Juliet Eilperin is The Washington Post’s senior national affairs correspondent and author of “Fight Club Politics: How Partisanship Is Poisoning the House of Representatives” and “Demon Fish: Travels Through the Hidden World of Sharks.”
Covering the current health-care debate in Washington, I hear politicians every day (and read them on Twitter) describing our current system as a disaster. Health and Human Services Secretary Tom Price informed a key House Appropriations panel recently that the Affordable Care Act is making health “unaffordable for so many Americans.” President Trump has predicted that the federal insurance exchanges the ACA has created will both “explode” and “implode” (in which order, I’m still unclear). Having just passed the American Health Care Act through the House, congressional leaders and administration officials have promised that the legislation will return the country to “patient-centered care” and lower the costs of premiums for Americans in some states who have seen them spike, once it’s eventually signed into law.
But with just one exception — Trump’s call for lower prescription drug prices — almost no one inside the Beltway is coming up with plausible ideas to cut the cost of health care. Luckily, Elisabeth Rosenthal, a longtime health-care journalist and former emergency room physician, has tackled this question in her new book, “An American Sickness: How Healthcare Became Big Business and How You Can Take It Back.” Reading it is a sobering experience, one that shows what’s really at stake when it comes to our sprawling, costly and illogical health-care system.
Other authors have taken on this territory before: David Goldhill’s 2013 book, “Catastrophic Care: How American Health Care Killed My Father — and How We Can Fix It,” provided a persuasive case for applying free-market principles and greater transparency to the health-care industry. But Rosenthal — who practiced medicine before entering journalism and now serves as editor in chief of Kaiser Health News — combines her reportorial and medical skills to provide an authoritative account of the distorted financial incentives that drive medical care in the United States. As a result, she has produced a fairly grim tale of how patients — and at times, insurers — are getting ripped off, sometimes with devastating consequences. In short, this is the antithesis of a feel-good book.
Yet it is illuminating, because Rosenthal does plenty of digging to explain the puzzling outcomes that patients and those who care for them often encounter. How does the American Medical Association determine the value of specific services that are entered as codes in a given bill? The AMA convenes the Relative Value Scale Update Committee three times a year, where representatives from different specialties argue over how much they’re worth. One former committee member, a dermatologist, tells her it’s like having “26 sharks in a tank with nothing to eat but each other.” Why did the reimbursement rate for immunological tests done by pathologists drop? Rosenthal offers one theory: “Pathologists tend to be quiet, antisocial types and have never been very good at forming alliances or lobbying.” Why doesn’t the Food and Drug Administration have more tools to ensure that drug development is cost effective? Because Congress was in a rush to respond to the thalidomide tragedy in the early 1960s, when the babies of some women who took the morning-sickness drug were left with permanent birth defects.
Plenty of Americans are familiar with the idea that pharmaceutical drugs are vastly more expensive in the United States than in other nations and that drugmakers spend enormous sums on advertising their wares while keeping generic versions of these same medicines off the market. But few probably know that many medical devices get scant scrutiny from the FDA because they fit into the “Class 2” category of devices, which are “substantially similar” to ones on the market and used for a similar purpose. While this might sound reasonable in theory, it means different versions of a vaginal mesh taken off the market in 2002 continued to sell, even though the original one had caused a significant number of internal injuries.
Throughout the book, Rosenthal intersperses human stories that demonstrate what happens when the medical profession fails us. Wanda Wickizer was a healthy 50-year-old until she had “a random explosion deep within her skull” on Christmas in 2013; since she was uninsured, her physical injuries were accompanied by hundreds of thousands of dollars in bills. At one point, a hospital official suggested seizing her home as a way to help erase the debt. A 36-year-old diabetic in Memphis, Catherine Hayley, noted that the insulin pump she wears on the waistband of her jeans is “made of plastic and runs on triple-A batteries, but it’s the most expensive thing I own, aside from my house.”
While Rosenthal does her best to squeeze in a few jokes (mostly lighthearted references at pathologists’ expense), the subject matter makes for dense reading at times. This is a thorough book, but it’s hard to envision a casual reader picking it up and whiling away the weekend with it. And on occasion her obvious immersion in the medical field slows the writing down a bit, as when she decries the disappearance of two anti-nausea generic drugs. “Not having prochlorperazine available in an emergency room is like not having acetaminophen (Tylenol) in a drugstore.” I couldn’t help wondering why the book’s editor hadn’t just struck “acetaminophen” and left “Tylenol” in its place.
Still, Rosenthal does include a set of very practical tips at the end of the book for ensuring that individual patients lower their bills and obtain the treatment they need. This sort of “news you can use” served as a pick-me-up after the parade of horribles that preceded it. She provides smart questions consumers can ask not just their doctors, but also hospitals and insurers. She even strikes a rebellious tone by suggesting that readers consider importing “long-term medicines whose efficacy can be clearly measured” since that’s an easy way to cut costs. “Importing drugs for personal use is technically illegal,” she notes blithely, “but intercepting small packages of medicine is impossible from a practical standpoint — and the U.S. government has for a long time intentionally turned a blind eye to the practice.”
There are several policy prescriptions at the end, too, but even Rosenthal acknowledges that most of them aren’t going to be adopted anytime soon. And that’s the irony of this book: At a time when the national health debate is largely centered on how to manage insurance rules for about 15 percent of Americans, Rosenthal has made a powerful case for everything else that’s wrong in the way that we treat illness in this country. Maybe every lawmaker and administration official should pick up a copy of “An American Sickness.” Then, at last, the serious debate could begin.
By Elisabeth Rosenthal
Penguin Press. 416 pp. $28