Brill - iant

Stephen Brill is a journalist who has specialized recently on critiquing the US healthcare system. The best article – by far – that I have ever read in Time magazine was by Brill two years ago. Now he has followed that up with a second article, promoting a full book he has written on the subject.

When you read Brill’s material, you don’t know whether to laugh or cry. He dissects US healthcare like a surgeon. He has a knack for investigation and follow up that can reach in to uncover the full extent of a failure, right to root causes and assignment of blame.

His writing is fully consistent with my own experience of US healthcare, explaining so much and credibly. But the real tragedy is that the way politics and the healthcare industry is structured in the US, nothing will happen to fix it.

An early shock of mine in the US was when I mentioned to my new GP that I thought I was a little bit deaf, as part of my initial discussion with her. She immediately sent me off to a hearing specialist. Two weeks later, I met him, and did a series of tests similar to those I had done in Europe before. The specialist concluded that indeed I was a little bit deaf, especially in my left ear. The good news was that he did not see any recent deterioration, and indeed that I was not unusually deaf for a male of my age. Then came the shock. He recommended that I take an MRI exam – just in case there was something involved that he could not see.

I complied, went for the MRI, and discovered that indeed there was no additional reason for concern. All of this was covered by my medical insurance, except for small co-pays of maybe $20 to each of the three parties (the family doctor, the specialist, and the MRI clinic).

Later, I reflected on the whole process. It has its good elements. There is a clear emphasis on prevention compared with Europe – another example is routine colonoscopies for men over fifty. But where was the balance? MRI’s are very expensive – surely it was more than a bit over the top to recommend one for a bit of deafness?

I started noticing that Forest Hills had several MRI clinics, and virtually every apartment block had medical specialists crammed into the ground floor. I had already concluded that incentives must be skewed, and then I read Brill to confirm all my suspicions.

As soon as I mentioned deafness to my family doctor, she had two big incentives to refer me. First, she had to protect herself against any future liability claim from me. Next, she could make money from the referral. And she knew I’d go along with it because it would cost me next to nothing and I was bound to be curious about my health. And she had already checked that my insurance would cover it. Then exactly the same incentives worked for the specialist in sending me for an MRI.

Here is another example. A month ago my wife had a routine mammogram – again, good that such preventive checks are in place. A few days later she got a letter proposing a second check up, without really specifying why. She duly went along a second time. Meanwhile she was chatting to a friend in the medical industry, telling her about the recall. The friend immediately guessed, correctly, that our insurance was with a particular company. Funny how everyone with that insurance gets a recall, she mused, perhaps it is partly because they pay for a follow up visit.

So we have what amounts to close to a scam, and a brilliant one since it appears almost victimless. In the end the unnecessary cost is borne silently by the employer of my wife, and by the US economy (since the excessive healthcare cost incentivizes firms to outsource jobs to other countries). If we had been over sixty-five or poor, the cost would be borne directly by taxpayers.

Brill dissects how this has happened. The root causes are clear. One is that we are all inclined to be cautious over our own health, have little knowledge and have historical trust in medical professionals. Another is the American hatred of state control, giving market methods an advantage even when plainly wrong. Here I might add the American reluctance to learn from other countries. And a third is the takeover of congress by lobbyists. Brill claims that the medical lobby spends four times as much as any other lobby – defence coming a distant second.

Those root causes lead to the ugly outcome we see today. Total costs are 50% higher per head than those of any other country, yet medical outcomes are average at best. The vulnerable do the worst, with outrageous fees for those without insurance. And it is administrators who get the richest, hiding away in their non-profits drawing obscene salaries. Big Pharma and equipment suppliers do very well too.

In Brill’s book, he looks at the story of Obamacare, which started as a well-intentioned and well-designed partial fix for this. The plan was to bring more people into coverage, while also correcting some of the most perverse incentives to control costs.

Once Obama gained power, he set a team to negotiating a bill past the industry and past congress. His team had some political experts and some economic ones. The industry, and congress via the industry lobbyists, would not accept any economic reform. In the end, the politicians conceded that the only way to get a bill at all, one that would offer coverage to new groups, would be to negotiate away almost all the economic provisions. That was precisely how it panned it.

What a disgrace! Yet what else could Obama do? Even with the bill that was passed, opponents (sponsored by lobbyists) have tried to undo things. That way further reform will have to wait for another generation. The same politicians that argue against a decent minimum wage on the grounds that it would destroy jobs also argue for bloated health care costs that have precisely the same effect.

The only part of this story that I sometimes struggle to understand is the absence of popular revolt. The lobbyists just seem to have control of public opinion, no matter how hard Brill and a few other brave journalists work to educate them. Part of the explanation for this may lie in the media itself – the same lobbyists also seem to control what passes as news for most of the USA.

Much though I love Brill’s articles, I am not sure I could wade through his book. I suspect his style would become quite tiring in longer format. Further, in the book he feels obliged to offer solutions as well as problems. He comes up with one whereby hospital trusts would be allowed to expand into health insurance. This feels rather a desperate attempt at a solution to me: at least it might be politically feasible, but would it not create even bigger problems than the ones it solved?

Another excellent article last week, by Amartya Sen and a colleague in the Guardian Weekly, puts a global perspective on this disaster. I learn that Sen was the master at Trinity Cambridge for many years, my alma mater. If this article is typical, I can understand how he rose to such heights.

Sen makes a compelling argument that a developing state should concentrate resources on achieving universal basic healthcare for citizens. The investment pays for itself through jobs created, and leads to smaller families, female emancipation, and longer productive lives. He supports his arguments through case studies, including Rwanda, Thailand, China, and some states in India such as Kerala, by drawing correlations between universal healthcare provision and other positive developments.

Now wouldn’t it be great if the next UN development goals, to be set this year, would include universal basic healthcare provision? And here is the real tragedy: the main reason why they probably won’t is that the US will probably not let it happen. How can they, when their own system has such opposing priorities?  So the scandal exposed so well by Stephen Brill doesn’t just hold back his own country: it can block development across the whole globe.