Politics for the People Book Club Recordings — A Conversation with Dr. Elisabeth Rosenthal

AmSick__StewartRosenthal (1)

On Sunday, December 2nd the book club had the pleasure of spending an hour in conversation with Dr. Elisabeth Rosenthal, the author of An American Sickness: How Healthcare Became Big Business and How You Can Take It Back. You can listen to our full conversation at the end of this post.

Dr. Rosenthal is a graduate of Stanford University and Harvard Medical School.  Dr. Rosenthal practiced emergency medicine before joining the New York Times where she was a senior writer. She is currently editor-in-chief of Kaiser Health News, an independent non-profit DC-based newsroom focusing on health and health policy.

In the introduction of the call, you can hear Dr. Rosenthal and P4P founder and host, Cathy Stewart, discuss Dr. Rosenthal’s journey from the emergency room to writing about healthcare reform, thinking she would one day be able to return to her calling as a doctor. Twenty years later, Dr. Rosenthal decided to write An American Sickness and told us that in working on the book she “…dug into each area of healthcare to see for myself really how it came to be that we put profit on the front burner and health on the back burner.”

Give a listen here or below:

 

Steve Hough of Florida Fair and Open Primaries kicked us off by asking what Dr. Rosenthal’s views were on the demand for the U.S. to move to a single-payer healthcare system. You can hear Dr. Rosenthal’s response and how she feels that the solution to our healthcare crisis is a political decision here or below.  On the role of the insurance industry, Dr. Rosenthal thinks “…much of what we get from the insurance world, or from a lot of the layers in our healthcare system, has nothing to do with health care, it adds layers of complexity and cost…”

 

Our next question came from Cynthia Carpathios of Independent Ohio. Cynthia asked about part two of Dr. Rosenthal’s book—Diagnosis and Treatment: Prescriptions for Taking Back Our Healthcare—specifically how she sees us changing the culture of healthcare and how can we transform our healthcare system into one where patient care is the primary concern. Listen here.

 

Harriet Hoffman of New York, a consultant who helps people understand the Medicare system and make the best, most cost-effective and access-friendly decisions, raised the push by some for ‘Medicare for All.’ She asked if Dr. Rosenthal thinks a ‘Medicare for All’ system would be viable or even desirable as it is now. Hear her answer or check it out below.

 

Dr. Jessie Fields pointed out that though the healthcare industry spends $3 trillion a year, our life expectancy is going down in the United States. Dr. Fields went on to talk about how the medical industry is the country’s biggest lobbying force, which requires political reform and the removal of profit incentives from healthcare. Despite all of this, Dr. Fields asked Dr. Rosenthal what glimmers of change she can see. An enlightening discussion followed where Dr. Rosenthal shared her view that “…there’s great hope for a kind of physician-patient alliance to bring change.”

 

Reverend Carl McCluster, an independent organizer in Connecticut, spoke of how many of his parishioners are suffering from high medical and drug costs. Reverend McCluster asked Dr. Rosenthal for three suggested steps that advocates could take to push back against the medical industry. Listen to how to fight back here.

 

Susan Massad, a retired physician and a clinician educator of over fifty years, worked with young physicians on their listening skills and their abilities to respond to patients. Susan asked if there are things that Dr. Rosenthal thinks patients should be doing that will amplify their voices and could be helpful to challenge the system. Hear the response.

 

Cathy and Dr. Rosenthal wrapped up the conversation on a note of hope for change and reform. “I tell everyone when I go talk to hospitals,” Dr. Rosenthal said, “just do something. Do something in whatever space you exist to start changing things because I think that’s how empowerment starts.”

 

You can listen to our entire conversation below:

 


For easy reference, from An American Sickness:

Dr. Rosenthal’s

Economic Rules of the Dysfunctional Medical Market

  1. More treatment is always better. Default to the most expensive option.
  2. A lifetime of treatment is preferable to a cure.
  3. Amenities and marketing matter more than good care.
  4. As technologies age, prices can rise rather than fall.
  5. There is no free choice. Patients are stuck. And they’re stuck buying American.
  6. More competitors vying for business doesn’t mean better prices; it can drive prices up, not down.
  7. Economies of scale don’t translate to lower prices. With their market power, big providers can simply demand more.
  8. There is no such thing as a fixed price for a procedure or test. And the uninsured pay the highest prices of all.
  9. There are no standards for billing. There’s money to be made in billing for anything and everything.
  10. Prices will rise to whatever the market will bear.

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STAY TUNED
We will announce our next selection soon.

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An American Sickness New York Times Review

 

Why an Open Market Won’t Repair American Health Care

CreditPing Zhu

 

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

A few years back, the future of American health policy appeared to hinge on how similar medical care was to broccoli. It was March 2012, and the Affordable Care Act (a.k.a. Obamacare) was before the Supreme Court. Justice Antonin Scalia zeroed in on its controversial requirement that all Americans purchase health insurance. Yes, everybody needs health care, Scalia conceded, but everybody needs food too. If the government could make people buy insurance, why couldn’t it “make people buy broccoli”?

The Affordable Care Act survived, of course — though not before a fractured court made the expansion of Medicaid optional, leaving millions of poorer Americans without its promised benefits. But the question Justice Scalia asked remains at the heart of a debate that has only intensified since: Why is health care different? Why does it create so much more anxiety and expense, heartache and hardship, than does buying broccoli — or cars or computers or the countless other things Americans routinely purchase each day?

For those leading the charge to roll back the 2010 law, the question has a one-word answer: government. President Trump’s point man on health policy, the former congressman (and ultrawealthy orthopedic surgeon) Tom Price, has said that “nothing has had a greater negative effect on the delivery of health care than the federal government’s intrusion into medicine through Medicare.” Senator Rand Paul (another surgeon) and House Speaker Paul Ryan have claimed that the affordability of Lasik eye surgery — generally not covered by health insurance — shows that a much freer health care market would be much less expensive. Their idea of “reform” is to cut back public and private insurance so consumers have “more skin in the game” and thus shop more wisely.

Elisabeth Rosenthal
Credit Nina Subin

The physician-turned-journalist Elisabeth Rosenthal offers a very different answer in her eye-opening “An American Sickness.” Rosenthal — formerly a reporter for The New York Times, now the editor in chief of the nonprofit Kaiser Health News — is best known for a prizewinning series of articles, “Paying Till It Hurts.” In them, Rosenthal chronicled the seemingly endless pathologies of America’s medical-industrial complex, from prescription drugs that grew more costly as they became more dated to hip-replacement surgery so expensive it was cheaper for a patient to fly to a hospital in Belgium.

Rosenthal thinks the health care market is different, and she sums up these differences as the “economic rules of the dysfunctional medical market.” There are 10 — some obvious (No. 9: “There’s money to be made in billing for anything and everything”); some humorous (No. 2: “A lifetime of treatment is preferable to a cure”) — but No. 10 is the big one: “Prices will rise to whatever the market will bear.” To Rosenthal, that’s the answer to Scalia’s question. The health care market doesn’t work like other markets because “what the market will bear” is vastly greater than what a well-functioning market should bear. As Rosenthal describes American health care, it’s not really a market; it’s more like a protection racket — tolerated only because so many different institutions are chipping in to cover the extortionary bill and because, ultimately, it’s our lives that are on the line.

Consider the epicenter of America’s cost crisis: the once humble hospital. Thanks in part to hit TV shows, we think of hospitals as public-spirited pillars of local communities. Yet while most are legally classified as nonprofits, they are also very big businesses, maximizing surpluses that can be plowed into rising salaries and relentless expansion even when they are not earning profits or remunerating shareholders. And they have grown much bigger and more businesslike over time.

Rosenthal tells the story of Providence Portland Medical Center, a Northwest hospital system founded by nuns. Four decades ago, its operational hub in Portland, Ore., consisted of two modest hospitals: Providence and St. Vincent. As it happens, my mother was a nurse at St. Vincent for more than half those years, and thus had a front-row seat as Providence transformed from a Catholic charity into one of the nation’s largest nonprofit hospital systems, with annual revenues of $14 billion in 2015.

Along the way, Providence jettisoned most of its original mission, replacing nuns with number crunchers. Once run mainly by doctors, it filled its growing bureaucracy with professional coders capable of gaming insurance-reimbursement rules to extract maximum revenue. Meanwhile, Providence stopped paying doctors as staff and reclassified them as independent contractors (though not so independent they could skip a “charm school” designed by its marketers). Yet even as its C.E.O. earned more than $4 million, Providence touted itself as a “not-for-profit Catholic health care ministry” upholding the “tradition of caring” started by the nuns (now listed as “sponsors” in promotional materials). Rosenthal sums up the result as “a weird mix of Mother Teresa and Goldman Sachs.”

Actually, not much of Mother Teresa: Providence-like consolidation in every part of American health care has created a structure at least as concentrated as the European systems conservatives decry, yet without the economy or coordination of care such concentration might offer if it were focused on people rather than profits. The Yale economist Zack Cooper has shown that prices paid by private insurers are not just massively higher than those paid by Medicare. (They’re in a different orbit from those paid abroad.) They are also hugely variable from place to place and even institution to institution, without any evidence that higher prices produce better care. Providers charge high prices not when and where they need to; but when and where — courtesy of consolidation — they can.

Rosenthal’s book doesn’t conclude with conglomerates. She also provides an eye-opening discussion of skyrocketing drug prices, as well as the less-familiar pathologies of excessive medical testing and overpriced medical devices, such as artificial hips and knees — a market dominated by a few manufacturers that, like big drug companies, shun direct competition in favor of building cozy relationships with the people who prescribe their products. In each case, Rosenthal diagnoses the incentives of the system by recalling the professional advice of Willie Sutton, who said he robbed banks because “that’s where the money is.” What outsiders might see as inefficiency or a conflict of interest, she shows, insiders have carefully constructed to maximize their bottom line. She also weaves in moving tales of those who are paying dearly for that enhanced bottom line — which, in the end, includes all of us.

Where Rosenthal’s account falls short is in explaining why this deeply broken system persists. Early on, Rosenthal seems to side with Speaker Ryan and Senator Paul, describing “the very idea of health insurance” as “in some ways the original sin that catalyzed the evolution of today’s medical-industrial complex.” But, as Rosenthal (too briefly) discusses, countries where people are much better insured don’t have anything like our self-dealing, upside-down incentives and outrageous costs. Somehow, despite largely keeping citizens’ skin out of the game, other rich democracies manage to have much lower costs per person — as well as greater utilization of physician and hospital services and better basic health measures.

The fact is that people need insurance for the highest costs they face. They may be able to pay for Lasik, a nonessential, nonemergency procedure for which consumers have plenty of time to shop around. But the biggest-ticket items — cancer care, cardiac surgery, organ transplants — are beyond the reach of all but the richest, and not so easy to shop around for when they’re needed. Just as we shouldn’t blame the idea of mortgages for the financial crisis, we shouldn’t blame the idea of health insurance for the health care crisis.

The difference between the United States and other countries isn’t the role of insurance; it’s the role of government. More specifically, it’s the way in which those who benefit from America’s dysfunctional market have mobilized to use government to protect their earnings and profits. In every country where people have access to sophisticated medical care, they must rely heavily on the clinical expertise of providers and the financial protections of insurance, which, in turn, creates the opportunity for runaway costs. But in every other rich country, the government not only provides coverage to all citizens; it also provides strong counterpressure to those who seek to use their inherent market power to raise prices or deliver lucrative but unnecessary services — typically in the form of hard limits on how much health care providers can charge.

 

In the United States, such counterpressure has been headed off again and again. The industry and its elected allies have happily supported giveaways to the medical sector. But anything more, they insist, will kill the market. Although this claim is in conflict with the evidence, it is consistent with the goal of maximum rewards to (and donations from) the industry. As a result, Medicare beneficiaries have prescription drug coverage (passed by Republicans in 2003), but Medicare administrators have no ability to do what every other rich country does: negotiate lower drug prices. In January, President Trump said drug companies were “getting away with murder” because they had “a lot of lobbyists and a lot of power,” insisting he would get Medicare to bargain. Should we really be surprised that the dealmaker in chief dropped the subject after meeting with pharma executives earlier this year?

Without a clear view of the political economy of health care, it’s easy to see the problem as Justice Scalia did. If we could just start treating health care like broccoli, the market would solve the problem. But as Rosenthal’s important book makes clear, the health care market really is different. Speaking of her Times series in 2014, Rosenthal told an interviewer her goal was to “start a very loud conversation” that will be “difficult politically to ignore.” We need such a conversation — not just about how the market fails, but about how we can change the political realities that stand in the way of fixing it.

Jacob S. Hacker, a co-author of “American Amnesia: How the War on Government Led Us to Forget What Made America Prosper,” is the Stanley B. Resor professor of political science at Yale.
Original content at New York Times American Sickness Book Review

New P4P Selection: An American Sickness

P4P_bookclub_flyer_Rosenthal

P4P Conversation with Eric Foner Tonight

P4P Conference Call

 Sunday, April 19th, 7 pm EST

Call In Number: 805 399-1200 

Access Code 767775#

I am looking forward to our conversation this evening with Eric Foner as we explore together his book, Gateway to Freedom: The Hidden History of the Undergroud Railroad.  Bring your questions, and call in and enjoy the dialogue!

In closing, I want to share this note from Dr. Jessie Fields.

Freedom Rising and a Post Modern Moment

In reading Gateway to Freedom: the Hidden History of the Underground Railroad by Eric Foner I have become more aware of how much our democracy was shaped by the battles of the antislavery movement and the fight for freedom and equality in the years following emancipation. Using Sydney Howard Gay’s newly discovered Record of Fugitives of 1855 and 1856 and other historical documents and records Eric Foner captures the stories of fugitive slaves who reached freedom with the aid of black and white abolitionists. By their acts of running away and resisting slavery the fugitives pushed the nation to confront the brutal inhumanity of slavery. Not all slaves could escape, the ones who did were often aided by other slaves who hid them or provided them with food. Gateway to Freedom also describes the major role that free blacks played in assisting fugitive slaves. Free blacks in Northern cities often took to the streets to fight for the freedom of runaway slaves.

Fugitive slaves seeking freedom played a pivotal role in propelling the expansion of American democracy. Many African Americans who reached freedom in upstate New York, New England or Canada would go on to become active community leaders such as James W.C. Pennington and antislavery spokespersons such as Henry “Box” Brown and agents of the Underground Railroad such as Jermain Loguen in Syracuse, many would fight in the Civil War as did Harriet Tubman and Garland White. Thirteen of the twenty-two blacks elected to Congress during reconstruction were former slaves.

The turbulent decades leading up to the Civil War, the Civil War itself and the period of Reconstruction raised fundamental questions for the American people, questions such as who was an American citizen and what were the rights of a citizen and questions concerning voting rights and equal protection before the law.  It took the Civil Rights and mass movements of the 1960’s to move forward the promise of full equality.

Today the American political process has become a closed calcified system run by the Democratic and Republican Parties. The independent movement is raising fundamental questions such as: to whom does our democracy belong, the people or the parties and whether the parties have the right to use taxpayer funds to conduct “members only primaries”. Here in New York City over the last several months thousands of New Yorkers have signed petitions to Senator Schumer calling for opening up the primary system to all voters and not requiring voters to join a political party to have the right to vote in all rounds of elections. Efforts for primary reform are underway in other states as well.

It is out of the crucible of abolitionism, the Civil War and Reconstruction that the principles of birthright United States citizenship and equal protection before the law arose and were added to the Constitution as the Fourteenth Amendment.

We independents stand on those principles in leading the movement for structural and systemic reform to open up our political process. This is a moment to further develop American democracy that has been advanced by so many including slaves who had no material wealth but gave all. Gateway to Freedom gives testament to their sacrifice and courage.

Jessie Fields is a physician in Harlem and a founder of the NYC Independence Party. She serves on boards of Open Primaries and the All Stars Project.

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