After the failure of Paul Ryan’s American Health Care Act to get passed over the internal squabbling of House Republicans despite their forty four vote majority, David Brooks wrote an interesting tongue in cheek column entitled “The Coming Incompetence Crisis.” He articulated his concern:


…I worry that at the current pace the Trump administration is going to run out of failure. So far, we’ve lived in a golden age of malfunction. Every major Trump initiative has been blocked or has collapsed, relationships with Congress are disastrous, the president’s approval ratings are at cataclysmic lows.


Since the rapid failure of the AHCA there have been many articles reiterating the brilliance of the president’s epiphany when he reported with surprise, “Nobody knew that healthcare could be so complicated!” During Congress’s two week Spring/Easter recess some of its members had some boisterous town hall meetings where they faced angry crowds that were still concerned about the Republican healthcare agenda as both Ryan and the president began to talk about modifications of the AHCA that might win a majority of votes in the House.


I have been quite concerned about what would happen next since March 24 when the AHCA was withdrawn. My concerns quickly replaced the jubilation I had briefly enjoyed over the withdrawal of the AHCA. That brief joy was squelched within a few hours when the president concluded his comments to the press on the withdrawn bill by predicting that the ACA would explode. My smart aleck response was, “Sure, you know it’s going to explode because you can light the fuse!” The likely vector of how my concern will become a reality is nicely summarized in a recent New York Times editorial, “Donald Trump Threatens to Sabotage Healthcare.” Withdrawing financial support from exchanges will force insurers to exit, but there are also several other fuses that the president can light to make his prediction come true.


Elisabeth Rosenthal’s book, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back documents just how dysfunctional and greedy our current healthcare industry is. After reading the book I am wondering if perhaps letting Trump “blow up” the ACA might be the fastest route to the Triple Aim. Perhaps I am a little depressed, but the reality she presents leaves me mumbling that old piece of wisdom from Maine, “You can’t get there from here!”


To fully appreciate the book you need a little information about the author. Dr. Rosenthal is an internist who is currently the Editor-In-Chief of the Kaiser Health News. She graduated from Harvard Medical School and then did her residency at New York Hospital-Cornell Medical Center. She worked for five years in the emergency services of the New York Hospital. In 1994 she left practice to become a writer for the New York Times. In 2014 she published a series of articles on healthcare finance entitled “Paying Till It Hurts”.  I became aware of her new book through a pre publication review in the Times by Jacob Hacker, a professor of political science at Yale.


Professor Hacker’s review is a helpful orientation to the book. The book can be viewed entirely as her answer to the question of why healthcare does not conform to the concepts or mechanisms of a traditional market. He points out that the difference between the expensive care Americans receive and the equally effective but much less expensive care in other countries can be largely explained by an analysis of the role of government. Rosenthal expands this idea with the flourish of a story teller. There is a story to how the insurance industry evolved to its current state of dysfunction and confusion. There is a story behind the transformation of charitable hospitals into self serving margin generating “non profit” money minting machines. There is certainly a rapidly evolving story to the excessive prices of drugs and medical devices.


Rosenthal’s story is not limited to the “how” of how we got to this dysfunctional moment in time. Her story is personalized to reveal the toll of pain and suffering that “good business” decisions extract from patients whom she has meet and presents as real people with real names and real reasons to despair from what they have endured. Her story subtly reveals that the ACA has not failed because it caused increases in healthcare expense. It has failed because it was not designed or empowered to change the culture of business that has captured healthcare over the past three or four decades.


I was impressed with the truth she presents that demonstrates a lack of transparency in pursuit of profit. It was interesting to see that although she did not inform me of much that I did not know, she gave me new insights about healthcare by the way she wove the information together to demonstrate why the status quo represents such a simultaneously dysfunctional, self serving and impenetrable reality that it borders on being beyond repair.


This moment in healthcare is the perfect example of what some philosophers mean when they talk about structural evil. Paul Batalden’s famous summary was that every system is perfectly designed to get the results that it gets. Rosenthal reveals how things have evolved so that every player operates within degrees of freedom that are defined by law and defended from change by effective political connections, self serving interest groups, and talented and persuasive lobbyists armed with dollars to drive their success in a system funded by the insatiable appetite of lawmakers and elected leaders for campaign dollars that are necessary for their continued presence in office.


The book tells “why” patients experience unnecessary expense and inconvenience from a system that often seems to have forgotten its core reason to exist. She presents healthcare as a business with virtually certain profits, captive customers, and many practitioners who can rationalize their behavior in terms of good business decisions that generate a margin over the more traditional motivations that may have initially attracted them into service or practice.


The core to her analysis to which she returns again and again as she discusses each of the dysfunctional aspects of American healthcare is a list of the ten rules that describe a dysfunctional medical market. Those rules are:


  1. More treatment is always better. Default to the most expensive option.
  2. A lifetime of treatment is preferable to a cure.
  3. Amenities and marketing matter more than good care.
  4. As technologies age, prices can rise rather than fall.
  5. There is no free choice. Patients are stuck. And they are stuck buying American.
  6. More competitors vying for business doesn’t mean better prices; it can drive prices up, not down.
  7. Economies of scale don’t translate to lower prices. With their market power, big providers can simply demand more.
  8. There is no such thing as a fixed price for a procedure or test. And the uninsured pay the highest prices of all.
  9. There are no standards for billing. There’s money to be made in billing for anything and everything.
  10. Prices will rise to whatever the market will bear.


Against the background of these ten points, she has organized her book around a framework that mimics the process of a patient evaluation that she surely learned from “the little Red Book” at Harvard Medical School. In the introduction she gives us the chief complaint, “Unaffordable Healthcare.” Part I is “History of the Present Illness and Review of Systems.” Part II is “Diagnosis and Treatment: Prescription For Taking Back Our Healthcare.” The fix is a complete list and explanations of ideas like single payer, greater transparency, more effective use of digital healthcare, and other subjects presented to inform patients that other options are available than what they currently experience. The list includes no breakthrough ideas that are not a part of the current conversation. Her presentation underlines the reality that we are not ignorant of our woes or our opportunities. Rather, we are inept in organizing efforts to overcome the self serving control of the status quo.


It is one thing to suggest that we move to a single payer environment. It is another thing to agree on how to make the move. How do we dismantle enterprises that have enormous resources and employ hundreds of thousands of people performing tasks that may or may not be needed if there is a new form of payment? Similar questions arise when we talk about reforming the roles and deployment of medical specialists, or redefine the role of the hospital. The bad news is that at almost 20% of the economy healthcare is possibly too big to fail as an industry even as it can allow its customers to fail as individuals. Business has been and will continue to be good for the keepers of the status quo even if fifteen percent of the population remains on the outside looking into a process from which they are economically excluded. The outlook is bleak. I was disappointed that her recommendations did not include any breakthrough ideas. I guess that was too much to hope for against the well organized forces of structural and institutional evil.


Perhaps because she knows that there is little likelihood that we can overcome the organized power of structural evil in healthcare, in the Epilogue she presents a stark observation on the “fate of empires.” She reminds us of the “age of decadence into which all great societies…descend before they finally fall for good.” She continues by saying that the decadence flows from a period of wealth and power, selfishness, love of money, and a loss of a sense of duty. That list is perhaps a description of the realities that support “structural  or institutional” evil. To her diagnosis I would add a collective ineptitude in managing the conflicting interests of a complex world. It is possible for all of us, all of our businesses, all of our institutions, and all of our leaders to perform within the limits of law and current concepts of ethics and still have the outcome be a dysfunctional equivalent of contemporary concepts of evil.


Dr. Rosenthal looks to consumers to demand a different outcome now that she has shown them the problems. She sees patients and those providers, ones who have not forgotten why they were drawn to the service of preserving health and reversing disease, joining their efforts to make the transition to a better state. She finishes with a charge:


They [the doctors, nurses and other healthcare professionals] want to deliver patient centered, evidence based care at a reasonable price. We, the patients, need to help, to rise up and make that possible. We have to remind everyone who has entered our healthcare system in the past quarter century for profit rather than patients that “affordable, patient centered, evidence-based care” is more than a marketing pitch or a campaign slogan.


It is our health, the future of our children and our nation. High-priced healthcare is America’s sickness and we are all paying, being robbed. When the medical industry presents us with the false choice of your money or your life, it’s time for us all to to take a stand for the latter.


It sounds like she is advocating for a coalition that makes its mission the achievement of


…Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness.


She is hoping that the information that her book presented will create an army of educated and engaged patients who will work with committed professionals for mutual salvation and redemption from a system of care gone wrong. She believes that the virtues of information and engagement can cancel the powers of structural and institutional evil. The alternative is to relax while the president blows up the ACA and then hope that somehow we will be able to put the pieces back together again, minus the current flaws.