine a bright light on a very opaque system of medical procedure pricing.
Rosenthal's theme is consumer empowerment as an antidote to the profit-maximizing health services business. She says, “We must become bolder, more active and thoughtful about what we demand of our healthcare and the people who deliver it” (p. 330). However, there is a growing academic literature that does not dispute the value of price transparency and consumer engagement but concludes that this alone is insufficient to change the trajectory of health cost increases (Frakt 2016; Ginsberg 2016).
Rosenthal does not delve deeply into exploring systematic changes to improve the medical market. Although accountable care organizations are a major ACA initiative to address some of the problems she identifies, for example, she does not examine these or other policy proposals as responses to the current dysfunction. This is the book not written.
At this end of the review, the reader might ask, “Should I read the book?” If the various macroperspectives on health care costs seem too abstract and you believe the microlevel experience of real stories informs our perception of problems, then this book deserves to be read and kept on your bookshelf. If you are looking for a personal guide to improve you and your family's chances of navigating the current system, the book will be very helpful. But if you are on a quest to find a book that identifies and analyzes systemic policy change designed to control costs and relieve the growing financial pressure on individuals, part two of the book will disappoint you. Great stories help us understand the essence of a problem. Only systematic policy change will cure what ails the current financial structure and transform the existing health bureaucracies to the benefit of patients and citizens. This will have to be the subject of another book that builds on what Elisabeth Rosenthal has begun.