As the Trump Administration and American Democracy rapidly mutate into something vaguely resembling a third-rate political thriller — imagine James Patterson and Dan Brown teaming up for an afternoon of benzos and brainstorming — it’s easy to get caught up in the nonstop melodrama, over-the-top plot twists, and credulity-straining storyline:
Chapter 1: The American President — obviously an elderly gameshow host and “alleged” sexual predator with a spray-on tan and fake hair — is being investigated by the FBI for colluding with the Evil Russian President — who just might have in his possession an incriminating Golden Shower Sex Tape of the American President — to fix the U.S. Election.
Chapter 2: The American President acts quickly: he fires the FBI Director, who, it turns out, had previously refused to pledge his undying loyalty at a fancy White House dinner. But wait — ZANG! — the FBI Director produces a secret memo indicating the American President asked him to kill the Russia Investigation before he was fired.
Chapter 3: Unbowed, the American President logs into Twitter, telling the FBI Director in no uncertain terms that he’d better not leak anything to the press (a.k.a. the Enemy of the American People) because — ZANG! — there might be some super secret tapes of their conversations.
Chapter 4: Feeling chuffed by his threatening tweet’s 24,441 retweets and 76,219 likes, the American President hangs out in the Oval Office with some Russians, calls the FBI Director a “nut job,” and jets off to the Middle East to sell a bunch of weapons to Saudi Arabia. After that, the American President heads to the Vatican and makes the Pope really sad before globetrotting to Europe, where he shoves the Prime Minister of Montenegro (in an effort to better pose for photographs) and tells NATO to go fuck itself.
Chapter 5: The American President is feeling pretty ebullient as he prepares to head back home, but wait — ZANG! — did the Real-Estate Developer/White House Innovations Director/Son-In-Law really try to set up a secret communications channel with Russia after the election…only time will tell!
While the last month has indeed been a roller-coaster thrill ride — and who doesn’t like to check the latest impeachment odds — it’s important to remember that while TrumpGate slowly envelops the White House, these assholes and those assholes are working really hard to take away 23 million Americans’ health insurance, let insurers deny coverage for pre-existing conditions and, give a bunch of rich guys tax breaks.
As our Commander-in-Chief recently pointed out, health care is surprisingly “complicated,” what with its death panels and out-of-network deductibles and government funding for abortions and pap smears — all of which prompts an obvious question: How did health care in America become such a terrible mess?
That’s what physician and journalist Elisabeth Rosenthal sets out to determine in An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, a bestseller that not only documents the commodification of our medical system, but provides readers with common sense tips for reducing health care costs and dealing with insurance company bureaucracy.
Rosenthal recently talked with The Millions about fixing our health care system, why I can’t understand the forms my insurance company sends me, and the possibility of TrumpCare.
The Millions: So, just yesterday I got this seven-page explanation of benefits from my insurance company, and I looked at it briefly and then just threw it away. I didn’t owe them any money, but I had no idea what any of it meant. How did health care become this thing that almost no one can understand?
Elisabeth Rosenthal: It’s a hugely complex Rube Goldberg-like system now, much of whose revenue generation comes from the complexity, not from the health care. One of the reasons I wrote the book is because when you look at this health care system, you think who’d invent a system like this? It’s insane. No one would design something like this.
What I wanted to do with the book was to say how did we get here? What created this monster of a health care system?…It’s a classic case of the road to hell is paved in good intentions because everything, at the moment it was proposed, made sense. It was like, “Okay, you know, we need insurance.” Of course, we need insurance…because health care got more complicated, it got more useful, there are much better drugs and treatments, but that means they’re more expensive.
When we first got insurance—and my guess is you’re not old enough to remember this—it paid everything. Your employer bought it for you, if you were lucky enough, as most of us were then, to have employer-based insurance; you didn’t pay the premiums; there were minimal, if any, deductibles or co-payments.
Then what happens is everyone gets insurance and if you’re [a doctor] charging $30 before—when someone has to write a check—you start feeling like, well, nobody’s paying, right? You’re not having someone write a check. It’s all in back rooms that this money is getting shuffled around. So the $30 visit becomes $300, and then becomes $500. There’s this kind of inherently inflationary incentive in a system where nobody seems to be paying. No one feels the price in that way.
And then what happens, which is really a tipping point, is once you see this slow shift of looking at the finances of medicine rather than the care of medicine as being the driver of what we see and what we get. And what happens then—and particularly this accelerated during the ’90s where there was a lot of pressure to control costs from the early HMO movement—a lot of hospitals, feeling that pressure and really in financial troubles, start hiring, and the business consultants start offering, people from McKinsey and Deloitte to come in and say, “How can we make this right? How can we do this better?”
These are people not with medical skills, but with business operational skills. And they look at it kind of like reorganizing a chicken processing plant or a widget factory. And what they come up with is to say, you’re not billing very well for this stuff. You do all this stuff for free which is what hospitals do.
When I was practicing emergency medicine, there was a fee for the emergency room, but it included my services—nothing was billed separately. But when these consultants come in they go: Wow, you’re leaving all this money on the table—you could bill for the doctor separately. You could bill for the blood tests separately, you could bill for checking the oxygen, you could bill $17 for a Tylenol—that famous example—there’s nothing stopping you.
And that sets off this inflationary cycle where hospitals start thinking how can we do the same stuff but make a lot more money by billing differently? And that sets off this crazy spiral where hospitals hire a lot more business people to help them with the operations. And then the physicians who are working in this system as it’s becoming more efficiency and business focused are kind of rebelling. They almost sound Marxist: We’re producing the labor, why are all these funny guys with MBAs running this hospital now?
And they start wanting in on the money too, some of them, because they feel if 20 guys are making a million bucks, and I’m doing the work, why shouldn’t I get some too. So, the more entrepreneurial ones start charging more for what they do. And then the drug makers—it moves from sector to sector…And you kind of end up in this place where business is the driver and health care and what’s good for patients is kind of on the back burner.
I’m not saying that no one cares about it. Many physicians care deeply about it, but the system is not geared to those values. The problem is the values of business and the values of health care may intersect in some circumstances—I’m not opposed to people making profits—but in the abstract, they’re not very similar a lot of the time. Business wants efficiency, revenue generation, profit maximization….But the values of health care are really different. They’re caring, listening, healing, spending time. And that’s not a very inherently efficient process and it also may or may not be a great way to make money. It is now. But if you’re a doctor is sitting with the person with new diabetes and talking to them for an hour—that’s a terrible way to make money. There’s no business model for that.
TM: So what needs to change? How do we fix this?
ER: Whichever system we go to—whether it’s more market based or single payer or price regulation—you need to see prices, you need transparency. And I don’t get why that’s not required…I think price transparency is really important including, just a small example at FDA hearings. When FDA panels convene to approve a drug, they have no idea how much it’s going to cost—like zero. Because the metric of FDA approval from 100 years ago—maybe not quite 100, but decades and decades ago—was is it safe and effective? And that is effective compared to nothing, compared to placebo…
So, why don’t we—in a world where we have a lot of drugs for every condition—why don’t we say effective compared to the other drugs that are already on the market, and tell us how much you’re going to charge? What’s your price point? You see over and over again in FDA hearings where it’s like Voldemort, nobody’s allowed to discuss it. And the panels are trying to figure out, well, what are they going to charge…We need to change those standards.
Likewise, doctor’s offices, hospitals—they can show you prices, they just don’t want to…If a hospital had to say, we’re charging $8,000 for an MRI of your abdomen—which actually my daughter’s was $13,000 at one emergency room—no one would actually charge that because people would be up in arms.
And Australia is just a little example: if you’re going to the hospital for an elective procedure, you get a binding estimate of what the cost will be and what your expected charges are out of pocket. That can happen, it’s just there’s no business model for it happening. Price transparency is not good for the business in many cases.
Likewise, doctor’s offices and labs could list prices. Someone in the book discovered, much to her distress, that the vitamin D test that she’d been asked to pay $700 for was $7 at other labs—but she had no way to know that ahead of time. With that kind of price variation, I think we deserve to see prices. Transparency, whatever system we go to, I think is an essential component.
Every time there’s an EpiPen or Martin Shkreli episode, there’s outrage over high drug prices, and in Congress there are some hearings, and then nothing happens. Everyone promises we’re going to do something about it, including our new president, and nothing happens.
There have been bipartisan bills, for example, Sens. McCain and Klobuchar have suggested, for several years now at least, that Americans be allowed to import prescription drugs from Canada in a controlled way.
Other people on both sides of the aisle have suggested that Medicare should be able to negotiate drug prices for Medicare patients. Again, both ideas have had a lot of bipartisan support. Neither one ever gets through Congress because of pushback from the industry. That’s something we as patients and voters should be really on top of our representatives about.
TM: You mentioned business taking over, which leads us to the current moment. What’s your assessment of the current health care legislation in the House and Senate?
ER: The Republican proposals by everyone’s estimation will leave a lot more people uninsured. And I think the narrative that people choose to be uninsured, from where I sit as a reporter, is a really false narrative, you know: we want to give people the right to not have good insurance.
I think most people want insurance. They desperately want good insurance, but it’s really, really expensive. And the reason it’s really, really expensive, meaning they can’t afford it, is that our prices are so high. Whether you’re talking about the new Republican act, or you’re talking about the [Affordable Care Act] and the ways in which it didn’t deliver some of its promises—the problem is the prices are just too high, and you can’t really make the system work in any way unless we face that first step head on. It’s true many of the Obamacare premiums rose a lot. And why did they rise a lot? Because prices are rising a lot.
And insurers, they don’t eat those price rises. When a hospital changes from charging $60,000 to $100,000 for a heart attack, the insurer doesn’t eat that. They may negotiate it down a little bit, so maybe they’ll pay $80,000. But their primary response is to push those costs onto patients—and not directly, which is why we’re always so confused about it. It’s in the form of next year your premiums go up. Suddenly you have a deductible that’s $10,000 a year, so you can’t even really use your insurance.
Whatever choice we make—even whether it’s single-payer or a much more market-based approach with a lot of transparency—you need to bring down the prices because nothing will work when we’re paying two to three times more than every other country for drugs, a hip implant, getting stitches in the ER. People are just kind of gobsmacked when you tell them what we pay here.
TM: What do Americans need to do to kind of survive—and in the case of health care it’s more of a physical survival—Donald Trump?
ER: They need to become health care voters…All during the campaign last year, health care didn’t really come up except to say, “We’re going to repeal and replace.” People were not health care voters. It wasn’t a voting issue.
And now, you look at the town halls and see those same people, what are they talking about? What are they confronting their representatives on? It’s their health care. So, I think it did form a wakeup call to people that they need to be health care voters. They need to make noise about their health care, and they need to ask all those uncomfortable questions of their local doctors, hospitals, assemblymen, about what are you doing for me?
We have to make sure that our political representatives who, believe me, are hearing day in, day out from the lobbyists on behalf of pharma, hospitals, insurers, that they need to hear from us too…So, it’s a lot of really grassroots political noise where we hold our representatives accountable.