Elisabeth Rosenthal

The American healthcare system famously spends more per person than any other system in the world, yet in outcomes, it ranks 37th. In this work, Rosenthal examines why that is the case and what practically can be done about it. Her examination operates both at levels of the patient, healthcare worker, business, insurance agency, and government/public. This book will leave you fuming that too many people are profiteering off of Americans’ health. It will also leave you better equipped to show more meet the challenges of tomorrow.

With such high costs yet such low results, more than one problem exists in our system. Unfortunately, politics tends to oversimplify the arguments. Rosenthal spends the first eleven chapters reviewing the historical and systemic evidence of how we got to this place. She leaves no leaf unturned in dealing with central topics like insurance, hospitals, physicians, “big pharma,” ObamaCare (the Affordable Care Act or ACA), research, and more. She illustrates how just about every element in the system has become decadent and profit-hungry. She also compares how other countries are doing a better job with much less financial investment.

After this first part of the book, Rosenthal pivots to deal with specifics of what can be done, both as individuals and as a society. This book thus has great impact both for individuals who rely heavily on healthcare and for public policymakers who want to get a leg up on the next reform. The suggestions are eminently practical and possible. Examples include avoiding hospital labs in favor of commercial lab businesses like Quest and LabCorp, negotiating national prices on drugs, offering a standard price for procedures, and pursuing antitrust legal activity against medical conglomerates.

Rosenthal, a Harvard-educated practicing MD with further training as a journalist, spares no detail in confronting this societal ill. Readers will leave with a much better understanding of the problem and future options. She even has several appendices of resources available – for challenging bills, researching prices, or undertaking social advocacy. As someone professionally invested in our healthcare system, I notice that many authors show some kind of bias; Rosenthal, however, shows none as she shines a bright light on almost every player in the system. The pro-profit orientation claims the prime space as it seems that everyone seeks to claim a monopoly on patients’ pocketbooks by holding their healthcare hostage.

This book is as comprehensive as it is erudite. Think of it as preparation for the next battle in America’s healthcare war. The new afterword, written after the failure to repeal the ACA in 2018, updates her narrative amidst new points of social discussion (or perhaps battle). An American Sickness won’t cure our problems, but it sure does shine some light on what’s going wrong and what can be done. In treatment of the problem, she does not posit over-generalized socialized medicine but merely a slew of pragmatic next steps (which can be taken or rejected individually). Overall, however, she makes clear that the spirit of gaining profit by holding patients’ health hostage needs to go. Otherwise, any new system will surely morph into something weird again. I cannot help but think Hippocrates would be proud of her work. show less

Just really enraging to read about how our healthcare system evolved to value profit over health. Other countries have better systems to put patient health first and control costs; Rosenthal includes actions individuals can take (such as questions to ask of a doctor's office or hospital) as well as system-level changes we can advocate for or pressure politicians to support.

Quotes/notes

Imagine if you paid for an airplane ticket and then got separate and inscrutable bills from the airline, show more the pilot, the copilot, and the flight attendants. That's how the healthcare market works. (2)

We live in an age of medical wonders...but the healthcare system remains fantastically expensive, inefficient, bewildering, and inequitable....The U.S. spends nearly one-fifth of its GDP on healthcare....the that, the U.S. health system generally delivers worse outcomes than any other developed country, all of which spend on average about half of what we do per person. (3)

Economic rules of the dysfunctional medical market, #1-10, p. 8

The very idea of health insurance is in some ways the original sin that catalyzed the evolution of today's medical-industrial complex. (14)

The 1990s were the only decade since the 1940s when U.S. health spending did not increase faster than the cost of living. (32)

"Medicine is a business. It won't police itself" (William Sage, 86)

The new law required that drugs be labeled with adequate directions for safe use....Manufacturers were required to prove to [the FDA] that a drug was safe before it could be sold. (92)

According to U.S. law, the same product cannot be on the market as both a prescription and an over-the-counter product. (112)

...Medicare is not legally allowed to [bargain with pharmaceutical companies for a national price][like countries in Europe do]. (115)

...today there is generally far less careful scrutiny of new [medical] devices than of new drugs, even though...many decides are permanently implanted in the body. (133)

It was as if the baggage fees cost more than the plane ticket from New York to Paris. (re: medical testing, equipment, physical therapy, etc.) (149)

Uninsured and underinsured Americans often get less testing and fewer services than they need....But well-insured Americans suffer often from too much treatment...with tests and services meted out not for health but for money. (165)

Studies have shown that hospitals charge patients who are uninsured or self-pay 2.5 times more than they charge those covered by health insurance...and three times more than the amount allowed by Medicare. That gap has grown considerably since the 1980s. (171)

...a flaw in how we pursue evidence-based medicine. The specialists who make money from procedures create the guidelines for when and how often they should be performed. (202)

"I'm angry at the system because it seems predatory." (206)

In the U.S., EMRs [Electronic Medical Records] have evolved to put business before patients. (214)

"In healthcare, entrepreneurship outsmarts regulation every time." (232)

Every other developed country in the world delivers healthcare for a fraction of what it costs here. (243)

Questions to ask when choosing a doctor:
1. Is the practice owned by a hospital or licensed as a surgery center?
2. Will you refer me only to other physicians in my insurance network, or explain why in advance if you can't?
3. If I need blood work or radiology testing, can you send me to an in-network lab?
4. Will there be charges for phone advice or filling out forms? Is there an annual practice fee?
5. If I'm hospitalized, will you see me in the hospital? What is your coverage on weekends?

Questions to ask in the doctor's office:
1. How much will this test/surgery/exam cost?
2. How will this text/surgery/exam change my treatment?
3. Which blood test are you ordering? What x-ray? Why?
4. Are there cheaper alternatives that are equally good, or nearly so?
5. Where will this test/surgery/exam be performed...and how does the place impact the price?
6. Who else will be involved in my treatment?

Cost-effective, patient-centered, evidence-based care was often taking a backseat to generating as much revenue as possible... (260)

Check hospital safety ratings: https://www.leapfroggroup.org/
Check Medicare's Provider Utilization and Payment Data: https://www.cms.gov/newsroom/data
View your hospital's IRS Form 990

Questions to ask in the hospital:
1. Make it clear you did not request a private room.
2. When you sign the "willingness to accept financial charges not covered by your insurer" paperwork, add a limited consent clause (in-network care only).
3. Be clear on terms (are you being admitted, or under observation status? Get admitted!)
4. Ask for the identity of everyone who enters your room, what they're doing, and who sent them.
5. Refuse any equipment the hospital wants to send home with you if you don't need it.

Dealing with bills:
1. Negotiate!
2. Request full itemization.
3. Check the bill against notes you made in the hospital.
4. Protest bills in writing to create a record.
5. Argue against surprise out-of-network bills (informed consent!)

Insurers could have been saying "no more" to those fees for years, but as long as the costs could be passed on to the consumer in the form of higher premiums and co-payments, they keep paying. (300)

National price negotiations are an extremely effective tool in setting and curbing prices for drugs and devices, which is why the strategy is used by every other developed country. (313)

U.S. Preventive Services Task Force, Choosing Wisely (https://www.choosingwisely.org/) (324) show less

An American Sickness is a gripping, fast paced and revolting dive from 50,000 feet above into the morass of what passes for healthcare in the USA. Patients are barely tolerated in a system optimized to pass money from bank accounts to providers. The industry is mean, nasty and greedy, with worse results than comparable nations - for far more cost. Everything you feared is true, and there is much more in these 400 pages.

Because Rosenthal (an MD herself) was a columnist for the New York show more Times, she received thousands of contacts over the years. She researched them and they provide the vivid and shameful examples of financial abuse in the industry (with real names). She has distilled them into a perverse list of principles of US healthcare that explains everything and forms the backbone of the book:

1. More treatment is always better. Default to the most expensive treatment.
2. A lifetime of treatment is preferable to a cure.
3. Amenities and marketing matter more than good care.
4. As technologies age, prices go up rather than fall.
5. There is no free choice. Patients are stuck. And they’re stuck buying American.
6. More competition 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.

As the American economy freefalls into dysfunction, doctors and nurses have become “independent contractors”, just like everyone else. They must look out for themselves first. Administrators are no longer senior caregivers but numbers people who must limit the poorly insured and maximize the profit on every square foot.

What becomes obvious is that the “market” system has failed utterly and completely. Health cannot be left to capitalists, be they doctors, hospitals or manufacturers. The rest of the western world and history are the proof: “If the March of Dimes was operating according to today’s foundation models, we’d have iron lungs in five different colors controlled by iPhone apps – but we wouldn’t have a cheap polio vaccine,” Rosenthal quotes Dr. Michael Brownlee. The incentives are all wrong.

An American Sickness is a public service. It gathers, for the first time I know of, the various scams used by the professions to jack up bills. It explains the why and the how of all those bills being so high. It is well organized, clear and it puts everything into perspective as part of a greater scheme. It identifies what to look out for, what to ask, and how to skirt the event horizon. Rosenthal provides really useful links and sample letters, because customers are all in this same situation – ignorant and powerless. I particularly like her examination of prices for the same procedures around the world. You can afford to have treatments elsewhere, because the costs are so much less, that you can throw in the travel – for two – and still come out well ahead. This book is worth far more than a month’s health insurance; it can save you a fortune, and give you back your life.

David Wineberg show less

This book was actually painful to read. My brain hurt from all the information, my heart hurt from the stories of people mercilessly used and abused by the healthcare system, and my soul hurt from considering the greed and heartlessness exhibited in all the moving pieces that have converged to bring us to where we are today in American healthcare.

There doesn’t seem to be a single entity touching the medical world that hasn’t been implicated as having a role in the dismal mess we find show more ourselves in today. Insurance companies, pharmaceutical companies, and hospitals have long been perceived as money-sucking monsters, and it’s no surprise that legislators, lobbyists, medical device manufacturers and doctors are all complicit or even actively partaking in the erosion of average Americans’ ability to afford medical care. But charities whose missions claim to be the betterment of individuals suffering from chronic or devastating illnesses who reject funding research for potential cures because they’d prefer to have a stake in new and lucrative treatments?

The only reason I made it all the way through was the promise of something that can be done to combat this ridiculousness. And the author certainly delivered. Actionable ideas, a wealth of resources to seek out information, and a call to get involved as consumers and check ourselves for what’s really important when it comes to our medical care. Do we want the highest-tech gadgets and tech and comfiest doctor’s offices? What if that comes at the expense of reasonable costs and rising insurance premiums? The biggest takeaway here for me is that yes, this is a great big, gross mess, but yes, we can do something about it. show less