Steven Brill's 'America's Bitter Pill' tackles healthcare mess

Steven Brill's 'America's Bitter Pill' tackles healthcare mess
Author Steven Brill and the cover of the book "America's Bitter Pill" (Random House)

When it comes to healthcare, the United States is a pitiable mess. As Steven Brill writes in "America's Bitter Pill," the country spent $3 trillion on it in 2014, far more than any other developed country; more, in fact, "than the next ten biggest spenders combined." It is also the single largest expense for most American families and a driver of social and economic instability for millions.

But for all that Americans spend on health, the care we receive is often inferior to countries with similar standards of living. Not only that: America is still the only country in the developed world without some form of universal coverage, with an estimated 30 million Americans expected to remain uninsured for years to come. Why is the American healthcare system so woefully inadequate, and what, if anything, has been done to ameliorate this distressing state of affairs?


Brill, a journalist and entrepreneur (he founded Court TV and the American Lawyer magazine), provides an exhaustive and highly edifying answer to these questions. The book, based on a series of articles Brill wrote for Time magazine, tackles an inherently complicated (and some might say unnecessarily convoluted) subject — the politics and policy of healthcare — with notable diligence and analytical rigor.

The book begins with an indelible moment: Brill, preparing for emergency heart surgery, awaiting the terror of the surgeon's knife. It was in this instance of intense vulnerability, he writes, that he personally intuited why debates over healthcare are so fraught. They often broach matters of life or death, and it is hard to think dispassionately — in terms of abstract cost-benefit analyses — when confronted with the specter of our own mortality or of those we love. "America's Bitter Pill" seems driven by this key insight.

Overall, the book serves as a thunderous indictment of what Brill refers to as the "toxicity of our profiteer-dominated healthcare system." But it is far more than that, including a deeply sourced and expertly reported history of the passage of the Affordable Care Act of 2010 (commonly known as Obamacare) and of the calamitous launch — as well as eventual rescue — of the bill's signature online exchanges in October 2013; a series of often heart-rending vignettes about everyday victims of our broken healthcare system; and a sophisticated, and at times technical (but admirably clear) analysis of the long-term political economy of the U.S. healthcare market.

As Brill details, much of the dysfunction in healthcare can be traced to a single regulatory deficiency: largely because of the influence of the pharmaceutical, hospital and medical device lobbies, the United States does not engage in wholesale rate-setting in the healthcare market (although it does so in a limited fashion for those enrolled in Medicare and Medicaid). Through a price list known as a chargemaster, American hospitals engage in unconscionable gouging — marking up even the most basic products like Tylenol by 100% the retail cost. In some cases, hospitals inflate the price for cancer drugs by 400%. These markups are passed on to insurance companies and, ultimately, to patients.

Pharmaceutical companies also appear to conjure prices from midair. Take the particularly egregious example, described by Brill, of Sovaldi. A new drug that can potentially cure hepatitis C, Sovaldi has been priced at $1,000 a pill, with an 84-pill treatment regimen required — meaning that each potential patient faces an $84,000 course of medication, before whatever one's insurance will cover.

It is this reality of entrenched, powerful and moneyed interests that Democrats faced in 2008, when a newly elected Barack Obama resolved to make good on his party's half-century dream of providing universal coverage. But rather than essay a complete overhaul of a deeply flawed system — let alone seriously push for a transition to single-payer care — the architects of the Affordable Care Act tried to mitigate only its worst excesses and consequently failed adequately to address the "profiteering" that causes the underlying inflation in healthcare costs.

This failure was not incidental. While the legislation was in its nascent stages, Senate Finance Chair Max Baucus made deals with the pharmaceutical and hospital lobbies (former Rep. Billy Tauzin, representing Big Pharma, proved particularly adept at extracting concessions) to secure their cooperation or at least acquiescence with reform efforts. So to increase by millions the number of Americans with healthcare — a worthy and even morally necessary goal — the architects of Obamacare further entrenched an immoral system of runaway profit. This may have been, as Brill observes, "the right tragic choice," but it also represents a failure of progressive policymaking that may prove irreversible.

In the book's final section, Brill appends some inventive if not entirely convincing proposals for decreasing long-term costs and improving care. Though far from an ideologue — he has a businessman's pragmatism — he gives short shrift to proponents of a "Medicare-for-all" or single-payer option, failing to seriously analyze, or really analyze at all, the financial or social benefits of such a system. (The United Kingdom, that fearful bastion of socialized medicine, spends roughly 9% of its GDP on healthcare; in the United States the figure is close to 18%.)

I also believe Brill overestimates the healthcare industry's incentives to enforce its own cost-control regime, even with the increased consolidation and enhanced government oversight that he proposes. On the other hand, he underestimates the federal government's long-term ability and willingness to oversee rigorously an industry containing many powerful private interests.

Still, there is much to applaud about "America's Bitter Pill." I suspect it will help shape our judgment of the Affordable Care Act and of the systemic failures that the legislation sought to address for a long time. It is, moreover, a damning account of the parasitic, corrupting interests slowly degrading the legislative process and of the feckless state of American bureaucracy.

For its insights into our nation's fiscal, psychological and corporeal health — and for our own long-term social well-being — it is a book that deserves to be read and discussed widely by anyone interested in the politics and policy of healthcare.

Dorfman is the associate editor of Ethics & International Affairs, the journal of the Carnegie Council.

America's Bitter Pill
Money, Politics, Backroom Deals and the Fight to Fix Our Broken Healthcare System

Steven Brill
Random House: 512 pp., $28