Il­log­i­cal forces driv­ing a dys­func­tional health-care sys­tem

The Washington Post Sunday - - BOOK WORLD - RE­VIEW BY JULIET EILPERIN Juliet Eilperin is The Wash­ing­ton Post’s se­nior na­tional af­fairs cor­re­spon­dent and the au­thor of “Fight Club Politics: How Par­ti­san­ship Is Poi­son­ing the House of Rep­re­sen­ta­tives” and “De­mon Fish: Trav­els Through the Hid­den World

Cov­er­ing the cur­rent health-care de­bate in Wash­ing­ton, I hear politi­cians ev­ery day (and read them on Twit­ter) de­scrib­ing our cur­rent sys­tem as a dis­as­ter. Health and Hu­man Ser­vices Sec­re­tary Tom Price in­formed a key House Ap­pro­pri­a­tions panel re­cently that the Af­ford­able Care Act is mak­ing health “un­af­ford­able for so many Amer­i­cans.” Pres­i­dent Trump has pre­dicted that the fed­eral in­sur­ance ex­changes the ACA has cre­ated will both “ex­plode” and “im­plode” (in which or­der, I’m still un­clear). Hav­ing just passed the Amer­i­can Health Care Act through the House, con­gres­sional lead­ers and ad­min­is­tra­tion of­fi­cials have promised that the leg­is­la­tion will re­turn the coun­try to “pa­tient-cen­tered care” and lower the costs of pre­mi­ums for Amer­i­cans in some states who have seen them spike, once it’s even­tu­ally signed into law.

But with just one ex­cep­tion — Trump’s call for lower pre­scrip­tion drug prices — al­most no one in­side the Belt­way is com­ing up with plau­si­ble ideas to cut the cost of health care. Luck­ily, Elisabeth Rosen­thal, a long­time health-care jour­nal­ist and former emer­gency room physi­cian, has tack­led this ques­tion in her new book, “An Amer­i­can Sick­ness: How Health­care Be­came Big Busi­ness and How You Can Take It Back.” Read­ing it is a sober­ing ex­pe­ri­ence, one that shows what’s re­ally at stake when it comes to our sprawl­ing, costly and il­log­i­cal health-care sys­tem.

Other au­thors have taken on this ter­ri­tory be­fore: David Gold­hill’s 2013 book, “Cat­a­strophic Care: How Amer­i­can Health Care Killed My Fa­ther — and How We Can Fix It,” pro­vided a per­sua­sive case for ap­ply­ing freemar­ket prin­ci­ples and greater trans­parency to the health-care in­dus­try. But Rosen­thal — who prac­ticed medicine be­fore en­ter­ing jour­nal­ism and now serves as ed­i­tor in chief of Kaiser Health News — com­bines her re­por­to­rial and med­i­cal skills to pro­vide an au­thor­i­ta­tive ac­count of the dis­torted fi­nan­cial in­cen­tives that drive med­i­cal care in the United States. As a re­sult, she has pro­duced a fairly grim tale of how pa­tients — and at times, in­sur­ers — are get­ting ripped off, some­times with dev­as­tat­ing con­se­quences. In short, this is the an­tithe­sis of a feel-good book.

Yet it is il­lu­mi­nat­ing, be­cause Rosen­thal does plenty of dig­ging to ex­plain the puz­zling out­comes that pa­tients and those who care for them of­ten en­counter. How does the Amer­i­can Med­i­cal As­so­ci­a­tion de­ter­mine the value of spe­cific ser­vices that are en­tered as codes in a given bill? The AMA con­venes the Rel­a­tive Value Scale Up­date Com­mit­tee three times a year, where rep­re­sen­ta­tives from dif­fer­ent spe­cial­ties ar­gue over how much they’re worth. One former com­mit­tee mem­ber, a der­ma­tol­o­gist, tells her it’s like hav­ing “26 sharks in a tank with noth­ing to eat but each other.” Why did the re­im­burse­ment rate for im­muno­log­i­cal tests done by pathol­o­gists drop? Rosen­thal of­fers one the­ory: “Pathol­o­gists tend to be quiet, an­ti­so­cial types and have never been very good at form­ing al­liances or lobbying.” Why doesn’t the Food and Drug Ad­min­is­tra­tion have more tools to en­sure that drug de­vel­op­ment is cost ef­fec­tive? Be­cause Congress was in a rush to re­spond to the thalido­mide tragedy in the early 1960s, when the ba­bies of some women who took the morn­ing-sick­ness drug were left with per­ma­nent birth de­fects.

Plenty of Amer­i­cans are fa­mil­iar with the idea that phar­ma­ceu­ti­cal drugs are vastly more ex­pen­sive in the United States than in other na­tions and that drug­mak­ers spend enor­mous sums on ad­ver­tis­ing their wares while keep­ing generic ver­sions of these same medicines off the mar­ket. But few prob­a­bly know that many med­i­cal de­vices get scant scru­tiny from the FDA be­cause they fit into the “Class 2” cat­e­gory of de­vices, which are “sub­stan­tially sim­i­lar” to ones on the mar­ket and used for a sim­i­lar purpose. While this might sound rea­son­able in the­ory, it means dif­fer­ent ver­sions of a vagi­nal mesh taken off the mar­ket in 2002 con­tin­ued to sell, even though the orig­i­nal one had caused a sig­nif­i­cant num­ber of in­ter­nal in­juries.

Through­out the book, Rosen­thal in­ter­sperses hu­man sto­ries that demon­strate what hap­pens when the med­i­cal pro­fes­sion fails us. Wanda Wick­izer was a healthy 50-year-old un­til she had “a ran­dom ex­plo­sion deep within her skull” on Christ­mas in 2013; since she was unin­sured, her phys­i­cal in­juries were ac­com­pa­nied by hun­dreds of thou­sands of dol­lars in bills. At one point, a hospi­tal of­fi­cial sug­gested seiz­ing her home as a way to help erase the debt. A 36-year-old di­a­betic in Mem­phis, Cather­ine Hay­ley, noted that the in­sulin pump she wears on the waist­band of her jeans is “made of plas­tic and runs on triple-A bat­ter­ies, but it’s the most ex­pen­sive thing I own, aside from my house.”

While Rosen­thal does her best to squeeze in a few jokes (mostly light­hearted ref­er­ences at pathol­o­gists’ ex­pense), the sub­ject mat­ter makes for dense read­ing at times. This is a thor­ough book, but it’s hard to en­vi­sion a ca­sual reader pick­ing it up and whiling away the week­end with it. And on oc­ca­sion her ob­vi­ous im­mer­sion in the med­i­cal field slows the writ­ing down a bit, as when she de­cries the dis­ap­pear­ance of two anti-nau­sea generic drugs. “Not hav­ing prochlor­per­azine avail­able in an emer­gency room is like not hav­ing ac­etaminophen (Tylenol) in a drug­store.” I couldn’t help won­der­ing why the book’s ed­i­tor hadn’t just struck “ac­etaminophen” and left “Tylenol” in its place.

Still, Rosen­thal does in­clude a set of very prac­ti­cal tips at the end of the book for en­sur­ing that in­di­vid­ual pa­tients lower their bills and ob­tain the treat­ment they need. This sort of “news you can use” served as a pick-me-up af­ter the pa­rade of hor­ri­bles that pre­ceded it. She pro­vides smart ques­tions con­sumers can ask not just their doc­tors, but also hos­pi­tals and in­sur­ers. She even strikes a re­bel­lious tone by sug­gest­ing that read­ers con­sider im­port­ing “long-term medicines whose ef­fi­cacy can be clearly mea­sured” since that’s an easy way to cut costs. “Im­port­ing drugs for per­sonal use is tech­ni­cally il­le­gal,” she notes blithely, “but in­ter­cept­ing small pack­ages of medicine is im­pos­si­ble from a prac­ti­cal stand­point — and the U.S. gov­ern­ment has for a long time in­ten­tion­ally turned a blind eye to the prac­tice.”

There are sev­eral pol­icy pre­scrip­tions at the end, too, but even Rosen­thal ac­knowl­edges that most of them aren’t go­ing to be adopted any­time soon. And that’s the irony of this book: At a time when the na­tional health de­bate is largely cen­tered on how to man­age in­sur­ance rules for about 15 per­cent of Amer­i­cans, Rosen­thal has made a pow­er­ful case for ev­ery­thing else that’s wrong in the way that we treat ill­ness in this coun­try. Maybe ev­ery law­maker and ad­min­is­tra­tion of­fi­cial should pick up a copy of “An Amer­i­can Sick­ness.” Then, at last, the se­ri­ous de­bate could be­gin.

AN AMER­I­CAN SICK­NESS How Health­care Be­came Big Busi­ness and How You Can Take It Back By Elisabeth Rosen­thal Pen­guin Press. 416 pp. $28

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