Brill also details in his own frustrations with the health-care system when he underwent open-heart surgery during the reporting of his book, and people who's lives have been changed because of the ACA. And he closes with a vision for what he thinks health-care should look like. Below is a transcript of our conversation Monday morning, edited for brevity and clarity.
JM: This book dives into the process that led to the passage of the Affordable Care Act about five years after it became law. What lessons do you hope can be taken away from this account?
SB: The whole process by which Washington attempted to tackle and fix the largest industry and the most important industry in the country is really emblematic of how Washington works and doesn't work. What I realized as I was doing the first piece for Time Magazine — and what I realized in spades as I was reporting this book — was that the only way legislation this big, this important can possibly come out of Washington is if the most important group of special interest lobbyists say that it can.
The basic deal that the Obama administration and the Democrats in the Senate had to make was we'll get more coverage for people. But we'll get more coverage for people at the same high prices that allow the drug companies to be so profitable, that allow the non-profit hospitals to be so profitable, that allow the device-makers to be so profitable — and that is the result that is Obamacare.
So the good news is this couple I interviewed in Kentucky who hadn't had access to doctors in years suddenly had access to health care. The bad news is that you and I and all the other taxpayers are paying the same high prices for that health care that dominated and completely screwed up the system in the first place.
Is it too cynical to say that deal-making with industry is just what happens when you want to pass major legislation?
When the lobbying behind the industries that are affected by that legislation spends four times as much as the next largest industry when it comes to lobbying, which is the military industrial complex, this is what you get. The second sort of theme through the book is Washington not only is dominated by money, but it's dominated by a kind of partisanship which I think is also the result of too much money going into primaries and gerrymandering and everything else. The third overriding theme of the book is not only is Washington beset by money and by partisan politics, but it's also beset by a lack of attention being paid to the sheer competence of the government. We all missed the story, me included, in the run-up to the [Healthcare.Gov] launch. The Web site was a train wreck two or three years in the making.
Why do you think the administration missed this?
The administration missed it because they're big on policy, but when it came to governing, the nitty-gritty of governing, they just didn't pay attention to those in the White House who said we really have to focus on this. [Former OMB director] Peter Orszag reportedly wrote a memo to the president saying you've got to bring someone in from the outside to run this thing, and I asked the president about it, and his only answer was, "I don't want to engage in Monday morning quarterbacking."
Since then, they have brought on a CEO overseeing the exchanges.
Yeah, it works.
Now that the Web site works, does this the launch turn out to be a blip in the history of the ACA?
I don't think it's a "blip" because if you remember what happened on Oct. 1, the Republican party was in the doghouse with the American people. They shut the government down, and Obama was riding high. By Oct. 17, when the deadlock ended and the government was in essence re-opened, everyone was focused on the fact that this Web site was a total debacle. I don't think Obama's ever really recovered from that.
I want to come back to the idea that you can't do major health reform without cutting these major deals with the big industry players. What's the solution then?
We should allow the Cleveland Clinics of the world to cut out the middle man, sell their own insurance and become oligopolies or even monopolies. But then we should regulate them very, very tightly. Regulate their profits, regulate what kind of multiple the CEO of a hospital system can be paid as opposed to the lowest-paid practicing doctor. I think if we did that, we could save a ton of money.
Not because the insurance companies are the culprits. The insurance companies are in some ways as much victims as you and I are when we go to the doctor and get a bill. They're paying these high bills, so it's a lousy business, their profit margins are terrible and they also are terribly run. They're backed into a corner by high prices. The way they deal with it too often is abusing their customers.
What did you learn about your experience going through open heart surgery, about your own understanding of the costs and your ability to choose what health-care you receive?
It's very difficult to be a savvy consumer in the health-care marketplace, but I learned it in a very different way. I learned about the fear and confusion of being a patient in a very personal way. And what that really taught me is anyone who thinks providing health-care consumers with better information about pricing and quality — all of which is important — but anyone who thinks that's going to solve the problem just doesn't understand just how different health care is.
It seems here that you're pretty pessimistic on the ACA on cost-control measures.
It's not a cost-control measure. You look up up and down all the pages of that legislation, and you won't find any cost-control measures. You find a reference to a couple of pilot projects for bundled care and accountable care organizations. Those really can't work the way they're structured.
Though, there are health-care systems talking about the need to become more efficient because there are payment cuts built into the law. I'm not saying that's the sole driver behind this efficiency, but does the ACA deserve any credit there?
Sure, I think there's more focus, for example, on hospital readmission for Medicare patients, which is costly but in the sum total of things, it's kind of a drop in the bucket. There are little things like that, but there aren't any big things, there's nothing to control the price of drugs, there's no tort reform, there's nothing to control the profits of allegedly nonprofit hospitals. There's nothing to deal with the profits and the secret contracts that device-makers negotiate with hospitals that buy their products.
Given the industry influences you outline, what lessons can be made for future health reform efforts?
It's not just the lobbying influence. You combine that money with the emotional pull and fear that people have when they think about health care. People care more about their health than they do about health-care policy. And then you add to that the multi-channel political power of the health care industry in every congressional district, because in about every congressional district, the largest employer is the local hospital. And the local hospital is again seen as a charity. You combine that kind of local power with the lobbying power, with the fear and emotion that's attached to health care, and that makes for a toxic political stew.
How is that going to change? I think the only way it's going to change relates to what the thinking was in Massachusetts when Romneycare passed [in 2006]. They're very candid about this — we'll give everybody coverage and then when people see how much it costs, there'll be this huge political wave to say we have to reform this, or we're going bankrupt.
Given that, was the ACA worth all the effort?
I think it was. If you give me a choice between whether the Fords — the family I spent a lot of time with in Kentucky — whether she'd be alive or dead [without the ACA], she'd be dead without access to a doctor and realizing she had a near-fatal heart condition. So if you give me the choice between whether they get care or they don't get care, I'm all for the Affordable Care Act.