A question recurs throughout this book: Why do liberals seem to be the only ones offering genuine solutions to our health care problems, and why do conservatives seem to oppose everything? It is a question that Stephen Brill never really answers.
At over 450 pages, America’s Bitter Pill is long on details. Brill has attempted to give us a comprehensive account of the Affordable Care Act, more commonly referred to as Obamacare. His narrative begins before President Obama was elected to the White House and ends with the rollout of the law only months before the book’s publication.
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Brill expertly interweaves multiple storylines as he explains the law’s genesis, reasoning, and implementation. He is at his best when explaining the intricacies of health care and telling the stories of people who are affected—usually, but not always, for the worse—by America’s health care system. He is also full of insight about debates in the White House and maneuvering in Congress. He takes us to hospitals and into their executive suites for interviews with their administrators. He is an engaging writer and a tenacious reporter, and his book has an air of exhaustive authority.
But something is missing. Brill dismisses the GOP’s role during the debate in 2009 and the early months of 2010. He has little patience, too, for the party’s response after the Affordable Care Act became law:
Despite the president’s reelection, and despite the Supreme Court’s ruling, the Republicans acted as if Obamacare were still a pending bill to be debated, rather than the law of the land to be implemented.
The closest historical precedent might have been resistance to the Supreme Court’s Brown v. Board of Education decision desegregating public schools. Yet that at least could be attacked as the decision of nine men in robes, not the duly elected House, Senate, and president.
If this sounds flippant, to Brill it is at least justifiably so. Obamacare is, at its core, a Republican idea, first implemented in a state led by a Republican governor. Republican opposition to Obamacare shows that the GOP just isn’t serious.
That Republican governor was, of course, Mitt Romney, in deeply liberal Massachusetts. Romney enlisted the help of such people as the now-infamous Jonathan Gruber of MIT, and Robert Moffit, a policy expert at the conservative Heritage Foundation, to design a conservative health care reform proposal in Massachusetts.
Obamacare co-opted the basic architecture of Romneycare, according to Brill's account: an exchange in which people can go to buy insurance, a mandate requiring everybody to hold insurance, and subsidies so everybody can afford insurance. This reform preserves the centrality of private health insurance and tries to encourage competition among providers. It is not, in other words, the left-wing Holy Grail: a single-payer, government-run health system along the lines of the UK’s National Health Service. With Obamacare, conservatives basically won, Brill implies. The reform didn’t gut the insurance industry—if anything, it actually added to their profits by subsidizing the purchase of their product.
Heritage’s Moffit, "an icon of conservative orthodoxy" according to Brill, spoke at the ceremony in Boston at which Romney signed his state’s reform into law. "We have retained what is best in American healthcare while correcting its deficiencies," Moffit said, according to Brill. Moffit is, for Brill, the ultimate proof of the GOP’s health care hypocrisy: The "icon of conservative orthodoxy," who works at the Heritage Foundation, worked on and endorsed the blueprint for Obamacare. How then could conservatives, with any integrity, oppose it? They couldn’t and can’t now, Brill implies. As a result, the left has the only serious health-care reform game in town.
Throughout this book, Brill makes no attempt to hide his belief that health care should be treated as a public utility—like roads, to which everyone has access. He thinks that a single-payer system would be not only fairer but more rational and cost effective. His transparency is one of this book’s great virtues. America, he says, has taken "a different path from that taken by every other developed country, all of which produce the same or better healthcare results than we do at a far lower cost."
It is certainly true that costs are much, much higher in the U.S. than elsewhere in the West. Results, though, are a different story. A report put out last year by the Commonwealth Fund ranked the U.S. last in a comparison of 11 countries’ health-care systems. But that report ranked the U.S. third in "effective care," fourth in "patient-centered care," sixth in "coordinated care," and seventh in "safe care." In all but the "safe care" category we were ranked higher than France, Brill’s counter-example at several points.
Amusingly, Brill’s own reporting undermines much of the confidence he thinks we should have in the federal government’s ability to implement a comprehensive single-payer system. Much of his reporting focuses on bureaucracy. When he visits, the Center for Medicare and Medicaid Services, the federal agency in charge of creating HealthCare.gov, a few days before the launch in 2013, several of the officials liken themselves to sufferers of post-traumatic stress disorder. Here Brill is—rightly—unsparing:
Public relations people and government administrators comparing their stress to that of soldiers stopping bullets or stepping on improved explosive devices was more than an over-the-top expression of self-importance and self-pity. It was emblematic of their amazing ability to be indignant—to assume the role of victim—when it was their own failure to govern that had fortified and emboldened the opposition. From the president and Valerie Jarrett on down, they had sloughed off the details of governing when it came to their most important and difficult domestic initiative. It was as if they either believed that they were big policy thinkers who were above worrying about the details of making the law work, or that they didn’t understand that effective government does not just happen automatically. Or both.
Remind me why would we want these people running our health care system? We don’t, of course, and Brill’s honesty is refreshing when he admits that the private sector is the best place to turn for creative ideas about health policy. A team of private-sector computer wizards saved the Obamacare marketplace, as Brill details; a group of young entrepreneurs founded Oscar, a company that uses technology to improve the health-insurance experience and reduce costs. And private hospitals, both non-profit and for-profit, are creating their own insurance networks in an effort to bring down prices.
Brill sees in this arrangement the future of health care in America, and at the end of this book he proposes legislation that would place this kind of "Accountable Care Organization" at the heart of our system. He would allow hospitals to run their own insurance companies, but he would have them heavily—and I mean heavily—regulated. (The CEO of such a company under his scheme would have to be a practicing doctor whose salary was capped.)
Brill is right that this arrangement has a lot of promise, but his proposed regulations suggest that he has missed the obvious lesson from his own reporting: the market produces innovations in health care—but whence the next innovation? Central planners cannot tell. If Brill had his way, policy would perpetually be playing catch-up to the market.
Though he sneers at Moffit and other conservatives for opposing Obamacare while supporting Romney’s similar plan, Brill makes virtually no attempt to examine the ideas, sometimes very detailed, that they have proffered. (Nor does he bother to explore the political context out of which Romneycare emerged: Massachusetts is a very liberal state, and like any other state, it cannot, for example, alter the federal tax code, which distorts the insurance market and biases it against individual purchasers.) Instead, he tells us a politically convenient story about the the right’s fear of a "government takeover." This is a shame in a book that is otherwise useful and engaging. Conservatives can learn much from it, not least how the other side thinks about the provision of medical care. Opposition to Obamacare is at least half the story, however, which makes it far from definitive.