1. Young, Robert C. MD

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Whether you are a critic or a passionate enthusiast for Obamacare, you will finish Steven Brill's detailed, objective, and rigorous analysis of our health care system with a mix of anger, frustration, and perhaps some measure of satisfaction. The veteran journalist who has followed the Affordable Care Act legislation since its beginning has shared some of his observations in a series of TIME magazine articles including an entire issue in 2013. He has brought together all this and more in America's Bitter Pill.

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ROBERT C. YOUNG, MD.... - Click to enlarge in new windowROBERT C. YOUNG, MD. REVIEWED BY ROBERT C. YOUNG, MD Chairman,

He opens with a brief history of the origins of our peculiar health care system with President Roosevelt's wartime National Labor Relations Board decision that health insurance was not subject to wage controls. The Eisenhower administration added the IRS decision that it should therefore not be taxed. This created untaxed employer-based health care for almost all workers. This was followed by President Johnson's Medicare and Medicaid legislation, which focused on the needs of the elderly and the poor.


American health care became a gerrymandered system with large but incomplete groups covered by different systems. In this reviewer's view, this early history is more fully and richly covered by Princeton historian Paul Starr in his book Remedy and Reaction reviewed here in the April 10, 2013 issue (


Brill's analysis begins with a comprehensive discussion of the Obama plan modeled after the successful Massachusetts program, ironically termed Romneycare. That plan was based on three principles: (1) No exclusions for preexisting conditions; (2) Individual mandates to buy health insurance; and (3) Government subsidies for those who could not pay.


Brill digs deeply into the "sausage-making" between the White House and Congress in order to secure enough votes for passage. Deals with big pharma, insurance lobbyists, device manufacturers, and dissident senators were both odious and in Brill's view, necessary. The American Medical Association, weaker than in earlier years of health care reform efforts, was content with Obama's assurance that "if you like your doctor, you will be able to keep your doctor, period." Negotiators added the assurance that correction of the earlier Sustainable Growth Rate legislation would produce a permanent "Doc Fix." The legislation ultimately reneged on this commitment in an effort to achieve "net-neutrality" for the cost of Obamacare. This smoke and mirrors political chicanery is presented with such meticulous detail that it is both clear and disheartening.


'Bureaucratic Bungling, Incompetence, and Turf Wars'

Brill's scene then moves to the implementation of the now-passed legislation. Here Brill is superb. He documents a level of bureaucratic bungling, incompetence, and turf wars that are almost laughable if they were not so serious.


Seven different individuals from the Department of Health and Human Services (DHHS), the Centers for Medicare & Medicaid Services (CMS), the White House, and others were said to be in charge, and 55 separate contracts for implementation were issued. No one in the White House or CMS had any choice in the selection of the major contractor CGI.


While one might be tempted to assign all the blame to the present administration, the organizational dysfunction seems to be so systematic that one wonders whether the federal bureaucracy is able to carry out this type of complex initiative. It finally took a handful of very skilled outsiders from Google and Twitter working with other information technology super-stars to fix the government's mess.


But government agencies with the correct organizational structure and a passion for excellence can do this, as Brill illustrates with Kentucky's "kynect." There they had one general contractor, a single project headquarters, a single passionate and skilled project leader, and a committed and energetic Governor. Kentucky implemented Obamacare nearly flawlessly. By day four of the launch, Kentucky had enrolled 4,739 people compared with just 248 for In the end, Kentucky added 58 percent of its entire uninsured population to either kynect or Medicaid.


Poignant Stories of Ordinary Americans Caught in the Health Care Maze

As Brill narrates the stepwise political process, he weaves in poignant stories of ordinary Americans caught in the maze of our health care system. He explores our arcane "chargemaster" system, where hospitals propose ridiculous costs for ordinary medical materials.


He also contributes his own personal experience with health care when he has surgery for an aortic aneurysm. Here he presents the great health care cost paradox with his comment: "When it comes to our own health, we don't care about cost-benefit analyses; we only care about maximizing the benefits." He also points to hospital cost abuses-and unfortunately several of our most prominent oncology centers are featured.


So now that we have the Affordable Care Act, what has it done and not done? Brill praises the fact that we now have about 10 million newly insured Americans and an additional six million added to the Medicaid rolls. That has reduced the percentage of uninsured Americans ages 19 to 64 from 20 to 15 percent. That's progress, but at the outset, we had about 45 million uninsured or under-insured so many are still not covered through the Affordable Care Act.


As Brill indicates, the plan "was all about the government, through premium subsidies, giving everyone enough money to buy health care from the same private insurers who would pay the same high prices to the same private drug companies, doctors, device makers, and 'non-profit' but profitable hospitals to provide it."


In spite of the arguments to the contrary, the Act does little to control health care costs or even "bend the cost curve." Most of the cost savings proposed at the outset to achieve net-neutrality have been abandoned or never really existed. It should be no surprise that the permanent Doc Fix was finally enacted just this year, long after the Congressional Budget Office had estimated it as a $200 billion savings from the sharp reduction in physician payments that never occurred.


The attempts to build a robust Comparative Effectiveness (CE) research effort have also withered. Medicare cannot make decisions on pay based on CE studies, and only 37 percent of the CE research actually compares one therapy with another.


The winners from the Obamacare legislation appear to be hospitals, drug companies, insurers, and the federal government. Doctors, it would seem, are less likely to have the negotiating clout to compete on an equal footing. As Brill mentions, his insurer cut payments to New York-Presbyterian Hospital by only 12 percent because they needed this large hospital in their coverage plan. In contrast, it cut his payment to his surgeon by 65 percent.


Brill's own solution to health care reform is a shortcoming of the book. He recommends the development of monopolies or oligopolies of tightly controlled hospital systems acting as their own insurers. Unfortunately, essentially eliminating the insurance industry, controlling oligopolies, and increased government supervision over the health care system seem to be high hurtles indeed.


Still, if you are searching for the definitive work on the creation of the Affordable Care Act and its implications both good and bad for our health care system, this is the book for you.




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