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Obamacare = "America's Bitter Pill"

Jack Hays

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Steven Brill has written a book about Obamacare: America's Bitter Pill. Here is Malcolm Gladwell's review.

The Anatomy of Obamacare
www.newyorker.com/magazine/2015/01/12/bill-6
The New Yorker
6 days ago - Malcolm Gladwell on “America's Bitter Pill,” Steven Brill's new history of health-care reform in the age of the Affordable Care Act.

". . . "America’s Bitter Pill” consists of a series of parallel stories. Brill gives us case studies of Americans whose lives have been devastated by outrageous medical bills. He describes the launch of Obamacare in Kentucky; the early days of Oscar, a health-insurance startup in New York City; and his own terrifying experience with a life-threatening aortic aneurysm. Each of these stories orbits his central narrative, “the roller-coaster story of how Obamacare happened, what it means, what it will fix, what it won’t fix, and what it means to people.” Brill’s intention is to point out how and why Obamacare fell short of true reform. It did heroic work in broadening coverage and redistributing wealth from the haves to the have-nots. But, Brill says, it didn’t really restrain costs. It left incentives fundamentally misaligned. We needed major surgery. What we got was a Band-Aid. . . ."
 

Greenbeard

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Brill's bitter bill isn't Obamacare, it's the "lopsided pricing and outsize profits in a market that doesn’t work" he attacked back in his big 2013 Time article, "Bitter Pill: Why Medical Bills Are Killing Us."

He doesn't like the ACA because he doesn't think it attacks the profits and pricing power of hospitals and other health care providers. The review you linked to lays out Brill's perspective: "His solution for the health-care problem is to treat the industry like a regulated oligopoly: he believes in price controls and profit limits and strict regulations for those who work within the health-care world, restrictions that he almost certainly thinks would be inappropriate for other sectors of the economy." Brill is pretty far to the left of where the ACA is, which is why he thinks it's doomed to be ineffective at stemming rising health spending.

His problem isn't his philosophical leaning, it's that he doesn't seem to be following trends in the industry very closely. Or as Dan Diamond put it: "Brill’s an author, not an economist, doctor, or trained health policy expert. Enjoy his reporting, but take his analysis with a grain of salt."

I haven't read the book but from the reviews (including the one in your OP) it sounds like he now thinks the solution is providers taking on more financial risk for the cost and quality of the care the provide:
At the end of “America’s Bitter Pill,” Brill offers his own solution to the health-care crisis. He wants the big regional health-care systems that dominate many metropolitan areas to expand their reach and to assume the function of insuring patients as well. He talks to Jeffrey Romoff, the C.E.O. of the University of Pittsburgh Medical Center, who is about to try this idea in the Pittsburgh area, and becomes convinced that the same model would work throughout the country. “The [hospital’s] insurance company would not only have every incentive to control the doctors’ and hospitals’ costs, but also the means to do so,” he writes. “It would be under the same roof, controlled by Romoff. Conversely, the hospitals and doctors would have no incentive to inflate costs or over-treat, because their ultimate boss, Romoff, would be getting the bill when those extra costs hit his insurance company.” [. . .]

It’s at moments like this that Brill’s book becomes problematic. The idea he is describing is called integrated managed care. It has been around for more than half a century—most notably in the form of the Kaiser Permanente Group. Almost ten million Americans are insured through Kaiser, treated by Kaiser doctors, and admitted to Kaiser hospitals. Yet Brill has almost nothing to say about Kaiser, aside from a brief, dismissive mention. It’s as if someone were to write a book about how America really needs a high-end electric-car company that sells its products online without being the least curious about Tesla Motors.

This is, as Diamond noted, a reversal with what Brill was advocating with respect to hospital systems just a year or two ago. Probably more important than that or the existence of KP is the fact that the industry more broadly is shifting rapidly toward providers taking on risk. Attitudes and provider behaviors are being re-shaped as the way care is paid for and delivered shifts. Or as Peter Orszag observed in his own reaction to Brill's book:

A substantial amount of skepticism, perhaps even within the White House, existed about whether the health-care legislation did enough on costs. Yet the cost curve in health care is bending more drastically than even I believed possible in the fall of 2009. That’s because the collective impact of the legislation’s individual measures, along with similar changes in the private sector, has produced a shift in perspective and therefore behavior among health-care leaders.

This is a significant point that Brill fails to acknowledge -- to the great detriment of his thesis. Ironically, though, it's noted toward the end of the book by Gary Gottlieb, the outgoing chief executive of Partners HealthCare in Boston, who says, “There are a lot of problems with Obamacare. But the attention it focused, at least in the industry, on costs with those pilots made a lot of us realize we have to change how we operate.”

Disconcerting if he wrote a book about a complex industry without mentioning the major trends re-shaping it as we speak.
 

KevinKohler

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I loved his article in Time. And I can see why he doesn't like AHCA. Because it does nothing to address any of the issues he exposed.

Where I live, if you want to go to a hospital, you are going to one owned by the Yale hospital group. Period. Unless you drive to another state. Or have access to the VA.
 

BWG

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Yeah, I was wondering which denier was going to be the first to tout Brill and his book.

60 minutes did a piece on him and his book a week or so ago. Here's the conservative Forbes take on the book and 60 minutes presentation of it.

Sunday night’s interview of Steven Brill by Leslie Stahl on 60 Minutes was much anticipated in large part because of Brill’s new book ‒ America’s Bitter Pill.

[...]

The story as it was recounted Sunday night was reminiscent of Brill’s masterful style of describing everything that was wrong with healthcare (before Obamacare).

'60 Minutes' Stumbles On How Health Insurance Works - Forbes
 

Jack Hays

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Yeah, I was wondering which denier was going to be the first to tout Brill and his book.

60 minutes did a piece on him and his book a week or so ago. Here's the conservative Forbes take on the book and 60 minutes presentation of it.

I'm not sure what you meant by "denier."
 

Threegoofs

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Brill makes some very good points. He writes a lot about healthcare price transparency, which is a huge issue.

But I love how his newfound cheerleaders think he's anti-ACA, when he's actually for a much more radical revision in health care that they would all hate.
 

blaxshep

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"His solution for the health-care problem is to treat the industry like a regulated oligopoly: he believes in price controls and profit limits and strict regulations for those who work within the health-care world, restrictions that he almost certainly thinks would be inappropriate for other sectors of the economy."

While I agree in theory, add the elimination of the insurance industry overhead, this idealism will end up just like communism, a complete failure.
 

Jack Hays

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Brill makes some very good points. He writes a lot about healthcare price transparency, which is a huge issue.

But I love how his newfound cheerleaders think he's anti-ACA, when he's actually for a much more radical revision in health care that they would all hate.

Uninformed as usual. I too would favor a more radical revision in health care.
 

Threegoofs

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Uninformed as usual. I too would favor a more radical revision in health care.

Think it could be because you never post what you favor, but just copy and paste stuff? Or could it be that you entitled the thread Obamacare = America's Bitter Pill, which is not the title or the substance of the book.. the bitter pill refers to the US healthcare system as its been constructed over the last fifty years.
 

Threegoofs

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Not at all. I have many times posted my views on health care. You should read more.

Could it be that you entitled the thread Obamacare = America's Bitter Pill, which is not the title or the substance of the book.. the bitter pill refers to the US healthcare system as its been constructed over the last fifty years.
 

Jack Hays

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Could it be that you entitled the thread Obamacare = America's Bitter Pill, which is not the title or the substance of the book.. the bitter pill refers to the US healthcare system as its been constructed over the last fifty years.

Gladwell summarizes Brill's point and captures my view as well: "Brill’s intention is to point out how and why Obamacare fell short of true reform. It did heroic work in broadening coverage and redistributing wealth from the haves to the have-nots. But, Brill says, it didn’t really restrain costs. It left incentives fundamentally misaligned. We needed major surgery. What we got was a Band-Aid. . . ."
 

274ina

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Universal Healthcare is the only real solution. (and is the lowest cost too)

Insurance gone.
VA, Medicaid, medicare, Tricare all gone.

Salarys only for all medical people. Including dental.
 
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