Dr. Elisabeth Rosenthal's book on the dysfunctional American healthcare industry is well-researched and informative. Dr. Rosenthal brings the training of both a Harvard Medical School-trained physician and a New York Times reporter to bear on the issues endemic in the American medical sector, finding serious cause for alarm. Despite her sound diagnosis, her proposed solutions were somewhat anemic and seemed inadequate to cure the current ailment.
Reading An American Sickness is sometimes hard to stomach. The book is at times depressing, enraging and absurd. Many of the anecdotes recounted seem like the kind of grifting that could take place in a Kafka novel, not occurrences that should be conscioned in American medical practice. Dr. Rosenthal recounts stories of patients being told to pay $50,000 for face stitches, being told they would have to pay for follow up surgery to replace a faulty knee implant, hospitals being purchased by huge hospital chains and then downsized to take advantage of Medicare programs for small hospitals, and other disgraces.
Dr. Rosenthal does an excellent job of providing some of the history behind why our healthcare industry holds its particular topography. For instance, a longtime question of mine was answered by the book: why is health insurance so closely tied to employment in the US? It's anomalous in developed countries. The reason is historical. American employers were prohibited from increasing wages above government prescribed levels during World War II, owing to wartime shortages of employable men. Therefore, in a bid to offer potential employees a more enticing package, some companies began bundling group-policy health insurance into their hiring packages. The government encouraged this practice by making corporate expenses on health insurance tax-deductible, and the rest is history.
Dr. Rosenthal did a nice job of explaining the current health care market in terms that are approachable by people from multiple political and economic positions. She strikes a good, middle of the road approach, and I think her book is effective in convincing people of most economic and political persuasions that there are real problems in healthcare. However, while her book is good at reaching a diverse crowd, I think she sacrifices some truth to appeal to a broader readership.
The truth is that capitalism is the problem here. Healthcare is not and cannot be a good economic marketplace because the consumer is always at a disadvantage. A proper capitalist system is one in which the buyer and the seller are on equal footing and can individually choose not to conduct business. The healthcare system is not such a system, because patients are often forced to do business. They have to buy treatment that may save their lives, or at least allow them to continue working and supporting a family. That leverage can always be exploited by the healthcare industry.
Capitalists have two options when discussing the healthcare system's insufficiencies. They can either deny that the system is truly broken or place the blame on government (losing arguments) or they can do the smart thing and acknowledge that healthcare is not an appropriate venue for capitalism. I've never understood why capitalists don't just make the second argument. It's such an easy get out of jail free card. When a filthy lefty like me criticizes the healthcare industry, the capitalist could just get out of it easily by saying “Well the healthcare industry shouldn't be a venue for capitalism. Capitalism is fundamentally a system where leverage is required on both sides, and healthcare is not such a system. It is not conducive to capitalism.” That's such an easy escape, but so few capitalists make that argument. Rather, they usually insist that the problems of healthcare are the fault of government, typically by invoking “crony capitalism” or overregulation.
The crony capitalism arguments do have some bearing, but rather than being arguments against government, they're arguments against capitalism. The FDA and other regulatory agencies do often have too close ties to industry and established industry players are often given preferential treatment and can skirt the regulatory apparatus through such loopholes as the FDA's 510(k) approval pathway. However, my particular view is that crony capitalism doesn't exist. Arguments against crony capitalism are simply arguments against capitalism itself. Capitalism inevitably devolves into crony capitalism in the presence of government. There are two solutions: get rid of capitalism or get rid of government. I'm in favor of retaining government for many reasons, ergo capitalism must go. If you're interested in why I think crony capitalism doesn't exist, read the section on socialist critique on Wikipedia, and it will point you to some good resources, including Jane Jacob's critique.
The other argument, of overregulation, is also easily combatted. Healthcare is a very regulated industry, but there are very good reasons for that. In the past, freewheeling medical practitioners injured or killed many patients. Phony medicines on the market either killed patients or were simply totally ineffective. Medicine is a system built on trust, as patients rely on doctors prescribing them medication and recommending procedures that are really in their best interests. Therefore, a certain amount of regulation is vital to the safety of the system. If a doctor prescribed me a medication, I probably wouldn't know much about it and would acquiesce to her advice. If it turned out that the medicine was dangerous and the doctor knew that and prescribed it anyway because she owned stock in that company, I would want her prosecuted. And I would want that kind of activity made illegal. In short, I would demand regulation. Many Americans over the years have demanded regulation to protect them from unscrupulous doctors, so the idea that regulation is the problem is absurd. There are some areas where regulation should be relaxed. Dr. Rosenthal addresses several of these in her book, including pharmaceuticals imported from other countries, and experimental medical procedures for patients with terminal or currently incurable diseases. However, these are relatively small parts of the system, and regulation is not the ultimate cause of most of the problems we see. The real cause of most of these issues is that capitalism has been applied to a commodity where the buyers are unfairly disadvantaged. Healthcare is a necessity, not something individuals can simply forgo until they find a better deal.
Dr. Rosenthal spends roughly 100 pages on “treatment”, her individual and policy recommendations for bringing healthcare costs down to more terrestrial levels. While many of her proposals are great places to start, the best way to fix most of the problems enumerated in her book is a simple solution: implement a robust single-payer healthcare system. In 2019, it is unconscionable that the US is still one of the very few developed nations without a single-payer healthcare system. A government-run system that pays for patient costs would be the bare minimum. A socialized medical system is even better. Ideally, the government should shoulder patient costs, run state hospitals, employ physicians and hospital staff, and subsidize the costs of medical school. All of these activities can work in tandem. Make medical school free for any doctors who agree to work at a government hospital for 5 years. Once they finish their term of repayment, they can enter private practice if they so choose, or work for a private hospital. All persons would be eligible to receive medical care at a state hospital, but private and specialist clinics would still be available for those who want to pay a premium.
The reason a single-payer system is needed is that it fixes the inequality present in healthcare. Doctors overprescribe drugs and diagnostic tests because each item is billable. If a government program is paying for each test, the government won't pay unless there is proof the test is required. That should drive costs down considerably. If hospitals are run by the government, the amenities arms race currently ongoing in the American hospital scene will be over, as government-run facilities will be focused on cutting costs on their fixed budgets. In short, a government-run healthcare system is probably the closest thing to a panacea that we're likely to find in the healthcare sector.
In summary, An American Sickness is a very good book in terms of its diagnosis. American healthcare is indeed very broken. We have the highest healthcare costs anywhere, and yet receive substandard care for most diseases and problems. While I found many of Dr. Rosenthal's anecdotes and descriptions of medicine to be alarming, disgusting or tragic, her policy recommendations were not radical enough for me. They're great ways to fix our status quo, but our problem is the status quo. And it's time for it to go.