Despite some of the policies instituted by the Affordable Care Act, America’s medical system is still plagued by problems. Insurance premiums and drug prices have skyrocketed, leaving Americans struggling to access affordable care. A 2016 survey of 11 countries from the Commonwealth Fund found that U.S. citizens were far more likely to go without care because it was too expensive.
The U.S. is also one of the only wealthy, industrialized nations that does not have universal health care. American health care prices are at least two to three times what they are in other countries, and nearly two-thirds of all bankruptcies in the U.S. are due to illness and medical bills.
How did we get into this mess? Former Harvard physician and veteran New York Times reporter Elisabeth Rosenthal breaks down the evolution of American medicine ― from an industry in the business of providing care to one that’s geared entirely toward maximizing profits. With her new book An American Sickness: How Healthcare Became Big Business And How You Can Take It Back, Rosenthal’s goal was to start a “very loud conversation” about an institution in crisis.
“The current market for health care just doesn’t deliver. It is deeply, perhaps fatally, flawed,” Rosenthal writes. “Even market economists themselves don’t believe in it anymore.”
Rosenthal, who also authored the Times’ popular “Paying Till It Hurts” series, has become a vocal advocate for patients’ rights and consumer education. Her book includes a glossary for medical bills and explanation of benefits, a list of pricing tools, and templates for protest letters to hospitals and insurance providers, among other resources for concerned patients.
We sat down with Rosenthal to learn more about how this dysfunctional system came to be ― and how a critical mass of educated consumers can create real change.
How did we get into this mess? Was there a particular moment in American history that health care really took a decisive turn for the worse?
When I started researching the book, I knew the outcome ― prices are really high compared to the rest of the world, and our outcomes are worse ― and I wanted to know how we got to this crazy place that the patients hate and the doctors hate. I found that there was a long chain of events over decades ― decisions that looked smart when they were made, and good ideas that got perverted when the profit motive came into play.
At some basic level, you could say that the problem started with insurance, but that’s not to say that insurance is a bad thing. What those insurance policies did was to separate the payment from the services, and in the early days, we became blind to what was paid because we didn’t pay it ourselves. Up until a couple decades ago, if you had good insurance, your insurer pretty much paid everything. Now, that’s not the case anymore because people have higher co-pays and higher deductibles, and suddenly they’re saying, “Whoa, how did things get so expensive?” This allowed the system to become so costly, because consumers didn’t notice for a long time.
Another event was the entrance of businesses into the hospital space. Over the years, business jobs have become more common and much more powerful in health care. The people running hospitals are usually no longer doctors ― there’s a layer of MBAs that didn’t used to be there. Now, you find companies run by businesspeople who often have very little knowledge of the needs of medicine. They are, in the end, for-profit companies, and their goal is to maximize their revenue. I think they’ve done that very effectively.
How does the American health care system stack up compared to other developed countries?
Well, the single most startling difference is that Americans think about cost and bills and whether they can afford a medical procedure ― and that’s just not even in the conversation in other countries. I started this book while living overseas, and I’ve interacted with many other health care systems. My experience in those other countries has been, for instance, profuse apologies for having to pay $100 for stitches. I remember thinking, “You don’t even know how lucky I am,” because if I had gone into a hospital in New York with this, I’d come out with a $500 copay, and my insurer would be billed thousands of dollars.
Money is very much not part of the individual calculation in other countries, and it’s become the center of the conversation in ours.
Where is all the money going? Who profits the most from this system?
It’s kind of everything and nothing. When you look at salaries of hospital, pharma or insurance CEOs, they’re really high ― millions, often tens of millions, annually. That’s one issue. But what I learned as I was researching this book was that it’s everything that contributes to the cost, and the money goes everywhere ― except to patients! It’s basically being pulled out of our wallets.
The money goes everywhere, but it often doesn’t go towards what the patients really want or need or care about. On the whole, we see from our health outcomes that higher costs doesn’t lead to better care.
How can patients protect themselves?
The first principle is that you’re not helpless. The first step is to feel empowered, and not just to write the check but to start asking questions ― even before you see the doctor or go to the hospital.
One thing I always ask my doctor now is, “If you’re going to send me for blood work, can you please send out the samples to an in-network lab?” I’ve seen so many patients with in-network doctors who send blood to an out-of-network lab, and the prices for something simple can be literally 20 times more what they would be if they were sent to one of the commercial labs that’s in-network. Another question that patients should ask is, “Why?” Do I really need that extra X-ray? Will the X-ray change what we do? And if the answer is no, then maybe you hold off for now.
So if you start demanding transparency, there will be pressure on hospitals to provide it.
Are you hopeful for the possibility of change?
I would say we’re at a tipping point where it’s become pretty unsustainable. We saw this at some of the town hall meetings recently, when people started to realize that repealing the Affordable Care Act would affect their own insurance.
People are really struggling. But I do think there’s a kind of groundswell of recognition that things are really not working well for most Americans with health care. The ACA shifted the dialogue on what the government’s role is in ensuring that people get the health care they need. Now we’re back at the drawing board again. I echo what Obama said as he was leaving office: If the Republicans can provide real health care to all Americans at an affordable price in a different way, then great. Let’s see it. President Trump says he’s a good dealmaker, and we’re getting a really bad deal.