America's Bitter Pill

The first book to appear on my reading list is America's Bitter Pill by Steve Brill. This candid look at America's health system from the early 1900s to the implementation of the Affordable Care Act (ACA) (ObamaCare) started when Steven Brill found himself in the hospital for a medical procedure. As the humongous bills came flooding in, he wanted to learn where the system went wrong. This book piqued my interest through conversations in my professional issues class. Occupational Therapy practice is inseparably linked with Health Care Policy.

The fight for national health care reform did not just start with ObamaCare. The book provides a nice timeline of Health Care Policy in the United States. The timeline of Health Care for business can be traced back to 1929 at Baylor University with Blue Cross. In 1929, Blue Cross Plans are established to provide pre-paid hospital care, based on a prototype developed at Baylor University in Dallas, Texas by Justin Ford Kimball. In just 10 years, enrollment in these plans will grow from just more than 1,300 covered lives to 3 million (BlueCross). At this point in history, health care could not be offered to employees, however this created the first Group Hospital Health Plan.

This new plan lead to competition between other employers to start offering Health Care benefits to their employees or prospective employees. in 1932, Blue Cross Blue Shield was given non-profit status which is tax-free and free from insurance regulations.in 1933, Kaiser Co extended insurance plans for employees and their families--furthering the gap for those that are not insured. Over the next couple of decades into the 40s and 50s-employee health care expands and commercial healthcare begins to take root. Between 1930 and 1945 National Health Care Reform is tackled four separate times to no avail (opposed by doctors). Deductibles are introduced for the first time in 1949.

There is a lot more details over the next couple of decades, however the main themes are: (1) Employee insurance increases (2) Medical costs increase exorbitantly and (3) National Health Care reform is continuously shot down.

Cost of Health Care:
1960: $27 Billion
1970 $79 Billion
1980: $257 Billion
2000: $1.2 Trillion
2005: $2 Trillion

Major Legislation Passed:

In office: Lyndon B. Johnson
1965: Medicare:  Part A (hospital coverage)  and Part B (voluntary physician insurance). Medical care for adults over the age of 65
1965: Medicaid-State assistance for the nation's poorest individuals
In office: Richard Nixon
1973: HMO's are created. A network of providers that offers care at a set rate instead of fee-for-service
In office: Ronald Reagan
1983: Reasonable and Customary charges are to curtail exploited fee-for-service fees.
In office: George W. Bush
2003: Medicare Part D extended prescription drug coverage. The law prohibited Medicare from negotiating discounts with the drug companies

After this history lesson, the bulk of the book is about the passage of ObamaCare and the back and forth wrangling across the aisle between Republicans and Democrats. I won't harp on that too much of that, because there is no point, however I will pick out some intersting facts that I did not know.

The Affordable Care Act was built on what is known as "Three Legs of the Stool": (1) Get rid of pre-existing conditions (2) Everyone must purchase insurance* (3) Government subsidies are allocated to those that cannot afford health insurance.

* Interestingly, Obama's plan did not start out with a mandate, but was created to ensure that people didn't just buy insurance once they became sick.

• Rolling out ObamaCare was nothing short of a debacle (4 Reasons Why it Went Wrong), however one state did get it right (KyNect).
• Reported throughout the book is the major benifit the ACA has been to hospitals and Pharmaceutical companies, which has also been in the news lately (5,000% Increase in Drug)
• ObamaCare had several tenants based off RomneyCare (RomneyCare)

Issues still to consider:

"Bundled Payments": Hospitals and doctors are paid based on succesful treatment, not on how many times a doctor sees a patient. This had become a big problem because some health professionals were exploiting the system and giving unneccesary tests to individuals to get their own slice of the pie.

Regulations that Steve Brill believe will continue to help the Health Insurance Industry:

1. Placing urgent care centers under the banner and branded accountability of a big hospital system.
2. Cap the operating profits of oligopolies. This would force prices down. Those that are making higher profits would have to contribute the difference to struggling hospitals in small markets
3. Cap the total salary and bonus paid to any hospital employee who does not practice medicine full time of sixty times the amount paid to the lowest salaried full-time doctor (first-year resident)
4. Streamlines appeals process staffed by advocates and ombudsmen (an official appointed to investigate individuals' complaints against maladministration, especially that of public authorities) for patients who believe adequate care had been denied them or for doctors believe they are skimping on care for the sake of profits.
5. Require that any government-sanctioned, oligopoly-designated integrated system has to have its CEO be a licensed physician who had practiced medicine a minimum number of years.
6. Any sanctioned integrated oligopoly provider would be required to insure a certain percentage of Medicaid patients at a stipulated discount.
7. Oligopolies would be required to charge any uninsured patients no more than they charge any competing insurance companies whose insurance they accept, or a price based on the regulated profit margin if they don’t accept other insurance. In other words, no chargemaster.

Additional References of Interest:

• Health Care Timeline
• HillaryCare

What are your thoughts?!?