Houston Southard
a name that looks so fake you'll care just as little to learn it's not
America’s Bitter pill
Steven brill
Chapter 1 - Looking Up from the Gurney
We spend $17 billion a year on artificial knees and hips, which is 55 percent more than Hollywood takes in at the box office.
2014 Healthcare spending: $3 trillion.
More than ten biggest spenders combined: Japan, Germany, France, China, the United Kingdom, Italy, Canada, Brazil, Spain, and Australia
America pop 2014: 320 million
Next top 10 big spenders: 2.06 Billion
$85.9 billion spent on treating back pain
Equal to total amount spent on all country’s state, city, county, and town police forces.
1.5 million people working in health insurance, but only have as many doctors available to provide the actual care.
Healthcare is the only industry where technology advances have increased costs instead of lowering them.
America doesn’t control prices of prescription drugs the way every other developed country does (we spend more than 50% on them than other countries)
9/10 of the largest pharmaceutical companies in the world have signed settlement agreements with federal prosecutors, paying millions or even billions in criminal and civil penalties for violating laws involving kickbacks and illegal marketing of their products. Nine out of ten.
Chargemasters - $77 for a box of gauze pads or hundreds for routine blood test.
Healthcare is america’s biggest industry: it employs one sixth of the country’s workforce.
American family’s single largest expense, direct cost or tax and premiums.
Healthcare spends 4 times as much on lobbying than the military industrial complex.
But in a country that treasures the marketplace how much of those market forces do we want to maintain when we’re trying to “cure the sick”
It’s funny because all the shit we can stir up, all the indignation we can espouse, when we get sick none of it matters. We’re emotional beings, and when we feel fear, when that sense of mortality smacks us in the chest, we will do absolutely anything to survive. Including putting up our house as collateral to cover medical bills.
When you’re staring up at someone from the gurney, you have no inclination to be a savvy consumer. You have no power. Only hope. And relief and appreciation when things turn out right. People care about their health a lot more than they care about healthcare policies or economics.
60% of nearly one million bankruptcies in 2013 resulted from medical bills.
People need to learn how to take care of themselves and to recognize what’s risky symptoms and what’s not, because even when it's not an emergency, the toughest customers lose their leverage when they think their well-being is at stake.
The question
How do you pay for giving millions of new customers the means to participate in a marketplace with inflated prices—and with a damn-the-torpedoes attitude about those prices when they’re looking up from the gurney? Is that possible? Or must the marketplace be tamed or tossed aside? Or must costs be pushed aside, to deal with another day?
Chapter 2
Health Care premiums have increased four times faster than wages
“The insurance companies make money by spending a lot of money and employing a lot of people to try to avoid insuring you, and then, if you’re insured, to try to avoid paying for the health care you received”
What was before what people spent on snacks is now every family’s #1 financial burden.
Theodore Roosevelt (01-09) proposed national health insurance in 1912.
It got shot down the next two decades as we were at war with germany and structuring our healthcare like the kaiser’s program wasn’t a good image for patriotism.
Same time also as the red scare, and it was lobbied that governmental insurance would smack of socialism and communism. They worked because at the time people still weren’t paying too much.
Labor union leaders were FDR’s (33-45) core political base, and the unions were against government-supplied healthcare due to FDR’s War Labor Board (enforced wartime wage controls in automobile, shipping, rail, telegraph and mining industries to prevent work stoppages that might hinder the war effort, chaired by William Hammatt Davis).
1943: board said fringe benefits (health insurance) not subject to wage controls (prohibits employers from encouraging workers to join/stay with higher pay).
Instead, employers can lure by offering to pay for health insurance, supplied by the incoming flood of insurance companies sprouting up after blue cross in dallas, 1929 and now surging demand for employer sponsored insurance.
Passed with 0 opposition
Because of the labor board ruling: unions began pushing for/winning HI in contracts with employees.
To usurp this lure with government, single payor system was said would undercut the important new benefit unions could offer workers who joined their ranks.
Truman (45-53) took up roosevelt's banner and disbanded WLB, but the WLB had solidified healthcare coverage as key to collectively bargained contracts (unions even more opposed to the idea of single payor)
Other opponents [insurers/hospitals/drug companies, and AMA lobbied millions to campaign that single payor was the key to a socialist state and would “ruin pts relationships w/ doctors” and make them govt ees. Now doctors are owned by the insurance companies [employees of hmo] and pharmaceutical companies.
From 1940-1950 enrollment in private insurance went from 10m to 80m.
1965 LBJ (63-69) established medicare, since employer-sponsored health plans did not protect retired people, disabled people, and medicaid with limited protection for those living below the poverty line.
IRS says: if board says HI benefits aren’t wages, they shouldn’t be taxed. As insurance steadily rose over time the tax break got greater and greater.
The 1954 Eisenhower (53-61) IRS regulation launched america’s most gaping tax loophole, which helped change the course of american health care. And no one in power [the rich] wanted to change this.
The Scooter Store - used millions in TV ads to get people over 65 [meaning medicare paid their bills] to ask drs for prescriptions for scooters/wheelchairs.
Deployed countless salesmen across us to push drs to write prescriptions, even for people who could get around without them.
Had to pay almost 50m to medicare.
THE STARS ALIGN
1) Cost of advances in science of medicine explode
Insurers have to pay more for claims, so premiums go up.
2013 average family policy costs 12k/yr (1k more than full time minimum wage worker makes a year)
Better medical care also meant living longer, longer care. 1965 HOR says by 1990 medicare will cost $12b. Reality: $110b
45m uninsured americans faced with burden of purchasing insurance on individual market [10k/yr in 07]
2) Plight of people who had what they thought was good ins.
Employers trying to stem their insurance costs by allowing insurers to set limits on coverage to incur less risk, and therefore offer lower premiums.
Allowed employers to avoid short-term budget trauma of escalating insurance premiums, but made it less protective.
Workers might be fucked after $50k a year, or $300k in lifetime.
3) A new reform model that seemed politically achievable.
Three legged stool taking romneycare into the federal eye.
1. Insurers in individual market wouldn't be allowed to screen for preexisting conditions [sick people could buy affordable]
2. To stop people from waiting to get insurance until they got sick, anyone who didn't have employer sponsored healthcare or wasn't covered by medicare or medicaid would have to buy insurance or pay a penalty.
Idea was for insurers to compete to sell individual policies, to presumably drive prices down.
3. There would be subsidies for people below certain income levels, and employers [other than small businesses] would be penalized in they didn’t pay for workers insurance.
Chapter 4 - This is what I thought the senate would be like
From a business perspective, as our health care costs approach a billion dollars a year in a couple of years, it’s going to be increasingly an economic disincentive to do business in the United States
Chapter 5 - A New President Commits, and His Camp Divides
Changing healthcare is either about expanding coverage or controlling costs. If you try to control costs, one, that means you’re taking it away income from some of the ⅙ americans employed in the healthcare industry, and two, the lobbyists will kill you. There is no greater machine in the developed world than healthcare lobbying.
Jarrett was the real chief of staff and obama’s closest advisor
Chapter 6 - Every Lobbyist’s Favorite Day
The US is the only developed country in the world that doesn’t guarantee health coverage for all of its citizens.
Why do liberals think single-payor system solve cost-cutting and coverage expansion?
Doctors conflict of interest relationship with drug companies by providing free samples or paying consulting fees. 94% of all practicing physicians… drug companies spend $7 billion on visits to physicians, and $18 billion worth of free samples.
Chapter 7 - Punting to Capitol Hill
Emanuel: one way to cut costs would be to penalize hospitals that had high rates of patients who were discharged and readmitted within 30 days
Chapter 8 - Deal time
More than 75% of America’s 5,700 hospitals are officially nonprofits
One of the more surprising ironies of the American healthcare economy: The nonprofits—whether affiliated with universities, community charities, or spin-offs of religious organizations—typically had the same (or higher, when their tax-free status was accounted for) operating profit margins as the for-profits.
There was talk of giving deeper discounts to medicaid's prescription coverage, taxing drug companies based on their respective market shares, subsidizing drugs for medicare patients when they stopped being
Medical malpractice reform:
Penalties for hospitals with high patient readmission rates:
Allow hospitals/doctors to consolidate their services into bundled payments:
Doctors trying to make more money, the AMA not having the clout it did in the Truman era where they denied heavily the idea of universal health care, because then they didn't want to work for the government, now they work for insurers and can only up their pay by increasing fee for service