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America's Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System

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NEW YORK TIMES BESTSELLER • A NEW YORK TIMES NOTABLE BOOK • America’s Bitter Pill is Steven Brill’s acclaimed book on how the Affordable Care Act, or Obamacare, was written, how it is being implemented, and, most important, how it is changing—and failing to change—the rampant abuses in the healthcare industry. It’s a fly-on-the-wall account of the titanic fight to pass a 9 NEW YORK TIMES BESTSELLER • A NEW YORK TIMES NOTABLE BOOK • America’s Bitter Pill is Steven Brill’s acclaimed book on how the Affordable Care Act, or Obamacare, was written, how it is being implemented, and, most important, how it is changing—and failing to change—the rampant abuses in the healthcare industry. It’s a fly-on-the-wall account of the titanic fight to pass a 961-page law aimed at fixing America’s largest, most dysfunctional industry. It’s a penetrating chronicle of how the profiteering that Brill first identified in his trailblazing Time magazine cover story continues, despite Obamacare. And it is the first complete, inside account of how President Obama persevered to push through the law, but then failed to deal with the staff incompetence and turf wars that crippled its implementation.   But by chance America’s Bitter Pill ends up being much more—because as Brill was completing this book, he had to undergo urgent open-heart surgery. Thus, this also becomes the story of how one patient who thinks he knows everything about healthcare “policy” rethinks it from a hospital gurney—and combines that insight with his brilliant reporting. The result: a surprising new vision of how we can fix American healthcare so that it stops draining the bank accounts of our families and our businesses, and the federal treasury.   Praise for America’s Bitter Pill   “A tour de force . . . a comprehensive and suitably furious guide to the political landscape of American healthcare . . . persuasive, shocking.”—The New York Times   “An energetic, picaresque, narrative explanation of much of what has happened in the last seven years of health policy . . . [Brill] has pulled off something extraordinary.” —The New York Times Book Review   “A thunderous indictment of what Brill refers to as the ‘toxicity of our profiteer-dominated healthcare system.’ ”—Los Angeles Times   “A sweeping and spirited new book [that] chronicles the surprisingly juicy tale of reform.”—The Daily Beast   “One of the most important books of our time.”—Walter Isaacson   “Superb . . . Brill has achieved the seemingly impossible—written an exciting book about the American health system.”—The New York Review of Books


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NEW YORK TIMES BESTSELLER • A NEW YORK TIMES NOTABLE BOOK • America’s Bitter Pill is Steven Brill’s acclaimed book on how the Affordable Care Act, or Obamacare, was written, how it is being implemented, and, most important, how it is changing—and failing to change—the rampant abuses in the healthcare industry. It’s a fly-on-the-wall account of the titanic fight to pass a 9 NEW YORK TIMES BESTSELLER • A NEW YORK TIMES NOTABLE BOOK • America’s Bitter Pill is Steven Brill’s acclaimed book on how the Affordable Care Act, or Obamacare, was written, how it is being implemented, and, most important, how it is changing—and failing to change—the rampant abuses in the healthcare industry. It’s a fly-on-the-wall account of the titanic fight to pass a 961-page law aimed at fixing America’s largest, most dysfunctional industry. It’s a penetrating chronicle of how the profiteering that Brill first identified in his trailblazing Time magazine cover story continues, despite Obamacare. And it is the first complete, inside account of how President Obama persevered to push through the law, but then failed to deal with the staff incompetence and turf wars that crippled its implementation.   But by chance America’s Bitter Pill ends up being much more—because as Brill was completing this book, he had to undergo urgent open-heart surgery. Thus, this also becomes the story of how one patient who thinks he knows everything about healthcare “policy” rethinks it from a hospital gurney—and combines that insight with his brilliant reporting. The result: a surprising new vision of how we can fix American healthcare so that it stops draining the bank accounts of our families and our businesses, and the federal treasury.   Praise for America’s Bitter Pill   “A tour de force . . . a comprehensive and suitably furious guide to the political landscape of American healthcare . . . persuasive, shocking.”—The New York Times   “An energetic, picaresque, narrative explanation of much of what has happened in the last seven years of health policy . . . [Brill] has pulled off something extraordinary.” —The New York Times Book Review   “A thunderous indictment of what Brill refers to as the ‘toxicity of our profiteer-dominated healthcare system.’ ”—Los Angeles Times   “A sweeping and spirited new book [that] chronicles the surprisingly juicy tale of reform.”—The Daily Beast   “One of the most important books of our time.”—Walter Isaacson   “Superb . . . Brill has achieved the seemingly impossible—written an exciting book about the American health system.”—The New York Review of Books

30 review for America's Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System

  1. 5 out of 5

    Margitte

    The question is: What time is it? The possible answers: "It's late" - politicians and academics. "It's exactly nine thirty am" - scientists and economists. This is how the question of an Affordable Care Act for all citizens were addressed by the different role players, and with the democratic process applied to it, got answered. All stakeholders claimed part of a victory that never happened. Nobody is smiling. In came Brill on the Bill. This book, yes. In his lengthy TIMES article, author and journal The question is: What time is it? The possible answers: "It's late" - politicians and academics. "It's exactly nine thirty am" - scientists and economists. This is how the question of an Affordable Care Act for all citizens were addressed by the different role players, and with the democratic process applied to it, got answered. All stakeholders claimed part of a victory that never happened. Nobody is smiling. In came Brill on the Bill. This book, yes. In his lengthy TIMES article, author and journalist, Steven Brill, shot the first rounds on a broken system, and followed it up with this in-depth book on the sensitive issue crippling the American economy. The political promise, to address this issue, made to 324,833,714 million interested stakeholders , caught many role players acting like cats on hot bricks, with a bout of the heebie-jeebies thrown in for good measure. This is the informative, high-density word account of the processes, decisions and actions behind America's Affordable Health Care Act and how a few thousand square pegs were forced into one round hole to find a solution. But was it the best one? At least the the book provides an amazing insight into the process. With so many affected parties standing in line, it is almost impossible to reach a common decision. The actions behind the final bill actually demonstrated the pitfalls and perfection of a democracy, so by the way. The gigantic profits in the health industry, the biggest money-spinner in the world, and that's been exposed and thoroughly referenced in the book, blows the mind, when 63% of all bankruptcies in America is a direct result of health care expenditures. How is it possible that a woman, who lost her footing at her back door and fell on her face, received a medical bill of $9000.00 which she was forced to pay by the court? She broke nothing, did not receive stitches and no medicines? She became a victim to the 70% of unnecessary MRI's done in hospitals. And that's just one of the aspects of her treatment and concluding hospital bill that forced this single mother of two, without medical aid, to declare bankruptcy. Ambulance services are one of the most lucrative businesses in the country! Imagine that. While the aim with the new health care system was to widen the umbrella of coverage to include more people, as well as bring down the monstrous costs of health care, only the middle class got slammed with the consequences and they ain't smiling. This book explains the HOW and WHY. EVERYBODY should read it, since it is relevant to all citizens of the world who aim to cover themselves against The Unthinkable. It is sad to think that The Unthinkable now not only includes a serious accident or illness, but also being grabbed by the tentacles of an industry behind the treatment or cure. Something will kill you, it just depends on which of the two killers will get to you first: your illness/accident, or your medical insurance and -bills. Usually it is both anyway. This book is a really good, excellently researched, comprehensive exposure of a health care dilemma effecting America and ultimately the world. If America coughs, the world catches the cold. While trying to get more people covered, less and less people can afford it. As a helpless citizen, how do you find an alternative solution when nobody cares when your purse does not jingle the tune they want to hear? Why are the term state capture by big industry through control of government representatives not blatantly featured in this exposé? Free market or free choice. Why insist on a free market, but vigorously prevent a free choice option for people suffering helplessly and hopelessly from the supporters of a so-called free-market who prevented government from passing a law to allow American citizens to buy cheaper medicines from Canada? Free choice got shot down to protect this illusory and so-called free market? No compromises allowed. Who's rights are served here? Similar to the 'Ban hemp fabrics to protect a cotton industry' - effect. A little bit of good news to all participants. A little is better than nothing? On the other hand there's the age-old question of providers and provided for: A jobless, alcoholic or drug addict (all addicts for that matter), clogging up the health system as a result, pushing crime-related injuries and accidents to ever-increasing heights, should have the same right of passage as an employed citizen, drowning in taxes to subsidize both big business's lack of tax contributions, and unemployed people who cannot contribute. Introduce the addicts of prescription meds to the mix. They do not welcome any action stopping them in their tracks. They don't care if their actions are milking a system to the detriment of everyone else. Nobody dare curb their actions, and sadly, neither does the pill pushers want it to happen either. Add the investors in research and product development who have the right to protect their interests and the situation becomes boiling hot. Then there are the mediators, the stirrers of the mixture, the politicians, maneuvering a highway traffic jam holding the ladles of compromises and solutions to prevent the hot mess from burning and overflowing, but sadly, with their re-election chances safely protected first. The book, although biased in a way, exposes the history of Obamacare and the aftermath. Mistakes made, as well as benefits to millions. Just about everything else related to this challenge are questioned. Following his exposé in TIME magazine, the book offers insider-, as well as behind-the-scene information on the new ACA Bill. Neither the Democrats or the Republicans are the main peanut in the packet, in fact, both political parties are brought down to earth. The information provided undoubtedly leads to more understanding, but also more anger and frustration with a complex system that is failing the people of America, especially when government costs escalates to unaffordable levels for current generations, leaving the bill to be paid by innocent future generations. This is an educational experience. (view spoiler)[ This is not a spoiler per sé. It's my personal opinion. A lot of unnecessary babble. Although I am an outsider, I found this book a necessary read, since it reflects around the world, including my own country where the private sector (insurance and health care) follow the American model with the same consequences. Our government however, did provide alternative solutions, enabling the citizens to make choices. With that said, the difference between services, and the affordability thereof in the private and public sectors, are in striking contrast with each other. But, with many friends working in the health care system, it is interesting to know that thousands of Americans are flogging to South Africa for serious operations. Not only does the exchange rate benefit them, but our private health care services are deemed the be the best in the world and doctors are working at much more affordable rates than elsewhere. The South African government also capped the prices of medicines through legislation and brought down the price of prescription medicines to a realistic level for most citizens. So, although Americans are prohibited from buying cheaper medicines from Canada, their choice to seek assistance elsewhere, through travelling, were not inhibited. It's a difficult choice, and should not be like that, but it is still a choice. One traveling patient told me that her five-star hotel stay after the operation while recuperating under professional supervision, her traveling costs and the medical treatment combined, cost less than half of what she would have paid in America. She had a fabulous holiday as an extra bonus. Sadly it is not a solution to all Americans. If your vote does not count in government anymore, what alternative choices do you have? May I humbly offer an additional solution? Don't buy the product of those companies, buy their shares. The product often makes you sick, while the return on your investment in this highly profitable companies which control medical care, can contribute positively your medical bill. Don't stand on the beach and try to stop a Tsunami, find a surf board that can handle the wave and go for it ... (I know it's insane, but that's what these industry figure heads are doing to the innocent victims to their profit-reaping businesses). If you can't beat them, join them in their own game. Is it really insane? What about the contradiction a few years back when a wave of mass shootings at schools and churches in America topped the media coverage in the world and it was discovered that teachers pension funds, caught red-handed' if you like, were big investors in weapon manufacturing companies. "Krueger, an industry analyst, noted that the main reason Cerberus Capital, the owner of Remington, a gun maker company, faced a big backlash over Remington was because many Cerberus investors were pension funds for teachers' unions as well as endowments." http://money.cnn.com/2015/12/03/inves... "The BC Teachers' Federation, who prides itself on a 'social justice' union, and claim to be a living wage employer, an advocate against child poverty, an environmental stewart, a fervent defender of public education, are also, through their pension plans, managed by BC Investment Management Corporation (bcIMC), investors in Pearson, Enbridge, British American Tobacco, Haliburton, and other corporation who are associated with environmental destruction, sweatshop labour, and weapons manufacturing. " http://thetyee.ca/News/2012/11/13/BC-... It was also the year when weapon sales in the USA were the highest ever, delivering top returns for stake holders and company alike, while innocent children and teachers were killed. In fact the stocks were big winners for investors. How many teachers objected to these investments of their pension money? Many people are unaware of these kind of investments through their 401(k) or other retirements accounts. The other benefit of becoming a shareholder in these companies, is to have a say in what should happen, changing the moral of the story completely. With more and more insurance companies trying to ditch chronic ailments and hoping to benefit from contributions made by people who are not likely to get sick, or promise medical coverage which turn out to be bogus, one has to reconsider all the options. After all, they are not interested in your illness,they are interested in your money. You're not suppose to get sick! Governments and politicians are more often than not the marionettes of their constituencies and backers. They can try to find solutions, but ultimately the solution is often hidden in plain sight. (hide spoiler)] RECOMMENDED!

  2. 4 out of 5

    Dave

    Steven Brill has written a well balanced, clear-eyed account of the tortured passage of the Affordable Care Act (ACA). No one involved, including President Obama receives a grade of 'A' in this saga. Brill's account is clear, detailed, well-researched, and exhaustive. Although reading this can get slightly tedious at times, I believe Brill was spot-on in providing the detail he did. It gives the reader a good feel for how and why the law wound up in its final condition. Washington politics is cl Steven Brill has written a well balanced, clear-eyed account of the tortured passage of the Affordable Care Act (ACA). No one involved, including President Obama receives a grade of 'A' in this saga. Brill's account is clear, detailed, well-researched, and exhaustive. Although reading this can get slightly tedious at times, I believe Brill was spot-on in providing the detail he did. It gives the reader a good feel for how and why the law wound up in its final condition. Washington politics is clearly broken (mostly by money) and this is one of the absolute best examples of why and the results. We cannot afford to continue our national political discourse in the manner it has become in the last 30 years. The original motives for health reform were targeted and commendable. ALL people in the U.S. should be able to access good, affordable health care, as folks in all other first-world nations do. We are spending entirely too much of our national treasure on a product that is excellent for a few, acceptable for more, and unacceptable/too expensive for 30-45 million of us. And the sad truth is we pay the price regardless,so why not make a greater effort to get it right! As Brill says, the ACA has made a start at increasing health care access, and that is commendable. But it missed the boat on many, many details including most notably cost control. The author's ideas on fixing our system are intriguing and deserve more consideration. This book should be a must read for every tax payer and voter!

  3. 4 out of 5

    Gilda Felt

    Reading this book, I was almost inclined to think “a plague on both your houses,” except at least with the Democrats it comes down to what they didn’t do, like push for a public option, and failing to deal with the staff incompetence and turf wars inside the White House that were the major reasons for the ACA website crash. It’s a different story on the other side. Over fifty attempts at overriding the bill, but with no solution of their own? For the Republicans, that’s business as usual. There we Reading this book, I was almost inclined to think “a plague on both your houses,” except at least with the Democrats it comes down to what they didn’t do, like push for a public option, and failing to deal with the staff incompetence and turf wars inside the White House that were the major reasons for the ACA website crash. It’s a different story on the other side. Over fifty attempts at overriding the bill, but with no solution of their own? For the Republicans, that’s business as usual. There were, of course, other players. The drug lobby that supported the law, but only because of a deal to protect their profits. The hospitals whose prices won’t be coming down, no matter that their customer base has expanded. There’s a bright side of sorts, though. We’re introduced to people who were affected, usually for the good, by the Act–unlike the four people suing the Federal government, irregardless that they were already either covered by Medicare or the VA. “I have mine, but I don’t want you to have yours.” Unfortunately, the Act just added tens of millions of new customers to a health care system that charges exorbitant amounts. But giving health insurance to people who couldn’t afford it before is a good thing, isn’t it? If not this way, and not a public option, then what? Somehow, that question never gets answered. I wasn’t taken with the author’s solution, of having large mega-hospitals with little or no compassion also provide insurance coverage. Power corrupts, and absolute power corrupts absolutely, as the old saying goes. But truer words were never spoken.

  4. 5 out of 5

    Richard Nelson

    If you have been paying attention the last six years there's little to surprise you in this thoroughly reported novelization of the horror movie that has been our national health care reform debate and implementation. Still, Brill does a good job of keeping track of the myriad compromises that were made along the way in order to pass the bill and placate the opposition after its passage (albeit mostly unsuccessfully--nothing seems to slake the thirst for blood of Obamacare opponents). His best an If you have been paying attention the last six years there's little to surprise you in this thoroughly reported novelization of the horror movie that has been our national health care reform debate and implementation. Still, Brill does a good job of keeping track of the myriad compromises that were made along the way in order to pass the bill and placate the opposition after its passage (albeit mostly unsuccessfully--nothing seems to slake the thirst for blood of Obamacare opponents). His best and also most annoying section--because the writing becomes pompous and judgmental of such failings as not copying people in other agencies on emails, and he clings to anger about a small-ball reorganization inside HHS by italicizing every reference to it--is the one that gets deep into the implementation weeds, specifically the process that led to the Healthcare.gov calamity. If you have ever worked in a bureaucracy you will recognize the layers of authority and the difficulty in getting important information from those who know things are a mess to those who need to know. He could have easily called this section "Why tech projects fail: a case study." Brill's prescription for further reform, in the form of embracing industry consolidation and using regulation to tame its worst impulses, has the benefit of being in line with where things are going anyway and of being executable without the buy-in of Congress, which he acknowledges will not be passing more meaningful health care legislation any time soon. He takes Obama to task quite a bit in the book but does give him credit for the will he showed in never allowing the ACA to be stopped, even in the dark days of Scott Brown's election and the later rollout fiasco. He spends less energy than one would perhaps prefer taking to task the Republicans who started out at the negotiating table and ultimately decided, cynically, to let Democrats own every problem in health care and attack every action without ever, even now, offering an alternative. Worth reading, even if you will occasionally want to throw it across the room.

  5. 4 out of 5

    Bobbi

    There were moments in the long discourse on how the launch of Obamacare got bungled when my patience grew thin, because I'd followed this all at the time. But then Brill would come through with some inside story that I hadn't heard, and I would be fascinated. Here you can read about the incompetency and turf wars among top-level mismanagement handling the ADA roll out, the maneuverings of special interests and on occasion, revisit the pain of the "little people" being slammed by medical/financia There were moments in the long discourse on how the launch of Obamacare got bungled when my patience grew thin, because I'd followed this all at the time. But then Brill would come through with some inside story that I hadn't heard, and I would be fascinated. Here you can read about the incompetency and turf wars among top-level mismanagement handling the ADA roll out, the maneuverings of special interests and on occasion, revisit the pain of the "little people" being slammed by medical/financial catastrophes. Brill weaves in updates on the families he wrote about in his famous Time article. There's plenty of new material here though, like a close up look at the Silicon Valley techies who rescued Healthcare.gov. And I think where Brill does a real service is in detailing how the pharmaceutical companies, medical device makers, hospitals and insurance companies all got theirs in Washington, which meant that Congress and the Obama Administration failed utterly to wring out any savings and bring medical costs down. Political expediencies simply wouldn't allow it. So US residents continue to pay more than anyone in other developed nations for care that's good, but not necessarily any better than in those other countries. This book is an excellent snapshot of the dysfunction that is our healthcare system. Brill's work suggests many answers, and he offers one surprising proposed solution at the end of it. I won't spoil it here, but it's not the public option.

  6. 4 out of 5

    Book

    America's Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System by Steven Brill “America's Bitter Pill” is a comprehensive story of how Obamacare happened, what it means, what it will fix, and what it won’t fix. American lawyer and journalist-entrepreneur, Steven Brill takes the reader on a journey of how the Affordable Care Act (ACA) took place. This far-reaching 530-page book includes twenty-three chapters broken out by four parts. Positives: 1. Exhaustiv America's Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System by Steven Brill “America's Bitter Pill” is a comprehensive story of how Obamacare happened, what it means, what it will fix, and what it won’t fix. American lawyer and journalist-entrepreneur, Steven Brill takes the reader on a journey of how the Affordable Care Act (ACA) took place. This far-reaching 530-page book includes twenty-three chapters broken out by four parts. Positives: 1. Exhaustively researched and well-written book. Brill has an excellent quality track record. 2. An important topic in the very capable hands of Steven Brill. Healthcare is one of the most important political and social topics of our time. 3. This is a very methodical and chronologically paced book. Brill leaves very few stones unturned and his criticism is fair and even handed. He interweaves his own personal medical emergency story without making it about that; it’s all about the process of passing Obamacare and its implications. 4. Right from the get go Brill does not mince words and provides readers what this book is all about. “It’s about money: Healthcare is America’s largest industry by far, employing a sixth of the country’s workforce. And it is the average American family’s largest single expense, whether paid out of their pockets or through taxes and insurance premiums.” 5. This book is full of eye-opening facts about the healthcare industry in America. “And in the cradle of democracy, or swampland, known as Washington, how much taming can we do when the healthcare industry spends four times as much on lobbying as the number two Beltway spender, the much-feared military-industrial complex?” Bonus, “The U.S. is the only developed country that does not guarantee health coverage for all of its citizens.” 6. Describes the impetus behind the ACA. “In describing the forces that impelled the push for healthcare reform, Harvard Business Review would later cite a 2007 study reporting that medical bills “had become a factor in 62 per cent of personal bankruptcies, an increase from just 8 per cent in 1981.” 7. Describes in understandable details the three-legged stool approach of the ACA. “Prohibit insurance companies from discriminating based on preexisting conditions; keep premiums relatively low by requiring everyone without employer-based insurance to buy insurance on exchanges (while requiring employers to keep offering insurance); and provide subsidies for those who needed it to pay those premiums.” 8. Does a great job of capturing the difficulty in getting the ACA approved. “In other words, reform will be difficult because it would mean taking money away from those who directly benefit from it—people who sell healthcare, and will be motivated to hire lobbyists—in order to benefit the more general population who, because of insurance, won’t get the direct benefit of the healthcare savings.” 9. Reveals a lot of the inner workings of our federal government. “With that send-off, each attendee was assigned a room in the White House or the Executive Office Building, where breakout sessions were to be moderated by White House staffers to address two questions: “What are the best ideas for getting all Americans covered?” and “What are the best ideas for bringing down costs?” 10. Details specific shortcomings of the ACA. “There would be no prescription drug importation. Medicare would not be set loose to negotiate drug prices. There would be no draconian cuts in Medicaid payments. And, yes, there would be twelve years of protection for biologics rather than Waxman’s zero years or Obama’s seven.” 11. The impact of lobbyists spews throughout the book. “Amgen deployed the kind of muscle on Capitol Hill that had become standard: More than $1.1 million in contributions from individuals associated with the company and its lobbyists had been doled out to the members of the Senate Finance and HELP committees in just the 2008 election cycle (with higher totals on the way for the 2010 cycle). Amgen also spent lavishly on lobbyists, deploying dozens (including some who had worked for Baucus) from multiple firms. Its total lobbying bill from 2007 through 2009 alone was more than $38 million.” 12. Explains how the Congressional Budget Office (CBO) makes scoring results. “In short, CBO was an only-in-Washington institution—an independent body whose only virtue was its independence. Which meant not only freedom from political influence but also freedom from having to do its job the way people in the real world did.” 13. Find out which Republican state embraced the ACA and why. 14. The essence of Obamacare. “Put simply, between the subsidies and Medicaid expansion, Obamacare was a massive income redistribution program providing health insurance to those who could not pay for it—something Democrats in a different time might have been proud, rather than afraid, to acknowledge.” 15. The exorbitant medical expenses exposed: hospitals, pharmaceuticals, and insurers. “By 2012, more than $280 billion would be spent each year on prescription drugs in the United States. If Americans paid what other countries did for the same products, they would save about $94 billion a year.” Bonus, “All the numbers seemed to tell one consistent story: Regulating drug prices the way other countries do would save tens of billions of dollars while still offering profits that would encourage the pharmaceutical companies’ quest for the next great drug.” 16. A fascinating look at how the Supreme Court impacted the ACA. “However, as the chief justice read on, he declared that the mandate could be allowed, because although the Obama administration had not called it a tax, the penalty for people who did not buy insurance was, indeed, a tax.” 17. A look at the challenges in implementing the ACA. “TurningPoint also delved into all the technical specifics, such as whether the website was being built with enough capacity to handle anything close to the traffic and complex transactions it might generate. “The existing capacity planning is not adequate,” the auditors said. “The system’s capacity to support future growth cannot be verified.”” 18. Obstructionism against the ACA. “President Obama lashed out at the Republicans: “One faction of one party in one house of Congress in one branch of government shut down major parts of the government. All because they didn’t like one law. This Republican shutdown did not have to happen.”” 19. An interesting look at the team of software experts that came in to save the day. “On Wednesday, October 23, the day after their first breakthrough with the caching, Abbott, Dickerson, and the rest of the team gave Zients and Park their verdict: They could fix the site by the end of November, six weeks away, so that “the vast majority” of visitors could go on and enroll.” 20. Describes how the ACA reached its goals. “By the beginning of the last week in March, they were nearing 6 million sign-ups for the combined state and federal exchanges. The 7 million target suddenly seemed possible.” 21. Adds a chapter in a question and answer format that describes what the ACA does and what we can do to improve it. “The basic message of the book is that even in societies that try hard to be fair or to appear to be fair, the combination of politics, emotion, and unequal distribution of power rarely makes these decisions rational or satisfying to many on the receiving end of them.” 22. Q&A with President Obama. Negatives: 1. At 530 pages, it requires a commitment of your time. On the verbose side. 2. Some topics are exhaustedly looked at and at times bogs down. 3. Lacks visual supplementary material that could have complemented excellent narrative. 4. Repetitive. 5. No formal bibliography. In summary, this is a very important book. It describes how the Affordable Care Act came about in a very comprehensive yet accessible manner. Brill treats the subject with the utmost respect and care and is fair and even-handed. A difficult book to score but I’m feeling generous and give it 5 stars based on the level of detail and author’s pedigree. Not perfect but if you want to find a book that best captures how the ACA came about you will be hard-pressed to find a more accurate and thorough account. I highly recommend it! Further recommendations: “An American Sickness” by Elisabeth Rosenthal, “The Healing of America” by T.R. Reid, “Unaccountable” by Martin Makary, “How Do We Harm” by Otis Webb, “Reinventing American Health Care” by Ezekiel J. Emanuel, and “Over-Diagnosed” by H. Gilbert Welch.

  7. 4 out of 5

    Don

    I know not everyone will have the time to read this book, so I will share what I learned because I think it is important for more people to know this. Time Magazine's Steven Brill takes on a big project in telling the story of how our modern health care system and particularly Obamacare came to be and what has happened since then. Reading this book was like watching an impending train wreck in slow motion. The reader knows it is not going to end well and the numerous mistakes along the way make y I know not everyone will have the time to read this book, so I will share what I learned because I think it is important for more people to know this. Time Magazine's Steven Brill takes on a big project in telling the story of how our modern health care system and particularly Obamacare came to be and what has happened since then. Reading this book was like watching an impending train wreck in slow motion. The reader knows it is not going to end well and the numerous mistakes along the way make you want to pull your hair out. The power of the medical industrial complex to fight reforms and enrich itself while the consumers overpay is disheartening. Until I read this book, I did not know that the industry makes more on hip and knee replacements than Hollywood makes from producing movies. We spend more on back operations than we do on all the costs for police and firemen nationwide, despite the fact that half of the operations do not help. I learned that ObamaCare has some winners and some losers: WINNERS 1. Trial Lawyers. Brill estimates that at least 5% of medical costs are due to extra defensive medical testing and other excesses related to dealing with ambulance chasers. ObamaCare did nothing to reduce this contributing cost to high health care costs because trial lawyers are big Democrat donors. 2. Drug Companies. Because of heavy contributions to both Republicans and Democrats, congress won't take actions to control the cost of prescription medicines. A proposal to allow people to buy drugs from Canada for significant savings was shot down. A rule that requires Medicare to pay higher than average prices for drugs was also not addressed. As a major buyer of medicines, Medicare should be able to demand significant discounts, just like all insurance companies do, but they are not allowed to in order to protect drug company profits. At one point ObamaCare was structured to favor generic drugs. However, in the final version, Big Pharma was able to get co-pay free drugs approved. This means that a more expensive name brand drug would be picked because it was available without a co-pay - no upfront cost to the customer, but higher costs overall that increases premiums for everyone. 3. Hospitals. For years hospitals have had to absorb losses from serving people in emergency rooms who could not pay their bills. Brill estimates this could be 5% of their revenues. Now that many of these people have insurance, they will be collecting fees from insurance and writing off fewer bad debts, resulting in another new source of income. Hospitals were big ObamaCare supporters because the recognized they would be getting more customers out of the deal, with hardly any change to their billing practices. 3. Lower Middle Class Families. In pre-ObamaCare 21st Century America, many people worked in low paying jobs with no medical coverage. These people went without medical care or used emergency rooms. There is no question these people are big winners. They are getting more access to health care because other people (or future people) are footing the bill. 4. Federal Contractors. Creating heathcare.gov cost hundreds of millions of dollars, even when it didn't work! This was a windfall to the federal contractors who won bids to create the program. LOSERS 1. Obama's Leadership Reputation. Even rabid Obama supporters can't defend the way the Obama administration botched the creation of healthcare.gov. White House advisers recommended bringing in an experienced high tech business manager to run the operation. Obama instead gave the lead job to a former college professor with no business or tech experience. 2. Secretary Sebelius. Her Health and Human Services job was supposed to have gone to former House Majority Leader Dick Gephardt, a health care reform wonk and Washington insider, but his nomination would not go through. Instead we got a cabinet secretary who was clueless to the disastrous ObamaCare rollout. She was pushed out the door once it was clear it would not overly embarrass the president. 3. Democrat Office Holders. The number of Democrats in congress has dropped by 70 and in the senate by 14 since ObamaCare passed. Obama squandered the big lead the nation gave Democrats because they were weary of Bush's wars. 4. Health Care Reformers. All health care experts acknowledge that American health care is too expensive for the results we get for the money spent. Some reformers were naiive and believed that ObamaCare would find ways to reduce costs. That might have been possible with a capable leader, but not easy. What we got, from Mr. Lead-From-Behind, was a program that gives more people access to our expensive system. No wonder Obama got no opposition from doctors, hospitals, and drug companies - ObamaCare gave them all more customers pretty much paying the same rates, with the government footing the bill. How bad did ObamaCare blow its chance to fix health care? Here is a quote from Confidence Men: Wall Street, Washington, and the Education of a President where he talks about Dartmouth Method reformer Dr. Jim Weinstein, whose research had found widespread waste and unnecessary procedures throughout the health care industry and was hopeful that ObamaCare would address these obvious problems. However, special interests squelched any chance at these much needed reforms. To spend a ¨once-in-a-generation¨ effort on extending coverage to the uninsured--without any real teeth in using evidence about what was effective in reducing unnecessary procedures, and driving down costs--was a ¨stunning error.¨ ¨It made things worse,¨ he said solemnly. And then he got frustrated. ¨I can´t believe how wrong they got it. This was our one chance, and we completely blew it.¨ 5. Future Generations. The biggest loser by far is future generations. Too late to be included in Brill's book, earlier this year the Congressional Budget Office scored ObamaCare and released a report showing that ObamaCare spending is only covered by 1/3 in new ObamaCare revenue. The other 2/3 must be paid for by borrowing, to the tune of over $1 trillion over the next ten years alone. This means that with ObamaCare we will be spending health care dollars now and expecting our children and grandchildren to pay it back later. Who really wants to defend this funding system?

  8. 5 out of 5

    John

    Healthcare coverage has never been something I’ve paid a whole lot of attention to. Why? Because for my entire life I’ve been covered by an employer Healthcare Plan, one of which was a “Cadillac” plan. However, now that I’m in the Medicare system, and my spouse is in a non-Cadillac retiree employer plan, I’m paying more attention to healthcare. All it takes is paying twice as much or more as last year to get my attention. This book is causing me to read all the current newspaper/internet article Healthcare coverage has never been something I’ve paid a whole lot of attention to. Why? Because for my entire life I’ve been covered by an employer Healthcare Plan, one of which was a “Cadillac” plan. However, now that I’m in the Medicare system, and my spouse is in a non-Cadillac retiree employer plan, I’m paying more attention to healthcare. All it takes is paying twice as much or more as last year to get my attention. This book is causing me to read all the current newspaper/internet articles about our Healthcare system that is still broken even after the Affordable Care Act. There are so many infuriating aspects of our healthcare system mentioned in this book. Some of them are: The drug lobby successfully thwarting attempts to lessen the cost of prescription drugs by letting Americans buy them from Canada, the legal inability of Medicare to negotiate lower prescription drug costs, the ability of service providers such as ambulance companies to charge more than the usual and customary amount, hospitals causing people to go bankrupt over obnoxious “chargemaster” bills, and the chargemaster itself. I am appalled at all the people and organizations that have stopped attempts at a Single-Payer, Medicare-for-All system in the U.S. We are stuck, more than ever, with a multitude of private health insurance companies who all have millionaires for CEO’s, along with the legions of redundant administrators in each company. Why is it that we don’t accept that the single-payer system in Canada or the U.K., is better and cheaper than ours, and model our healthcare system after theirs? It’s probably for the same reason that we don’t convert to a flat tax system and eliminate the IRS. Our healthcare “system” is probably too entrenched to fix with the reasonableness of a medicare-for-all system. This was not an easy book to get through, but was well worth it for the insights into how Obamacare came about, what it does, and what it does not do. The book had a good, detailed explanation of what went wrong with the initial startup of Obamacare, and what they did to fix it. It was a good overview of our healthcare system too. It made me laugh over how the current majority leader, the clueless Mitch McConnell, said that he wants to stop Obamacare, but keep Kynect. Kynect is the Kentucky state run Obamacare exchange system.

  9. 4 out of 5

    srdjan

    An impressive overview of the key components of the healthcare system as well as an illuminating view on the legislative process. The breadth of topics covered (in what seems like a generally sound way) is remarkable. But the most lasting impression i had from this book was how it highlighted a "unknown known" for the author's generation. "No amount of savings is worth a 10% discount on your life". What if those savings meant your family could stay in their home? What if it meant your kids could An impressive overview of the key components of the healthcare system as well as an illuminating view on the legislative process. The breadth of topics covered (in what seems like a generally sound way) is remarkable. But the most lasting impression i had from this book was how it highlighted a "unknown known" for the author's generation. "No amount of savings is worth a 10% discount on your life". What if those savings meant your family could stay in their home? What if it meant your kids could go to college? What if it had implications for a community you care about? The passage is seemingly rational in isolation, but by ignoring the implications and tradeoffs it reveals the character of baby boomer America: one that is entitled, selfish, and atomized. The individual is expected to be purely narrow mindedly selfish- in fact its presented as a clear and obvious given. But its not the position, as much as the lack of awareness of it, that struck home for me. Its impossible to make tradeoffs if you cant recognize one of your most basics assumptions eliminates the potential for tradeoff. While the text could be read as the authors awakening awareness of these tradeoffs, i found it to be telling. There are other passages where the author's "obvious solutions" also appear ignorant of the important tradeoffs dictated by his positions. But hey, ignorance is bliss...or in many cases (like this review) salty and condescending

  10. 5 out of 5

    David

    I respect and appreciate the author’s thoroughness and attention to detail but, as a book I was reading for pleasure, I think the final product would have been better off if much of the political wrangling and policy details had been moved to an Appendix. In the several cases where the details started to get too thick Brill could have offered a general insight and referenced the particulars elsewhere. Had he done that I would have rated this 5 stars. If you’re completely interested in the nitty I respect and appreciate the author’s thoroughness and attention to detail but, as a book I was reading for pleasure, I think the final product would have been better off if much of the political wrangling and policy details had been moved to an Appendix. In the several cases where the details started to get too thick Brill could have offered a general insight and referenced the particulars elsewhere. Had he done that I would have rated this 5 stars. If you’re completely interested in the nitty gritty of how the Affordable Care Act (Obamacare) came about then this book is perfect as is. On the positive side Brill is an excellent writer and unafraid to challenge anyone that offers a specious argument. With very few exceptions he depicts the good and bad of the people involved in the shaping and implementation of the ACA. That’s real life and too often lacking in the nonfiction I’ve read. The history of health insurance in America as described by Brill is very informative along with his descriptions of chargemaster billing, balance billing and other patient/taxpayer-fleecing techniques previously unknown to me. The book’s greatest strength is the collection of stories of health insurance gone wrong. The stories are clear and demonstrate the author’s points very well. Every story made me wince and feel very sorry for the people involved. I may be underrating this book a star.

  11. 4 out of 5

    Sean McKenna

    How much you like this book will depend on how interested you are in the blow-by-blow details of how the ACA got passed and implemented. While it contains a good explanation of the healthcare ecosystem in the US and why reform is so difficult, it is dominated by the strictly chronological, often tedious account of the political machinations required to get the law passed and then the bureaucratic challenges involved in putting it into practice. Brill does wrap up the book with a bunch of recomme How much you like this book will depend on how interested you are in the blow-by-blow details of how the ACA got passed and implemented. While it contains a good explanation of the healthcare ecosystem in the US and why reform is so difficult, it is dominated by the strictly chronological, often tedious account of the political machinations required to get the law passed and then the bureaucratic challenges involved in putting it into practice. Brill does wrap up the book with a bunch of recommendations for how to improve things but it's a long road to get there and arguably could have been written up as a standalone magazine article for people who aren't that interested in the precise ways in which the federal government was ill-prepared to create an intuitive, reliable, scalable consumer website, for example.

  12. 5 out of 5

    Monica Willyard Moen

    This book goes beyond political parties to discuss the failures and successes of the new healthcare system. It gave me a lot to think about, and I'm a little less against the healthcare act than I was before reading this book. However, I am concerned that costs are spiraling out of control, and i'm still concerned that we can't pay for this act. Medicare is broken, and I think it will go bankrupt soon. At least, this book showed me clearly where those spiraling costs are coming from. We haven't This book goes beyond political parties to discuss the failures and successes of the new healthcare system. It gave me a lot to think about, and I'm a little less against the healthcare act than I was before reading this book. However, I am concerned that costs are spiraling out of control, and i'm still concerned that we can't pay for this act. Medicare is broken, and I think it will go bankrupt soon. At least, this book showed me clearly where those spiraling costs are coming from. We haven't gone far enough to fix our broken healthcare system, and I hope whoever is elected next year will do a better job. This system will break if we don't address drug costs, the charge masters, extra nlab and consulting fees, and other medical abuses of power.

  13. 4 out of 5

    Joshua Miller

    My intentions in reading this book were a) get a better understanding of American healthcare (I always confuse Medicare and Medicaid) and b) get an unbiased evaluation of Obamacare. My advice to someone who has similar intentions is to read only the beginning chapters of part 1 and part 4, or better yet check out the Time Magazine article also written by the author instead. The rest of the book is dense and tedious political storytelling. I only recommend it for serious history buffs who want to My intentions in reading this book were a) get a better understanding of American healthcare (I always confuse Medicare and Medicaid) and b) get an unbiased evaluation of Obamacare. My advice to someone who has similar intentions is to read only the beginning chapters of part 1 and part 4, or better yet check out the Time Magazine article also written by the author instead. The rest of the book is dense and tedious political storytelling. I only recommend it for serious history buffs who want to know every single detail of how the ACA was passed. Surprisingly enough (not), these parts were a complete snooze fest. I still respect the author and his credibility; such a unique perspective to have a journalist simultaneously reporting on healthcare and then go through an unexpected medical emergency and receive life-saving care. 2 stars may be harsh, but I just think this book concept could’ve been accomplished in a much more streamlined way. Takeaways to remember: Healthcare in the U.S. is really, really broken – We spend 30% of our GDP on healthcare while other countries spend half that and we get the same or worse care. This pattern follows with individual Americans spending a third of household income on medical expenses. Obamacare isn’t terrible but isn’t great – As intended, it provides coverage to millions of people who never had insurance before. However, the whole ACA process happened because a slim majority wanted to provide healthcare to a small minority so naturally, there will be a lot of unhappy people. I understand upset people who are truly struggling and had their medical costs increase because of Obamacare, but there are lots of others whose wellbeing was hardly impacted and they are some of the loudest opponents. Insurance coverage is a basic necessity in this day and age. More coverage for more people ideally means fewer bankruptcies (unaffordable medical bills are the number one cause of bankruptcy) and hopefully, it also means less economic hardship. As far as the economy goes, unfortunately, healthcare seems to be on a similar track as social security which is a ticking time bomb. I guess wildly expensive healthcare isn’t sustainable. Lastly, I thought it was so interesting that Obamacare is based on Mitt’s Romneycare who ended up being Obama’s opponent in 2012 trying to repeal the signature plan he helped inspire. Talk about ironic. Romney has since said he never thought it should be done at a federal level. Both health plans are based on the 3 leg stool theory including: 1)Individual Mandate- every household has a responsibility to society to have insurance. If you’re sick and can’t afford care because you don’t have insurance, other people help pay your bill because you spent your money on other things or you could never afford it in the first place. This is a conservative idea in principle; i.e assuming personal responsibility. The individual mandate is essential because it ideally floods the market with healthy people. 2) Prohibit insurance companies screening for pre-existing conditions – this helps people who need insurance to receive it 3) Subsidies for low-income people – Ideally, if people can afford insurance and get preventative care which can be more effective and less taxing on the overall system, then we can avoid more emergency type services which are more expensive

  14. 5 out of 5

    Ray

    Steven Brill's book "America's Bitter Pill", won't help anyone with purchasing health insurance on State or Federal exchanges, and won't answer any specific questions on medical health coverage, costs, or options, but it does provide an interesting look into the development, changes, compromises, flaws and benefits of our Nations new complex and controversial health care law known as ObamaCare. With a law this massive, impacting so many people and one-sixth of our economy, it's no wonder getting Steven Brill's book "America's Bitter Pill", won't help anyone with purchasing health insurance on State or Federal exchanges, and won't answer any specific questions on medical health coverage, costs, or options, but it does provide an interesting look into the development, changes, compromises, flaws and benefits of our Nations new complex and controversial health care law known as ObamaCare. With a law this massive, impacting so many people and one-sixth of our economy, it's no wonder getting it started was flawed and controversial. If you want to understand how the law came to be, and whether it's as helpful to society as proclaimed by the Democrats, or as harmful to freedom, liberty, and the economy as proclaimed by the Republicans, this is a helpful book to read. Mr. Brill did a good job explaining the origins of Obamacare. He doesn't get bogged down with the specific details of this complex law, nor too much with the political battles for or against its passage. But he does clarify how "Romneycare" formed a basis for the law, the origins of the idea for the mandate for purchasing coverage, it's origin within the conservative Heritage Foundation, and how it fit in with Republican ideals, at least before Obama took it up as a worthy goal. To me, it's a must-read for anyone interested in the origin of "Obamacare". Brill provides the background, the history, the need, the nuances, the give-and-take, the politicking, the Industry lobbying, the tradeoffs, and the bargaining with doctors, insurance companies, hospitals, and politicians in trying to work out a health care cost control and reform program. Mr. Brill lists many examples of medical patients who had insurance obtained prior to Obamacare, and shows how the protection some of those policies provided were useless and borderline fraudulent in terms of providing financial protection or being of any practical use. These types of insurance policies were the types banned by Obamacare, and why the Obama promise that people could keep their insurance coverage if they liked it after Obamacare was implemented became an unfortunate yet necessary broken promise. Mr. Brill also provides a good background on how and why the initial implementation of Obamacare, the purchasing of medical insurance on the Federal Exchange, was so flawed. The loss of the strong leadership of ex-Senator Tom Daschle from Obama's team created a vacuum which nobody filled, and resulted in no one of sufficient stature being in overall charge during this complex implementation phase. The book also details how the federal insurance exchange ended up being rescued by the recovery team. The author also provides several recommendations to tweak Obamacare to address some of the identified flaws, to lower health care and insurance costs, and to improve health outcomes. Now, wouldn't it be great if lawmakers could put aside partisan ideology and work together to take some of the recommended steps for the good of the Country instead of focusing only on their reelection chances? It was interesting to see so many examples of people who have been helped by the Affordable Care Act, but still remain opposed to "Obamacare". As an example, an NBC/Marist poll conducted in mid-2014 found 57 percent of Kentuckians surveyed said they disliked Obamacare. But when asked about Kynect (the Kentucky state form of Obamacare), only 22 percent disapproved. Bottom line - Kentuckians like Kynect coverage as long as it's not called 'Obamacare', and that's apparently true of many people who still don't seem to understand that benefits which they are receiving and liking are due to this new law. It's also sad to read that because warring factions in congress seem to be dedicated to pleasing their financial backers and focused on their reelection instead of serving the public good, the result was that we’re left with a flawed health care program and no nation-wide health care system. The reluctance of the Political Parties to cross the aisle and work with the other side left us with a less than desired system. The Republicans wouldn’t budge on reducing costs of prescription drugs for fear of upsetting their big donors in Pharmaceuticals, and the Democrats wouldn’t budge on tort reform for fear of upsetting their big donors, trial attorneys. And on and on. So the public gets the short end of the stick while politicians keep the money train flowing and campaign contributions rolling in. Sad.

  15. 4 out of 5

    Coleman

    We’ve swallowed a bitter pill indeed, considering how divisive, controversial, and in many ways, utterly ineffective the Affordable Care Act is. Steven Brill leaves no stone unturned in his balanced investigation of the bill’s history, passage, and implementation over 6 or 7 years in Washington D.C. This makes the book a bit of a slog with its meticulous recordings of email correspondances and meetings, and its cast of thousands of congressmen, senators, aids, department heads, lobbyists, doctor We’ve swallowed a bitter pill indeed, considering how divisive, controversial, and in many ways, utterly ineffective the Affordable Care Act is. Steven Brill leaves no stone unturned in his balanced investigation of the bill’s history, passage, and implementation over 6 or 7 years in Washington D.C. This makes the book a bit of a slog with its meticulous recordings of email correspondances and meetings, and its cast of thousands of congressmen, senators, aids, department heads, lobbyists, doctors, and insurance salesmen. But it is worth wading into the swamp to see what Washington “deal-making” really entails, and how that deal-making has affected our country’s healthcare crisis. Or hasn’t. I’ll leave the nitty gritty details to Brill, but I’ll give you a few of my conclusions: First of all, everyone’s a hypocrite. President Obama and the Democratic legislators made and broke many of the promises that Republicans have been slamming them for ever since. They did indeed make backroom deals with lobbyists to protect corporate interests for pharmaceuticals and insurance companies among others, and they rammed a poor patch job of a bill all the way through to the top without bipartisan support as talks with Republicans gradually broke down. Of course the Republicans were no saints either, refusing to admit that Obamacare was based on a Republican idea (Massachusetts’s Romneycare) and using the benefits of the bill while publicly calling for its demise. Brill particularly nails Mitch McConnell, who has been one of Obamacare’s harshest critics while simultaneously promising to keep Kentucky’s successful healthcare marketplace: Kynect. As Brill astutely points out, Kynect would never have existed if not for Obamacare. Second of all, this bill is a mess. There is no single payer, no public option for insurance (In other words, we are forced to buy a product from a private company or face having to pay a mandate to the government), and pharmaceuticals can still set pill prices however they damn well please, even though every other developed nation on Earth has strict regulations and negotiating powers. I get incensed over this because pharmaceuticals have made it ILLEGAL for Americans to buy cheaper drugs from Canada (Who has much more effective regulations on prices), and they have also made it ILLEGAL for the government to negotiate for discounted prices. Combine that with pharmaceutical patents that don’t expire for years, and these scumbags can charge $1000 PER PILL (In the case of Sovaldi) while their CEOs make upwards of $13 million per year plus stock options. But that’s what happens when you let lobbyists write laws. Obamacare really bombed there. Third and finally, this bill (I guess I should say law) is a mess but it gives me hope. As we saw with the attempts to repeal this law in the past year, the genie is out of the bottle, and even a Republican controlled government could not erase its impact. It turns out that people like having healthcare, and if Obamacare did nothing else it gave millions of Americans a chance to afford that healthcare. On a personal note, I have a close friend who was able to get Medicaid while she was looking for full-time employment thanks to Obamacare and Governor Kasich’s choice to expand Medicaid in Ohio. I don’t think this law “fixed” our broken healthcare system, and taxpayers will be footing a lot of the bill, but you can’t deny that it has truly helped a lot of people get the coverage they need. Brill offers some ideas on how to make the fixes we need. Honestly, I’m not sure his ideas will work, and I don’t know that making fixes to the law will even be possible in Washington’s current state. Republicans want a repeal or bust, and Democrats are ready to defend the law to the death. Meanwhile the insurance companies, device makers, and Pharmaceuticals keep raking in the publicly-funded profits, but on the plus side I feel that I understand the law so much better now than I did before, and I’d recommend this book to anyone who feels confused about it. It’s a long book but so much more understandable than the 1,000 pages of the Affordable Care Act’s actual text.

  16. 5 out of 5

    Al

    Having read Steve Brill's long and eye-opening article on health care costs in Time magazine, I was eager to read his new book on ObamaCare. It was disappointing. Brill describes the tortuous and discouraging path of the ObamaCare legislation through Congress. We know most of the main facts, but Brill adds details and provides an overview of the major initiatives included in the bill. He then moves to a description of the totally bungled implementation process, and in this section produces a gr Having read Steve Brill's long and eye-opening article on health care costs in Time magazine, I was eager to read his new book on ObamaCare. It was disappointing. Brill describes the tortuous and discouraging path of the ObamaCare legislation through Congress. We know most of the main facts, but Brill adds details and provides an overview of the major initiatives included in the bill. He then moves to a description of the totally bungled implementation process, and in this section produces a great deal of new and interesting information about how and why the implementation failed, and how and by whom the errors were corrected. Brill presents all this in a chatty and readable style. The final brief section presents Brill's modest ideas about how our health care system can be reformed. So what's disappointing? First, it's apparent pretty early on that Brill believes that ObamaCare is a good idea, but he doesn't admit this and affects an air of objectivity in his presentation. For me, this impeaches his entire narrative. His attitude toward the need for ObamaCare's broader coverage is undoubtedly influenced by his own recent urgent need for a life-saving operation which occurred at the time he was preparing this book. He dwells on several anecdotal cases of people for whom Obamacare was literally a lifesaver. That's great for them, but this emphasis distorts what should be a more objective analysis (which I was hoping for) of how, in terms of both costs and coverage, the winners and losers balance out. Most important, though, is the complete lack of any attempt to predict what the future impact and costs of ObamaCare will be, taking into account the various exemptions and modifications which have been made to its provisions. It seems pretty clear that the net effect of these changes will be to increase costs, both to individuals and to government, and to decrease government revenues. The legislation was already slated to increase the Federal deficit, probably by more than the Congressional Budget Office claimed, and the changes must have materially worsened the situation. But by how much? We need to know. Brill never approaches, much less answers, that question. Perhaps some of the information I was hoping for doesn't exist, or can't be estimated, but I was looking at least for more than a rehearsing of the history of ObamaCare, particularly one which is evidently biased in favor of the program. Brill is a thoughtful investigative reporter, and should have been able to come with more. Maybe his failure to do so is meaningful in itself, given his bias toward the program.

  17. 5 out of 5

    Bm

    Being a European who knows nothing about American healthcare, I thought this book was absolutely fantastic. Incredibly thorough, clear-sighted and ultimately damming, Brill's overview of the genesis through to completion of the ACA is a worthy introduction to this tangled briar of a topic. Yet, for me, it worked best as an education in the realpolitik of the American political process. I thought back to Biden staffer and ex-lobbyist Jeff Conaughton in George Packer's the Unwinding, whose griping Being a European who knows nothing about American healthcare, I thought this book was absolutely fantastic. Incredibly thorough, clear-sighted and ultimately damming, Brill's overview of the genesis through to completion of the ACA is a worthy introduction to this tangled briar of a topic. Yet, for me, it worked best as an education in the realpolitik of the American political process. I thought back to Biden staffer and ex-lobbyist Jeff Conaughton in George Packer's the Unwinding, whose griping against the Beltway often seemed like the personal complaints of one man who had been tossed and turned by the system. Brill systematically lays out the compromises inherent in every single part of the process - the incessant lobbying, the interaction between the House and the Senate, Congress and the administration, Republicans and Democrats. It's grimey and damming and, like Connaughton, makes you feel like walking into the shower with your clothes on to wash yourself clean. Brill ultimately asks the question should the ACA be dammed for getting involved in this process or praised for dealing with reality? I admittedly skipped some of the more tedious 'he said / she said' chunks, and Brill's 'solution' at the book's end can't help but feel hokey and appended. Yet still, I would call this an important document and indictment.

  18. 4 out of 5

    Mack Hayden

    I had a love/hate relationship with this book. On the one hand, Brill does an absolutely excellent job of conveying the good, the bad and the ugly facts about Obamacare and its stormy history. Given how it may wind up on history's ash heap with the Trump Administration, this book may well serve as one of the better manuscripts documenting the conception and final days of a flawed but beneficial set of health care reforms. No one gets out of this book looking like a saint or a menace; instead, th I had a love/hate relationship with this book. On the one hand, Brill does an absolutely excellent job of conveying the good, the bad and the ugly facts about Obamacare and its stormy history. Given how it may wind up on history's ash heap with the Trump Administration, this book may well serve as one of the better manuscripts documenting the conception and final days of a flawed but beneficial set of health care reforms. No one gets out of this book looking like a saint or a menace; instead, the issues and people involved are all presented fairly and with nuance. On the other hand, the book is, as a whole, somewhat dull. It's hard to focus when the events are conveyed more as a long Wikipedia article than as a narrative. In other words, the book's just-the-facts approach is both its greatest strength and its weakness. Still, if you're willing to go in knowing this one isn't going to really keep you glued straight through, it's a very informative look at one of the more interesting and eventful social reforms of recent memory.

  19. 5 out of 5

    Marillyn Kelemen

    This book was highly informative. A must read for everybody struggling with issues of healthcare. At times it made me very angry, frustrated and embarrassed for the lack of knowledge by most Americans (me included). It also made me feel hopeless and helpless. All the power sits in Washington and with the pharmaceutical lobby. It all seems to be about money: who can get the most at the expense of others. It appears to be a game and the American public are pieces on the board. I'm not sure what th This book was highly informative. A must read for everybody struggling with issues of healthcare. At times it made me very angry, frustrated and embarrassed for the lack of knowledge by most Americans (me included). It also made me feel hopeless and helpless. All the power sits in Washington and with the pharmaceutical lobby. It all seems to be about money: who can get the most at the expense of others. It appears to be a game and the American public are pieces on the board. I'm not sure what the answer is but there has to be a better way. I'm a senior citizen and we seem to be a very vulnerable target. I strongly recommend this book.

  20. 4 out of 5

    Andrea

    Everyone should read this book. It's truly eye opening to see how the government operates and how the Health Industry operates in the United States. Everyone should read this book. It's truly eye opening to see how the government operates and how the Health Industry operates in the United States.

  21. 5 out of 5

    Justin Tapp

    Brill is a writer for TIME and wrote the seminal article on the Affordable Care Act, consuming an entire issue of the magazine, in 2014. This book was largely a result of his research for that article and his own experience, being hospitalized with a heart aneurysm and experiencing the "broken" health care system first-hand. Brill was given access to many in the White House, including President Obama, who wanted his "voice" to be part of the book. The book is the best history of the still-young Brill is a writer for TIME and wrote the seminal article on the Affordable Care Act, consuming an entire issue of the magazine, in 2014. This book was largely a result of his research for that article and his own experience, being hospitalized with a heart aneurysm and experiencing the "broken" health care system first-hand. Brill was given access to many in the White House, including President Obama, who wanted his "voice" to be part of the book. The book is the best history of the still-young ACA yet written. I work in an office of the Commonwealth of Kentucky that looks frequently at Medicaid. I was pleasantly surprised that Brill wrote so much about Kentucky's expansion in this book, several chapters. He juxtaposes Kentucky's competent rollout of Kynect with the federal government's Healthcare.gov disaster. He does not, however, delve too far below the surface of the decisions Kentucky policymakers and implementers faced. The Governor, the Cabinet for Health and Family Services, and the directors of KYNect come across very positively in the book. Brill neglects the political implications of Gov. Beshear's executive order, bypassing the legislature. He also could have strengthened the book by comparing Kentucky's border states and their hesitations and the political battles that have ensued there. Lest people forget what the impetus was for reform, over 60% of bankruptcies in 2013 were largely a consequence of medical bills, up from 8% in 1981. There was much hostility toward insurance plans that capped what an insurer would have to pay out for any individual, a real problem for those facing medical crises. Brill highlights the "corrupt" system with non-profits that are quite profitable, the "charge master" lists of the exhorbitant prices hospitals charge for supplies ($70 for a $1.50 pack of gauze, etc.) and the "discounts" negotiated with insurers. From wikipedia: "Brill claims patients receive bills that have little relationship to the care provided and that the free market in American medicine is a myth, with or without Obamacare...Time magazine's managing editor Rick Stengel wrote: "If the piece has a villain, it's something you've probably never heard of: the chargemaster, the mysterious internal price list for products and services that every hospital in the U.S. keeps. If the piece has a hero, it's an unlikely one: Medicare, the government program that by law can pay hospitals only the approximate costs of care. ..." Brill's history of the problem essentially begins with WWII, when the Supreme Court ruled health insurance were not wages and therefor not subject to taxes nor wage/price controls. This gave employers an incentive to provide an increasing amount of insurance as compensation and a flood of insurance providers into the market. The U.S. is the only Western country to require employer provision of insurance. He takes a brief look at the politics of the 1990s, from the early Heritage Foundation recommendations that citizens be held "responsible" to buy private health insurance, to Jon Gruber's analysis of the consequences of various health care changes, which got the attention of Gov. Mitt Romney. Brill outlines some of the ways Romneycare and Obamacare are similar, but does not do a good job showing how they're different. The penalties under Romneycare are much less, and tax deductible, for example. Obama's initial foray into health policy came at a debate in Nevada when he was an underdog in the Democratic primary. Obama seemed a bit clueless and didn't say anything substantive. Others, like Jonathan Gruber, who had met Obama knew him to be at least knowledgable on the subject (Gruber stayed out of the campaign but later, famously, helped put together the ACA). Eventually, Obama's evolution worked out for him-- but the legacy of him opposing the McCain/Republican-proposed tax credit for the purchase of private insurance came back to haunt him, as did his criticism of Hillary Clinton's preference of a mandate. In Obama's first term he had a crack health care policy team, but Sen. Max Baucus was negotiating his own health care bill. Ezekiel Emanuel got a seat at Obama's table because of Rahm Emanuel, and other wonks like Larry Summers and Peter Orszag also contributed. The hold-your-nose negotiations with Republicans like Mary Landrieu This dynamic is interesting, and I hope Chuck Todd's book The Amateur does a better job detailing the wrangling. Interestingly, the goal was always to eliminate bad insurance policies, yet when it came to millions of these inferior policies being cancelled due to changes in the law, the Administration was suprised and angry. Obama caved under the Republican's repeating ad nauseum his "if you like your insurance, you can keep it." That was never true, never intended to be true, yet somehow surprised Obama when it actually happened. This happened during the healthcare.gov rollout meltdown, which was already an embarrassment. "You guys figure it out" was apparently Obama's leadership style in this project. By the time of the launch, many of the architects had already left for the private sector, exacerbating the problem. Brill hears from multiple parties that Valerie Jarrett filtered complaints and warnings about the healthcare.gov building process from reaching Obama. "The President wants to hear your solutions, not your problems," they were told. Brill asks Obama specifically about this and the President refused to answer. Obama remained focused on the publicity-- making sure young invincibles enrolled. "Enroll America" was a group of secret donors working hard to promote the new health coverage. After meetings he is quoted as saying "But none of this matters if we don't get the technology right," but it's not clear he had met with anyone working on the machine. Part of the problem is that there was no one in charge, there were multiple agencies and contractors tasked with multiple moving parts. On the day of the launch, Healthcare.gov was only able to handle 10,000 users at a time while being overwhelmed with multiples of that. By contrast, Kynect alone was capable of handling 30,000 users-- just one small state. Brill writes that Obama questioned stakeholders individually, "no drama Obama," and some withered under his calm questioning. In the end, he appoints a "health care czar" and things seemingly improve. Brill's later chapters deal with the heart aneurysm. He notes that for all of Kentucky's health care strengths, the system is still not transparent enough for heart patients to compare the results and ratings of surgeons, like he can in New York. Brill tries to make sense of his bills, notes the chargemaster numbers and discounts. He even sits down with United HealthCare's CEO who can't make sense of the bill. Even the CEO doesn't understand the "basic communication he sends to customers," and that problem hasn't been fixed by Obamacare. Brill concludes that while basic medical care is made more readily available for Americans by the law, it still doesn't solve the fundamental problems of health care delivery. Brill's thoughtful solution is to see hospitals become insurance companies, be one conglomerate with price caps and caps on CEO pay and potentially profit. Regulate them like monopolies with anti-trust laws, require that there be a certain number of providers in various locations (New York City might have 5-6, for example). This would cause hospitals to get rid of the "chargemaster" list which CEOs admit is an archaic relic. This would also help do away with the fee-for-service problem. More transparency about prices would lead to better choices and competition. Real innovators and cost cutters could find profit. It's novel. In all, I give this book 3.5 stars out of 5.

  22. 5 out of 5

    Yousef M

    Topic: Narrative of how the Affordable Care Act (“ObamaCare”) came to be, how it was put into effect, and what the future may hold. Style: Author is a journalist with legal background, not an historian so largely a mix of various character-driven narratives of politicians, lobbyists, academics, hospital admins, entrepreneurs and average/sick Americans consuming healthcare (including the author), that run in parallel and converge between 2010 and 2015. This makes the topic more accessible for publ Topic: Narrative of how the Affordable Care Act (“ObamaCare”) came to be, how it was put into effect, and what the future may hold. Style: Author is a journalist with legal background, not an historian so largely a mix of various character-driven narratives of politicians, lobbyists, academics, hospital admins, entrepreneurs and average/sick Americans consuming healthcare (including the author), that run in parallel and converge between 2010 and 2015. This makes the topic more accessible for public given complex policy issues discussed. Organization/Plot: Part 1 starts off with state of healthcare in the US by 2010, touching on recent successes and failures such as “RomneyCare” in Massachusetts (which ACA’s original framework largely drew inspiration from) and introduces cast of characters that are relevant to the genesis for healthcare reform, how and why the legislation was formulated, argued over, and changed, what it sought to solve and what it didn’t, and how it was passed in Congress. Parts 2 and 3 focus on implications of the ACA’s passage, including legal challenges and how the ACA was implemented with a focus efforts to undermine its effects and how the Obama admin negligently bungled the rollout of the insurance exchanges with tech industry execs “saving the day”. Part 4 focuses on what the future holds, including what problems the ACA didn’t address (essentially cost control) and what further changes may be needed to address this. Takeaway: Engaging and accessible read for anyone interested in healthcare policy in the US and why it matters to citizens like you. Enjoyed Parts 1 and 4 very much as you get a good understanding of where industry players, consumers, insurers, and healthcare providers are each coming from and how a political compromise was reached that was due to luck, determination, and abandoning some arguably necessary reforms. Anecdotes of what underinsured and uninsured people were going through reinforced practical implications of what effect the legislation had. Particularly fascinating were the political rivalries and debates between different healthcare policy factions that were ostensibly on the “same side”, namely how the healthcare policy wonks like Jeanne Lambrew and Liz Fowler butting heads with Peter Orszag and Zeke Emanuel who were focused more on cost controls. Parts 2 and 3 were difficult to get through as narrative pivoted more to political partisanship post ACA and the constant It screw ups. Perhaps this is reflective of why the Obama admin failed as well, they were simply uninterested and underestimated it’s importance and just handed it off to incompetent contractors. I’d prob skim through this section (every second or third chapter is enough to understand the key takeaways IMO). My interest in the book largely stems from my work in pharmaceutical industry, some of which was touched upon in this book. The role of patents, FDA regulations, and litigation is certainly relevant to cost control and the author did a good job of simplifying some of the fairly complex concepts of the Hatch-Waxman and biologics framework for generic/biosimilar entry. But the bigger obstacle in the author's opinion is the consolidation of hospitals and other healthcare providers to the point where they can dictate prices to insurance with very little discounting. There was a great WSJ piece recently that went into more detail about how these large regional hospital systems like NYP have even added clauses to their contracts with their insurers to ensure they must always be included in any insurance package offered (which would ensure inflated premiums and undercut efforts to market cheaper, "slimmer", and more competitive insurance offerings to consumers that would exclude NYP and such large networks). Zeke Emanuel in the book was an especially vocal advocate for antitrust enforcement against such consolidation (which largely went nowhere unfortunately). It's ironic that the author's solution to the continuing problem of runaway costs is embracing this oligopoly model where the provider and insurance would become consolidated (separately, their interests are at odds but under one roof with some appropriate QC measures, they should work more harmonious in theory). All in all, a good starting point for a deeper dive into healthcare policy in the US.

  23. 5 out of 5

    Michael

    Excellent reporting and analysis of Obamacare's enactment (how it got passed) and implementation (how the exchange website was initially botched, because no one person owned the final result). For Brill, it all starts with two World-War-II-era agency rulings (a) that health insurance was not subject to the wage controls, and (b) that it therefore was not taxable income. These rulings led to our current system of employer-provided healthcare, which works fine (ish) for people benefiting from it, Excellent reporting and analysis of Obamacare's enactment (how it got passed) and implementation (how the exchange website was initially botched, because no one person owned the final result). For Brill, it all starts with two World-War-II-era agency rulings (a) that health insurance was not subject to the wage controls, and (b) that it therefore was not taxable income. These rulings led to our current system of employer-provided healthcare, which works fine (ish) for people benefiting from it, but left those without it in trouble if they got sick: “60 percent of the personal bankruptcy filings the year Obamacare was passed related to medical bills.” The Romney-care on which Obamacare is based (and which actually was first proposed, and nearly passed before the scandals, by Nixon), addressed these shortcomings by (a) prohibiting discrimination against those with pre-existing conditions; (b) requiring purchase of health insurance; and (c) subsidizing purchase for those with lower incomes. (b) was trumpeted as in line with conservative notions of individual responsibility. Although fairly successful in Massachusetts, it was a huge feat to get this law passed in Congress. One historical contingency that may have had a counter-intuitive effect: Ted Kennedy’s unexpected death, followed by Massachusetts replacing him with a Republican. At that point, the House had passed a more liberal version of the bill (with a public option, one national exchange for healthcare purchase), while the Senate’s was full of compromises to get to 60 votes (no public option, allowing state-run exchanges), that may have been impossible to resolve in reconciliation. When Brown was elected, however, the House Democrats realized they had to take what they could get, and essentially accepted the Senate’s version (which is Obamacare as we know it). While this version is far from single-payor, as Joe Biden said at the signing ceremony (where the mic was hot, unbeknownst to him): “This is a big fu**ing deal.” Making change for the entire healthcare sector is extremely difficult, as Brill shows: “[T]he lobbying was splintered, covering a range of interests as broad as an industry that on its own is larger than the economies of all but five countries.” You can't make up the behind-the-scenes dealing with industry lobbyists and unions. For example, the pharmaceutical lobby secretly financed pro-Obamacare ads ($70 million), secret in the sense that liberal groups anted up small amounts (e.g., SEIU put in $100k), so that the political action fund could list its donors and appear to be supported by a wide range of interests. The $70 million was actually a near quid-pro-quo in exchange for keeping the 2003 prohibition on Medicare negotiating drug prices. (Brill also documents how not-for-profit hospitals act essentially the same as their for-profit brethren, such that there are no innocent players in healthcare reform.) It's all incredibly reported, and left me a bit cynical but very impressed that Obamacare, such as it is, made it through the ringer. Brill's policy recommendations at the end of the book are essentially to allow more vertical integration, with hospitals becoming insurance companies (cutting out the middlemen) to align incentives. This will lead to more consolidation and running an insurance business and a hospital seem to require different employees/skill sets, but Brill thinks the alignment of incentives would be worth it. It certainly would be simpler.

  24. 4 out of 5

    Heath Salzman

    Very informative book on the history of the healthcare conversation in America, paying particular attention to the passage of the ACA.

  25. 5 out of 5

    Kurt

    A statistic that I often refer to is that, despite spending more than double what every other developed nation spends on healthcare (both as a percent of GDP and as a percent of average income), the U.S. still manages to have worse health and worse health care than all of them and our system fails to provide basic healthcare coverage for a huge percentage of its citizens, mostly those who are most in need of it, while every other developed nation has successfully tackled this hurdle long ago. Why A statistic that I often refer to is that, despite spending more than double what every other developed nation spends on healthcare (both as a percent of GDP and as a percent of average income), the U.S. still manages to have worse health and worse health care than all of them and our system fails to provide basic healthcare coverage for a huge percentage of its citizens, mostly those who are most in need of it, while every other developed nation has successfully tackled this hurdle long ago. Why is this so? How can every other developed nation provide better healthcare for all its citizens while we simply can not, not even when we spend twice as much and provide insurance coverage for only a percentage of our citizens? Anyone who spends even a small amount of time studying this issue, away from the noise and persuasions of the money-vested propagandists, will quickly realize some of the major flaws in our system. A well-written, easy-to-read comparative study of different nations' various healthcare systems is The Healing of America by T.R. Reid, which I highly recommend to the many Americans who are familiar only with the U.S. system yet are convinced it is the best system. America's Bitter Pill is a very detailed look at how Democrats and President Obama managed to make some small, but very needed, changes in our healthcare system. It tells how they tried to attain some level of bipartisanship in the legislation. They even patterned it almost exactly after Romneycare which was patterned after the conservative Heritage Foundation's plan. But unfortunately, Republicans had exactly only one goal, as was stated by Minority leader Mitch McConnell: to make Obama a one term president -- not to help America become greater, not to help their constituents, not to do the most good for the most people. No. Their goal was centered around destroying one man: the duly elected president. For them to cooperate in any way with him on an issue as vitally important as public health would simply be the same as aiding and abetting the enemy. In the next presidential election, the eventual GOP nominee, Mitt Romney, was even forced to disavow his landmark accomplishment as governor of Massachusetts, a decision I personally view as cowardly and evidence that he would say or do almost anything to achieve his presidential aspirations. This book covers all the details of all the negotiations and political maneuvering that went on behind the scenes. The influence of money prevails in every way imaginable as decisions are made as to what should and should not be included. The book also covers in glaring detail the causes of the massive failure of the rollout of the healthcare.gov website, which most people know about since people tend to take keen interest in disasters. On the other hand, few people know anything about the heroic efforts of a hastily assembled team of technological wizards who miraculously rescued the program. This story is amazing and the players deserve our admiration and thanks. A very good book with a little more detail than I needed or wanted, but that is hardly worth criticizing it for.

  26. 5 out of 5

    Heather in FL

    This is another book that may have been better for me in print or digital form instead of audio, so I could flip back to pages to review or clarify information. The book was chock full of information about how the ACA came to be, the deals that had to be made to push it through, the finagling in the legislative branch. Anecdotes from some of the people involved. I've always though the ACA was a good place to start. I'm not a fan of repealing it and replacing it with something else, because I'm n This is another book that may have been better for me in print or digital form instead of audio, so I could flip back to pages to review or clarify information. The book was chock full of information about how the ACA came to be, the deals that had to be made to push it through, the finagling in the legislative branch. Anecdotes from some of the people involved. I've always though the ACA was a good place to start. I'm not a fan of repealing it and replacing it with something else, because I'm not really sure what would be better... we sort of need the individual mandate or things like preexisting conditions, gender and age will have to matter again and put insurance premiums out of reach for a lot of people who really need it. It's ludicrous to think insurance companies will just keep lower premiums when their actuaries tell them they'll likely lose money on people with certain circumstances. But at the same time, this book pointed out that costs are out of control, and that's something that was never really addressed when creating the ACA. It seems like it was more about getting affordable health insurance, not necessarily affordable health care. When the heads of non-profit hospital systems are paid salaries in the multi-million dollar arena, I have to wonder what non-profit really means. When pharmaceutical companies are allowed to charge more in the US than anywhere else in the world (because we can "afford" it, and they have to make money somewhere), there seems to be a problem. When MRI prescriptions are passed out like candy, but the price of them can vary wildly, there seems to be a problem. Charge masters at hospitals are insane. On the one hand, I get that we're a capitalist society and money is a great motivator to improve existing processes or make great discoveries, but on the other hand, this is health care. Literally life and death in some cases. It seems a sad statement of our society that one of the leading causes of bankruptcy is medical bills, and many time people die leaving behind large medical bills for their estates to settle, leaving their survivors with nothing. So much for life insurance? Or there are those who wait too long for treatment because they can't afford it, only to learn there's not much to be done for them now because it's progressed too far. Or it's obvious the patient doesn't have money, so treatment options are limited. I don't have answers for our complicated health system, and I'm not sure I have hopes it'll get better, because there are so many fingers in the pot, so many factions lobbying Congress to make sure their own individual gravy trains remain intact... I think until we begin to view health care as a right instead of a profit-making venture, we're doomed to forever increasing costs.

  27. 4 out of 5

    Brian

    This book is Steven Brill's much ballyhooed look at the passage of Obamacare. The book was an interesting look into the passage of the bill and the back alley deals made to get its passage. It also does a good job of exposing the huge profits made by hospitals, pharmaceutical companies, and medical device manufacturers. There are two massive flaws with the book. It expertly shows how the government completely flubbed the building, testing, and implementation of the Obamacare website and rollout. This book is Steven Brill's much ballyhooed look at the passage of Obamacare. The book was an interesting look into the passage of the bill and the back alley deals made to get its passage. It also does a good job of exposing the huge profits made by hospitals, pharmaceutical companies, and medical device manufacturers. There are two massive flaws with the book. It expertly shows how the government completely flubbed the building, testing, and implementation of the Obamacare website and rollout. However he never assigns blame. At most he vaguely pins the problem on Washington Culture. I am sorry but there were people and officials in the Administration who massively failed. If Obama and Sebelius were told everything was fine and left it at that then they are fools. They should be held up as dismissive bureaucrats who are incompetent managers. This is a signature piece of legislation, hold those who pushed it responsible. People should have been fired and there should have been a cleaning of the house of multiple bureaucrats. Brill just sort of shrugs and says "well that is dysfunctional Washington." Call them out in very clear terms. The second huge flaw is that he buys the liberal line that millions of people are getting cheaper access to healthcare. He notes how coverage before cost x, but after a subsidy it now only costs y! A subsidy isn't free. Someone is paying for that. This bill is the large redistribution of wealth we have ever seen. It primarily takes from the young (limiting age band charges) and men (as women can not be charged more, everyone has to pay for reproductive coverage in their health etc.) and gives that money to the elderly and women. At no point in the book does Brill even broach the subject that someone else is paying more. The book is interesting, but Brill stop short of criticizing the players as much as he should.

  28. 4 out of 5

    Summer

    I was deeply interested in this book. Hearing about all the backroom deals was kind of like watching a train wreck. To me, this subject is fascinating because I'm conflicted at almost every angle. I really do think healthcare is a human right but I also think people should take care of themselves. I know profits incentivize innovation but I'm also horrified at drug companies charging literally $1K a pill for things that people have virtually no choice but to buy. The meat and potatoes of this st I was deeply interested in this book. Hearing about all the backroom deals was kind of like watching a train wreck. To me, this subject is fascinating because I'm conflicted at almost every angle. I really do think healthcare is a human right but I also think people should take care of themselves. I know profits incentivize innovation but I'm also horrified at drug companies charging literally $1K a pill for things that people have virtually no choice but to buy. The meat and potatoes of this story was healthcare.gov's preposterously bad launch... an entirely avoidable outcome caused by bureaucracy and politics. And then the rescue story of our country's best and brightest technologists, essentially volunteering their time to fix the debacle. The ACA has helped millions of people. But it's helped no one more than the profiteers at the top, at that's not fair. We are subsidizing billionaires by insisting on a free market in an area where one does not really have free choice (To live or to die is not really a choice, is it?) Mr. Brill's idea that solving some of the chargemaster problems might involve actually letting these companies get BIGGER was intriguing (let 'em get real big and then regulate them lightly, much like utility companies) Anyway, if you dig this stuff, politics or healthcare, you'll find a lot to like about this book. Brill digs into every aspect of the law and spares nothing, finding fault in Republicans and Democrats alike.

  29. 4 out of 5

    Mauricio Maluff Masi

    This book was excellent as a journalistic account of how the ACA became law, of the political challenges of passing the bill, and of creating (and fixing) healthcare.gov. I learned more about how a big bill becomes law from this than from any other source before, and it's worth reading just for that. The biggest flaws of the narrative are that Brill is simultaneously too cynical and not cynical enough: he gives too much benefit of the doubt to staffers involved in drafting the law who were indus This book was excellent as a journalistic account of how the ACA became law, of the political challenges of passing the bill, and of creating (and fixing) healthcare.gov. I learned more about how a big bill becomes law from this than from any other source before, and it's worth reading just for that. The biggest flaws of the narrative are that Brill is simultaneously too cynical and not cynical enough: he gives too much benefit of the doubt to staffers involved in drafting the law who were industry lobbyists before and after, and to special interest lobbyists that were very involved in the process. He's also too lenient on the Democrats for all their efforts to water down the bill for a compromise that wasn't needed and didn't happen anyway. His solution to the healthcare problem in the United States (which he unironically calls "put the foxes in charge of the henhouse") is too confident that hospital executives running healthcare oligopolies across the country would always act in the best interest of patients. On the other hand, he's completely cynical about any political solution to healthcare, such as a public option or single payer, as if the current political balance of forces were set in stone, despite the fact that by his own account most Democrats in congress supported a public option even as the ACA was passed.

  30. 5 out of 5

    victor harris

    It starts out well with Brill showing how his own health care woes are a microcosm of a corrupt, unwieldy medical system that has many actors (insurance, hospitals, etc.)who are committed to maximizing profits at the expense of the patient's health. From there he takes you through the play by play of the legislative struggles to reform the system in what would be labeled "Obamacare", although it is essentially a Republican-based plan resembling Romney's Massachusetts initiative. Although certain It starts out well with Brill showing how his own health care woes are a microcosm of a corrupt, unwieldy medical system that has many actors (insurance, hospitals, etc.)who are committed to maximizing profits at the expense of the patient's health. From there he takes you through the play by play of the legislative struggles to reform the system in what would be labeled "Obamacare", although it is essentially a Republican-based plan resembling Romney's Massachusetts initiative. Although certainly informative, it is a chore wading through the morass of committees, lobbying groups, and players from both the pro and anti-reform stances. Worth considering if you want a detailed breakdown of how powerful interests did and do dominate the health care industry much to the detriment of the people whom it is supposed to serve with the caution that it is rather plodding.

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