In her rousing, fast-paced and well-researched book, Elisabeth Rosenthal posits that our nation’s current dysfunction in health care began a quarter of a century ago. The “final nail in the coffin of old-fashioned noble-minded health insurance,” she writes, took place in the 1990s. That is when the board of Blue Cross and Blue Shield, a mission-minded, highly regarded nonprofit, allowed members to become for-profit insurers. Deeply in debt, the Blues could no longer compete with for-profit insurers that cherry-picked young, healthy customers, leaving to the Blues America’s sickest. Since then, the U.S. health care industry has become less patient centered and more market driven.
How did health care become so expensive? What can we do to change it? Can we provide universal coverage to all Americans? These are critical questions that Elisabeth Rosenthal and John Geyman, both physicians, address head-on.
Rosenthal graduated from Harvard Medical School, practiced medicine at New York Presbyterian Hospital, then spent 22 years as a reporter for The New York Times.Currently she is editor in chief of Kaiser Health News, an independent news venture of the Kaiser Family Foundation.
In this timely book full of passion, information and crystal-clear prose, Rosenthal names the problem, affordability, then gives readers a brief history of the commercialization of health care followed by diagnosis and treatment. She proposes actions regular citizens can take to improve health care—how to make demands and complain effectively, for instance (in writing and to the right people) about bad service, exorbitant prices and unreadable bills. In appendices she gives tools for price shopping, billing, negotiating, vetting hospitals and more.
Health care is market-driven, Rosenthal explains, yet the health care market is unlike other markets. Neither competition nor economies of scale bring lower prices or improve services or products. Rosenthal spotlights a Catholic hospital founded by the Sisters of Providence that has grown into a huge health system called Providence Health & Services. It is the third largest nonprofit hospital system in the United States., with billions of dollars in revenues and assets and a chief executive officer who is paid $3.5 million a year. Yet when it merged with a smaller secular hospital, Swedish Medical Center of Seattle, a patient Rosenthal reports on saw her bills rise rather than fall.
Health care is market-driven, Rosenthal explains, yet the health care market is unlike other markets.
Rosenthal cites other market aberrations. Government regulators cannot stop the flood of consolidations and mergers or flagrant conflicts of interest. And health care pricing is guarded like a trade secret. Prices for the same service can vary markedly within a single hospital or doctor's office, depending on a patient's insurance. Consumers do not know what they will be charged for tests or treatment. Why? Before buying a house, a car or even a meal, consumers routinely search for comparables. Prices are public, menus are posted. But people in need of critical health care find few comparables. Instead, patients receive bills after the fact. Hospital bills routinely lack transparency, few are itemized, most are long, opaque and/or indecipherable. Prices bear little relation to the real cost of an item or service.
Given the great size of the health care industry (roughly one-fifth of the U.S. gross domestic product), its decisions have an outsized, sometimes immediate, impact on consumers. A giant insurer pulls out of a state or regional market on short notice. Overnight a pharmaceutical company decides to stop producing a drug or to multiply its price by 10, leaving in the lurch all who depend on the medication. If competition is scarce, a drug maker may discontinue an old widely used drug, forcing consumers to buy its new expensive version or do without.
With maximizing profits as the goal, a hospital or medical business may discontinue any service or product it deems not profitable enough, life-saving or not. Finding a cure for a disease like diabetes or multiple sclerosis could be deemed less profitable than treating the illness over a patient's lifetime. What a cure would mean to suffering people never enters the calculation.
In health care, consolidations and mergers swallow small businesses, forming mega-insurers, huge hospital systems and pharmaceutical companies that can charge whatever the market will bear. As the nation’s largest lobby, the health care industry wields enormous power.
Market-driven health care has influenced doctors’ practices. Small practices run by self-employed doctors are rare today. Doctors are commonly employed by hospital systems. In affluent areas, some doctors refuse to treat insured patients, operating solely “out of network” at higher cost to patients. Concierge medicine has developed because indulging the wealthy is especially profitable. As medical students prefer high-paying specializations to general practice, the nation suffers a shortage of primary care physicians.
Americans now pay $3 trillion annually for health care, not including insurance.
Health care has spawned whole new layers of employees and consultants, from business managers and administrators to billing experts who help the industry maximize profits through strategic billing of Medicare and Medicaid. Taxpayers, of course, pay the cost of rampant fraud and fraud monitoring.
Americans now pay $3 trillion annually for health care, not including insurance. Studies show that we spend much more for worse health outcomes than do citizens of many other highly developed countries, including Canada, Scotland, Britain, France and Japan.
I cannot do justice in the space of this review to the nuance and breadth of Rosenthal’s book. She reports on real people's experiences in health care and masterfully blends these with academic data, historical research, analysis and solid argument. As a reader, I felt concerned, enraged, educated and inspired to do something. This book is invaluable for anyone concerned about U.S. health care. I highly recommend it.
That said, neither Rosenthal nor Geyman is a Catholic. They are not fans of Catholic hospital guidelines on end-of-life issues or women's reproductive issues. Rosenthal questions the tax-exempt status of any nonprofit that spends “surpluses” (a.k.a. profits) on things other than care. She has a point.
Crisis in U.S. Health Care: Corporate Power vs. the Common Good is the latest in a long list of books by John Geyman. He surveys health care history from 1956 to 2016, analyzes what is amiss and reaches conclusions similar to Rosenthal’s. Geyman's writing style is largely formulaic, chapter goals followed by bullet-points and a concluding comment. This makes the book less engaging. But alongside Rosenthal’s book, his experience as a doctor, educator in family medicine and writer/editor/publisher is additive.
Geyman spends a chapter each on mental health and public health, which are not covered by Rosenthal. When he tells his own story in Part II, we can picture his two separate stints as a rural physician. His wife with her horse, he piloting a plane to reach patients and teach. His voice sounds folksy; he loves what he does.
In Chapter 22, Geyman argues strongly for national health insurance (N.H.I.), a single-payer system sometimes described as “Medicare for all” that he considers the inevitable solution to our current dysfunction. National health insurance was much discussed during the planning stages of the Affordable Care Act, but was hijacked, in Geyman’s view. Bernie Sanders advocated it during his 2016 presidential bid. If proponents could interest the public, national health insurance might gain traction over the next few years as Americans respond to Republican efforts to replace Obamacare.
How would national health insurance provide affordable coverage for all? Progressive taxes would pay for it, costing most taxpayers less than the $25,000 a year a typical family of four now pays for health insurance. A single-payer system would negotiate drug prices for the nation and would simplify and standardize the process of offering options and providing health insurance in all 50 states. Under the plan, writes Geyman, Americans “will have universal access to affordable, comprehensive health care wherever they live and regardless of their income or health status. They will have free choice of physician and hospital. Their N.H.I. cards will be good anywhere in the country…. Benefits will include physician and hospital care, outpatient care, dental services, vision services, rehabilitation, long-term care, home care, mental health care, and prescription drugs.” No copayments or other out-of-pocket costs at the point of service, he continues, would be required. It all sounds dreamlike, except that Canada and Scotland already have national health insurance, models from which we could learn.
Especially important to Geyman (and consonant with Catholic social teaching as well, which sees health care as a human right), N.H.I. would replace health care's profit-driven core with a focus on the common good. Medicine might earn back public trust and its reputation as a noble occupation.