Hard Pill to Swallow

Some of you probably remember, and may have even read, Steven Brill’s remarkable, award-winning, 24,000-word piece for Time in February 2013 entitled Bitter Pill: Why Medical Bills Are Killing Us. [No link, because it’s behind a subscriber-only paywall]. It was an assessment of the U.S. health care system in the wake of the enactment of the Affordable Care Act that discussed what the law did, and perhaps more importantly, did not, accomplish, particularly in terms of the excessive cost of medical services.

Having written a book-length article, it’s not surprising that Brill went on to write a tome-length book based on the article, and so we have America’s Bitter Pill: Money, Politics, Back-Room Deals, and the Fight to Fix Our Broken Healthcare System, coming it at 512 pages.

Phillip Longman’s review of Bitter Pill–the book, not the article–in the latest issue of the Washington Monthly, is by turns admiring and exasperated. As someone who has done his own pioneering work on what Obamacare failed to address in terms of health care costs, Phil praises Brill’s original article for “concentrating on the profit-maximizing practices of America’s so-called ‘nonprofit’ hospitals.” But in terms of the book:

Now comes the inevitable book, based on the original story plus four others that Brill subsequently published in Time. Unfortunately, though America’s Bitter Pill contains important information about how the political economy of health care actually works and in the end comes to strong, if not original, policy prescriptions, it’s poorly argued and a pretty dreadful reading experience. You’d be well advised to let someone else distill the key take-aways.

Longman suggests that Brill’s otherwise-laudable “old-fashioned, face-time” journalism based on interviews leads him to trust and quote voluble sources (e.g., Max Baucus and his staff) too much. That along with Brill’s own strongly-held conviction that doctors had saved his own life may have created a blind-spot in his analysis. So he does not hold physicians to the same standards he demands of hospitals, drug companies, and medical equipment companies who are frequently the villains of his tale.

The ambivalence Longman feels about this book peaks with his mixed assessment of the final 100 pages:

The final 100 pages or so are largely taken up with a Q&A section in which Brill, somewhat bizarrely, interviews himself about what it all means, and then lapses into a rambling discussion of various policy options. The most prominent of these is one that, I have to say, I strongly agree with. Brill describes a breakthrough moment when it came to him that large, integrated health care providers such as the University of Pittsburgh Medical Center may actually have the potential to hold down prices by taking advantage of their size to deliver less fragmented, more evidence-based, integrated care. But this will only happen, he realizes, if rigorous antitrust enforcement ensures that they are subject to at least some meaningful market competition, and if government regulation forbids them from engaging in abusive price discrimination and profiteering—policy prescriptions we laid out over a year ago in these pages (“After Obamacare,” January/February 2014).

In short, Brill accepts that twenty-first-century health care systems need to become big and integrated to improve their efficiency, but wants them to be treated just “the way a public utility is—with still tighter controls on profits.” It’s a brilliant suggestion, and proof that great minds think alike.

If you’re a health care wonk, perhaps you owe it to Brill to slog through Bitter Pill. But the more important task is to stay focused on the cartels of providers that in the end are as big a threat to the big goals of the Affordable Care Act as the GOP and certain members of the U.S. Supreme Court.

Ed Kilgore

Ed Kilgore, a Monthly contributing editor, is a columnist for the Daily Intelligencer, New York magazine’s politics blog, and the managing editor for the Democratic Strategist.