America’s Bitter Pill — Wrong Diagnosis, No Treatment?
Las Vegas school bus driver Emilia Gilbert enjoyed the crisp air on a brisk walk to work– when suddenly she found herself tumbling face down on the ground, her nose making a sharp *CRACK* on the pavement. Unknowingly, she also tumbled into a dark rabbit hole filled with litigation after litigation against a judicial system rigged in favor of a corrupt healthcare system, along with harrowingly expensive medical bills– nearly ten thousand dollars for a simple broken nose. Esteemed journalist and entrepreneur Steven Brill mentions too many other similar cases in his book America’s Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System through compelling storytelling and vivid imagery; he details the political battle behind the Affordable Care Act (otherwise known as Obamacare)– a controversial bill attempting to reform the nation’s broken healthcare system. Brill describes the creation of unlikely political alliances, the passionate debates, along with the compromises that were fought for through a largely bipartisan government. He is a champion of journalism, reporting on popular social/political events such as the O. J. Simpson murder trial and the Lewinsky Scandal. He began reporting on the political struggle to make healthcare more accessible in 2013, and was the first author to ever take up the entire feature section in Time Magazine. Exposing healthcare industries’ desire for unethical financial gain has won Brill national acclaim; he expanded further on how corrupt healthcare executives often partake in efforts to extract as much profit out of patients’ wallets as possible in America’s Bitter Pill. Brill has scrupulously studied major figures involved in the establishment of Obamacare, created a unique narrative on the behind-the-scenes of political parties fighting for healthcare reform, and crunched the numbers/statistics that big pharma has largely kept out of the public’s eyes. However, there are a few glaring flaws that leave questions unanswered in the book, specifically pertaining to his biased stance against the broken healthcare system and the omittance of crucial perspectives, such as that of the pharmaceutical industry or healthcare workers, on potential solutions to improve healthcare accessibility.
Brill’s emphasis on how dysfunctional the healthcare industry is has been a topic already criticized by activists and journalists for almost a decade. Covering the political process of implementing Obamacare in such superfluous detail for hundreds of pages more affected my enjoyment of the book, but I am simultaneously impressed by the sheer detail and dedication Brill put into each influential individual involved in the ACA. However, he should consider making his arguments more concise to speed up the pacing of his work and focus more on analyzing the effectiveness of Obamacare. Brill frequently criticized healthcare employees for leeching off of the corrupt healthcare system to live a rather extravagant lifestyle. He emphasized the “galloping cost of advances in the science of medicine” and voiced his sarcastic appreciation for the MRI that was provided for him during a hospital visit and how it inflated his medical bills tremendously. Brill would also sprinkle examples of patients who would spend a ridiculous amount of money and time to pay their bills off throughout his book; doing so would appeal to the emotions of his audience/readers and inform them of the financial corruption in the medical industry. His audience was directed towards ordinary US citizens; but I believe this aspect was also the flaw in his position against healthcare, as he failed to consider the perspective of healthcare workers and the mechanisms that govern the “absurd” pricing of medical devices/treatment options.
From a healthcare perspective– these drugs/medications may be the key to saving millions of lives. If not for the MRI that “ballooned his healthcare costs across the board”, Brill will very likely not be alive to continue this work, especially given the fact that his nurses couldn’t tell outright that he was likely to have a deadly heart attack. A surgery or organ transplant vital to keep a patient alive would make sense to be costly because of the importance of such services– should the pricing of treatment options be adjusted to accommodate the economically disadvantaged, this would jeopardize the profitability and survivability of the nation’s healthcare industry overall. Especially given that the American healthcare system is the 6th most profitable industry in the world, this would severely impact the global economy. Although it is true that human organs are largely unaffordable and may serve as a barrier for many individuals in need (especially the economically disadvantaged), lowering the price of organs would subsequently lower the importance and value of such medical care. To resolve the issue of medical services being largely unaffordable, Brill proposed that economists should have a voice in the pricing of medical treatment; however, the nation should instead be focusing on maintaining medical service prices and making healthcare affordable.
Additionally, Brill criticized highly paid healthcare workers like New York-Presbyterian Hospital CEO Steven Corwin, who has a salary of about $3 million dollars annually. Brill should research Corwin’s role in the hospital to understand that Corwin is not paid seven digits simply due to his medical profession, but because of his impact in ensuring quality care for patients. Corwin has partnered his hospital with prestigious institutions such as Cornell and Columbia Medical School and led the New York-Presbyterian Hospital to where the 30-day mortality statistics are some of the lowest in the nation (NYP News, 2019). His astounding leadership, patient care, and networking makes him an essential figure when it comes to leading a hospital, saving patient lives, and ensuring that hospitals are safe. Not many doctors and hospital administrators merited the accomplishments, dedication, and care that Dr. Corwin has implemented into the New York-Presbyterian Hospital, which can potentially justify his high salary. If he were to be given another newly constructed hospital, his leadership at that hospital would be more effective, profitable and efficient than if others were hired to lead the hospital; in other words, his innovative and passionate drive to improve patient care makes him a valuable and unique asset as the head of a hospital. However, Brill focuses solely on Corwin’s salary amount and publicly criticizes him for being paid seven figures, paying no heed to his significance in his role and as the CEO of one of the best hospitals in the nation. Brill’s bias against the healthcare industry does not just end with critiquing the salary of influential healthcare figures, however.
What Brill failed to point out is that the healthcare industry itself also plays a vital role in reducing healthcare costs and increasing accessibility to the economically challenged. The author described the healthcare industry as a house with “bad plumbing and electricity, a leaky roof, broken windows, and rotting floors” where such corrupt financial interests are deeply rooted in its foundation; to specifically target the unethical fiscal incentive that have strained millions of American wallets would subsequently bring down the “house”. Brill hasn’t considered that there are a significant number of healthcare workers and activists that advocate for bringing down such a system, offering a new Medicare for all that would increase accessibility more effectively than the Affordable Care Act. The healthcare industry has implemented treatment options such as telehealth services, where patients who benefit from Medicare could visit doctors virtually, in order to increase accessibility for patients who are in more remote or rural locations (Telehealth.HHS.gov, 2023). Groups such as Accountable Care Organizations (ACOs) recruit healthcare providers that would provide care specifically for Medicare beneficiaries and seek to lower overall healthcare costs and improve quality of care (Centers for Medicare & Medicaid Services, 2023). Additionally, the industry has teamed up with Medicare to create new and effective treatment models that also seeks to reduce costs while expanding services already covered by Medicare. It is therefore evident that Brill has taken a more extreme perspective on the healthcare industry, generalizing all workers of the healthcare industry to be financially greedy when there are communities within healthcare workers established specifically to increase accessibility to healthcare. His suggestions of strategies that could improve healthcare accessibility and affordability is also compromised by his omittance of the healthcare industry perspective.
Brill criticizes the methods of how healthcare industries charge its patients and why treatment options are so expensive– for instance, he refers to the former director of Congressional Budget Office Peter Orszag who posits the dilemma of fee-for-service, where patients are charged for the individual amount of visits, offered services, and ordered tests. Paying through fee-for-service introduces the opportunity for hospitals to practice fraudulent billing, such as charging for services that weren’t provided to the patient or replacing the code for one procedure performed on a patient with a similar, more expensive one. Instead, Orszag proposes that patients should be charged for the results and effectiveness of the treatment. Today, opponents of the fee-for-service method of payment instead propose a “value-based care” model, where medical providers are more accountable for the improvement of patient outcomes and provide greater flexibility to deliver care at the right time (The Commonwealth Fund, 2023). However, measuring an individual’s health outcome quality is a subjective metric; this may call for medical institutions to invest in analysis and data collection to improve measuring an individual’s well being. Orszag provided another solution that could potentially lower both healthcare service and insurance costs– utilizing information technology to provide fair costs to medication/drugs and services, which would depend on how successful the treatment option is for patients. The downside for this argument that both Orszag and Brill advocated for is that such prices are already set by medical professionals/pharmaceutical companies, who are arguably the most qualified to set such costs; economists and politicians setting or revising the prices would be harmful towards the medical industry. With the fact that insurance premiums are paid by hard working Americans, our funds also indirectly pay for medical professionals to advise on the pricing and effectiveness of medications. Not many of us would be as enthusiastic to pay for healthcare costs if politicians and economists with very little knowledge of the purpose of a medication influences the pricing. Given how politicians can significantly influence the pricing of medication today, along with the fact that 14 years have gone by since Obamacare was passed by Congress, it is essential to examine if Brill’s suggestions in improving healthcare were considered.
The democratic majority that voted to pass this bill believed that Obamacare would make health insurance more accessible to millions of Americans without coverage. Was Brill’s criticism on the effectiveness of Obamacare correct? In a holistic economic perspective, the Affordable Care Act was beneficial to insurance companies by incentivizing ordinary citizens to purchase private insurance; pharmaceutical companies also profited more than $100 billion three years after the bill’s release. It was also beneficial to the millions of individuals who were able to afford insurance once private insurance costs decreased, reducing costs if their health was compromised. In a majority of his book, Brill positions himself as a sharp, non-partisan critic against the healthcare system both before and after Obamacare; although I do agree that the Affordable Care Act didn’t do enough to lower private insurance costs, the bill still is a vital step towards improving healthcare insurance accessibility. I believe that the creation of Obamacare was therefore still a win for citizens who struggled to afford healthcare insurance.
I commend Brill’s extensive research, mature thought processes and creative ideas that he imported into this book. His perspective is unfiltered, expressing criticism towards the deeply embedded corruption in the political system along with exposing the frequent fraudulent practices of the healthcare industry. Brill draws support for his critique of the Affordable Care Act from multiple angles; he obtains insight and thought processes formed from significant figures involved in Obamacare such as that of Ted Kennedy, President Obama, and Senator Baucus. However, I felt like America’s Bitter Pill was a bit one sided in antagonizing the healthcare industry. Most of my suggestions are related to how Brill goes into the economic costs behind a drug or a healthcare worker, but very rarely goes into the purpose that a healthcare worker or a certain medication would serve which would potentially justify the cost of their labor. I do not believe that my critique would invalidate the rationale and research he implemented into his book, but while reading I often wondered how he would re-formulate his argument if he were to incorporate more of the healthcare industry perspective, as his argument throughout his work is a bit one sided. Nevertheless, I would highly recommend this book to individuals with a more surface level understanding of healthcare as well as those with an interest in the intersection of economics and medicine. It is a great summary of the nation’s progress in addressing healthcare and a great conversation starter in how the nation can improve accessibility to healthcare. It leads to a fruitful discussion on how as a nation, citizens could utilize the Affordable Care Act as a stepping stone for better healthcare reform/policies.
Works Cited
Brill, Steven. “America’s Bitter Pill by Steven Brill: 9780812986686: Penguinrandomhouse.com: Books.” PenguinRandomhouse.com, Random House Group, https://www.penguinrandomhouse.com/books/240553/americas-bitter-pill-by-steven-brill/.
Centers for Medicare and Medicaid Services. “Accountable Care Organizations (ACOs): General Information | CMS Innovation Center.” Cms.gov, 2020, innovation.cms.gov/innovation-models/aco.
National Nurses United. “Book Review: America’s Bitter Pill, by Steven Brill.” National Nurses United, 6 Dec. 2017, https://www.nationalnursesunited.org/blog/book-review-americas-bitter-pill-steven-brill.
News, 10 Min Read •NYP. “NewYork-Presbyterian | inside NYP: CEO Dr. Steven J. Corwin.” NewYork-Presbyterian, 1 Apr. 2019, healthmatters.nyp.org/ceo-steven-corwin/.
Teachout, Zephyr. “‘America’s Bitter Pill,’ by Steven Brill.” The New York Times, The New York Times, 7 Jan. 2015, https://www.nytimes.com/2015/01/11/books/review/americas-bitter-pill-by-steven-brill.html.
What Is Telehealth? | Telehealth.HHS.gov. 20 Apr. 2023, telehealth.hhs.gov/patients/understanding-telehealth.
