These are questions for wise men with skinny arms

I was expecting this to be a dissection of the American Healthcare industrial-complex, but instead, this was the story of the ACA (Obamacare) with just enough industry explanation to understand the new regulations. The interesting part was then how the sausage got made and the politics that continue to shape health care policy, and by proxy the hospital and insurance market. Because I learned so much background that was easily digestible in narrative form, I’d give this a B.

Recommended Chapters

If I were to recommend this book as someone interested in healthcare policy, I’d say to skip the middle 3 chapters. The book starts strong with history and background for each of the players. The problem is that the book follows every single step that generally re-iterates the same points: for a compromise bill it was so poorly implemented that most of the key provisions took 5 years or were not done at all. There’s not much health-care content to these middle 200 odd pages that you couldn’t infer from just skipping to part 5 after part 1.

Lack of Appetite

The biggest problem he exposes is that no part of the health-care industry or government representative wants to change the current system of massive profits. Everyone benefits except the government’s bottom line and large employers, so as long as the taxpayers don’t complain about the inevitable collapse of healthcare entitlements there’s relatively little hope that all of the disparate businesses paying healthcare premiums will be able to beat the much better funded and organized health care lobbies. This is the bitter pill: the ACA’s compromise took all the wind from health-care reformers’ sails when it only treated the symptom of the problem.

What I found most fascinating is where Brill interviews hospital CEOs and finds that they are ‘good’ people with ‘strong’ intentions to improve the quality of care at any cost. I’m not sure if he expected to find smarmy suits, or was just utterly connived by their charms. He spends a few pages at the beginning of the book pointing out the outrageous sums of money and the total lack of economic incentives that made it into even the first draft of the ACA, but now that he’s met them in person that’s all A-OK?! His strategy is to let the current path of increasing cost and centralization run its course until healthcare basically becomes a monopoly utility before regulating them into a well-behaved government service provider. I don’t think he recognized that this is similar to how the military-industrial complex progressed; the same one that Brill chastises on its incredibly complex and inefficient contracting process that led to the failed launch of the healthcare exchange.

Far from this book’s depressing outlook, I found so much to enjoy about politics that I feel deeply empowered to do something. I think it will probably be another 50 years before anything is done, but I think that Brills’ moderate proposed reforms are most likely to occur in some form because they don’t require much additional legislation.