An American Sickness: How Healthcare Became Big Business and How You Can Take It Back

by Elisabeth Rosenthal

A  New York Times bestseller/ Washington Post Notable Book of 2017/NPR Best Books of 2017/ Wall Street Journal Best Books of 2017 

"This book will serve as the definitive guide to the past and future of health care in America.” — Siddhartha Mukherjee, Pulitzer Prize-winning author of  The Emperor of All Maladies  and  The Gene   

At a moment of drastic political upheaval, An American Sickness is a shocking investigation into our dysfunctional healthcare system - and offers practical solutions to its myriad problems.

In these troubled times, perhaps no institution has unraveled more quickly and more completely than American medicine. In only a few decades, the medical system has been overrun by organizations seeking to exploit for profit the trust that vulnerable and sick Americans place in their healthcare. Our politicians have proven themselves either unwilling or incapable of reining in the increasingly outrageous costs faced by patients, and market-based solutions only seem to funnel larger and larger sums of our money into the hands of corporations. Impossibly high insurance premiums and inexplicably large bills have become facts of life; fatalism has set in. Very quickly Americans have been made to accept paying more for less. How did things get so bad so fast?

Breaking down this monolithic business into the individual industries—the hospitals, doctors, insurance companies, and drug manufacturers—that together constitute our healthcare system, Rosenthal exposes the recent evolution of American medicine as never before. How did healthcare, the caring endeavor, become healthcare, the highly profitable industry? Hospital systems, which are managed by business executives, behave like predatory lenders, hounding patients and seizing their homes. Research charities are in bed with big pharmaceutical companies, which surreptitiously profit from the donations made by working people. Patients receive bills in code, from entrepreneurial doctors they never even saw. 

The system is in tatters, but we can fight back. Dr. Elisabeth Rosenthal doesn't just explain the symptoms, she diagnoses and treats the disease itself. In clear and practical terms, she spells out exactly how to decode medical doublespeak, avoid the pitfalls of the pharmaceuticals racket, and get the care you and your family deserve. She takes you inside the doctor-patient relationship and to hospital C-suites, explaining step-by-step the workings of a system badly lacking transparency. This is about what we can do, as individual patients, both to navigate the maze that is American healthcare and also to demand far-reaching reform.  An American Sickness is the frontline defense against a healthcare system that no longer has our well-being at heart.

Genres: Nonfiction, Health Care, Health, Medicine, Politics, Medical, Business

432 pages, Paperback

First published April 11, 2017

Reviews

[Elyse Walters · Rating 5 out of 5]

Audiobook— read by Nancy Linari who was excellent.....
But....there is soooooo MUCH INFORMATION — I almost wish I had bought the hardcopy. I bought the audiobook instead- which has advantages and disadvantages.
The advantage for me: was the easy listening - taking in an overview ( but some parts were so detailed she lost me) - of what Dr. Elizabeth L. Rosenthal had to say —-who was appointed editor in chief of Kaiser health news in 2016, after more than two decades with the New York Times. She received a BS degree in biology from Stanford University, an M. A. degree in English literature from Cambridge University, and an M.D. degree from Harvard medical school.

The disadvantage- is I don’t have an ‘easy-to-refer’ book to open for some USEFUL information. Especially towards the end - Dr. Rosenthal gives some great tips for patients.

I didn’t take notes— I simply listened - on and off - since I purchased this audiobook last month. My favorite location for listening to this book of all places was when soaking in the warm pool. My reasoning was to balance out the stress from the facts with some nourishing relaxation.
By the way - I should mention - Paul and I are one of the lucky Americans- we ‘have’ medical insurance and are satisfied with the service. You’d be surprised to learn the number of Americans our age and our daughters age that no longer have ANY medical insurance because it’s JUST NOT affordable.
I personally wish we had a healthcare system similar to Canada and Australia.

ON THE SURFACE, in “An American Sickness”,.... we get the general message: Our Health are system in the United States is FRIGHTENING- confusing - a jumbled mix-up -muddled-system that is often so shady —that well meaning doctors have learned how to fudge their part ( not breaking the law), - but play the game to ‘their’ advantage.
The book leans towards being biased— but I can’t fault Dr. Rosenthal for the truth.

BELOW THE SURFACE....is where the reader needs to pay close attention. There is a lot to learn. I admit - I didn’t understand it all. It’s hard for me to understand the break down financially between hospitals and the itemize tests that doctor’s orders from surgery costs - from the cost of a warm blanket used while in the hospital.

The personal - REAL STORIES in here kept me awake - shaking my head- but the full understanding of this system —-no way could I be expected to get it all in one listening read.

I learned to ask MORE QUESTIONS - and not just of our doctors.
It’s frightening when Dr. Rosenthal says our healthcare is a crapshoot. She gives some great tips of how to take back our healthcare.

Part 1 deals with the insurance industry, hospitals, the doctors, the pharmaceutical Industry, profit and nonprofit organization‘s, the government, bankers and outside organizations....etc.

Part 2 begins to stress the reality that Americans are only one step away from losing everything financially with one disease - if complacent- so Dr. Rosenthal begins to spell out how Americans can take back ‘their health care system’ and protect themselves.


One last word from me: when I first started listening to this book I never thought I would get through it. This is not exactly bedtime reading. I never thought I would rate this book more than 3 stars but by the time I got to the end - I knew I couldn’t give it anything but the entire five stars. THE LAST FEW CHAPTERS ALONE ARE WORTH IT.
It’s work reading - or listening to this book - plus it’s depressing and frustrating because you really hope and wish that things would change. We are speaking about people’s lives!!!!! VERY REAL!!!!!
When a patient needs to pay 20%... ( their portion) on a $100,000 knee replacement- that’s still A LOT OF MONEY OUT OF POCKET!

I recommend Americans read this book - perhaps the physical book will be more ‘handy’ as a keeper ( yet I liked the audiobook too)— At the end there are sample letters to write your Hospital and insurance company ( supportive information)

For non-fiction book groups- this is a great book choice!

[Marks54 · Rating 5 out of 5]

This is an outstanding book that should be read by anyone interested in healthcare and current US healthcare debates.

The book is not about Democrats versus Republicans or about Obamacare and various ongoing efforts to change it. The author is a physician and former NYT writer who knows much about both the practice of medicine and the business of healthcare. The point of the book is that the healthcare sector/industry has come to adopt a business model that is out to fully monetize every aspect of the business that is capable of being monetized. In the course of adopting this model, the practice of medicine has become detached from the business of medicine. The result of this is that patient care has become detached from business success. This business model has displaced the historical emphasis of "first do no harm" with a new emphasis of "first leave no money on the table". This is a detailed critique of healthcare business models that will not be surprising to those who have followed the sector. The shock value of the book is in the comprehensive assessment of how the "American sickness" of high cost healthcare has advanced everywhere in the US and how these trends have even accelerated in the last two decades. These forces were present before the advent of Obamacare (ACA) and will remain present after current efforts at changing the ACA have run their course and "Trumpcare" has become the new norm (whatever that will mean). We all have had inklings of how economic incentives may pervert medical decisions - for example if one get paid well to perform surgeries and less well to avoid them, one should not be surprised to find a lot of surgeries taking place. Rosenthal has written a book that shows how such economic and bureaucratic logics have come to dominate American healthcare, with highly dubious consequences for the national economy and for the health of patients.

I will not begin to summarize or recapitulate the various arguments in the book. One way to understand them is to deconstruct what it means when someone discusses a "market" for healthcare. It is easy enough to declare that a market or marketplace approaches is at work in some way in a business. The problem is that for markets to work as intended in organizing economic transactions, there need to be a number of conditions met. If they are not met, the result will be a highly distorted arrangement and not the efficient outcome claimed by market advocates. What are those conditions? Well, there needs to be lots of competitors in a given market, or else collusion will be likely. There needs to be a relatively free flow of information among decision makers so that they have a basis for making good judgments. Participants needs to be able to move their resources around to take advantage of market opportunities. This is opposed to participants being stuck in settings and not able to respond when contracts are invalidated, prices raised without warning, etc. Sellers should also have difficulty in colluding with other sellers to control entry or prices. Participants need to be smart and informed about their situations so that they can make good decisions. There are other factors as well and these market conditions vary by industries and sectors.

Rosenthal's critique is that the healthcare market is a very imperfect one and that as a result competitive forces do not (and likely cannot) work the way they are intended. The result is a system that accounts for over 17% of US GDP and is characterized by very high prices, lots of confusion, mixed health benefits, and significant trauma and distress for those who are poor. In one of her initial chapters Rosenthal outlines a set of rules of thumb that have developed in this highly imperfect market setting and she then proceeds to bring them up wherever relevant in later chapters. The story that results is a deeply troubling one that made me want to double check my insurance status before I read further in the book.

Rosenthal also provides well thought out and specific options for what readers can do in the short term and what lawmakers and voters can do in the long term to counter these trends. These chapters are helpful and make the book more than just a critique. The book is also carefully annotated for those seeking to read more. The author also provides some outstanding appendices with web and other resources to consult in considering how to handle healthcare business transactions to reduce the risk of being taken for a ride.

This is not a critique of the quality of healthcare in terms of the science. It is a call to rethink the benefits of thoughtful cost-benefit analysis so that healthcare can focus more on patient welfare and pose less of a risk to patient finances and solvency. This is only one book of many for getting up to speed with healthcare but it is a fine book to start with that I hope attains a wide audience.

[Kristin Butler · Rating 5 out of 5]

Doctors, Hospital employees, medical device reps, Health insurance agents anyone in Pharma should read this book. Anyone who touches medical care in any way should read this book. Anyone interested in healthcare reform should read this book.

The nation is fixated on "Healthcare Reform" but most Americans don't seem to understand that the rising cost of healthcare has more to due with the lack of transparency in pricing and the Byzantine American healthcare chaos (system would be too generous a concept), than any piece of legislation that merely addresses insurance coverage.

Rosenthal elucidates how the American obsession with making money has infiltrated every aspect of Healthcare ( or perhaps we should call it what it really is- sick care), bankrupting individuals across the country.

No one is immune from Rosenthal's impeccably researched critique- hospitals, drug makers, medical device manufacturers, pharmacy benefits mangers, insurers, physicians, Democrats, Republicans. We have all created this mess and it will take a village to get out from under it.

I have tried to explain this lack of transparency to my husband for years, but he tends to listen to talk radio and read the Wall Street Journal and it becomes a political argument with a lack of understanding regarding the complexity .

This book helps break down the problems into each component. Compelling stories. Easy to understand.

Read it!! Educate yourself!!

[Wick Welker · Rating 5 out of 5]

Profits over health.

This is THE book to read about the commercialization and exploitation of the American healthcare system by hospitals, private insurance, pharmaceutical companies and medical device manufacturers. The author goes into painstaking detail about the bloated, deprived and egregious state of the American healthcare system. As a double-boarded ICU doctor and anesthesiologist, this book made me scream into the uncaring void.

This book is about five years old so by now, hopefully, a lot of the facts presented are now commonly known to most. The US spends about 3 trillion a year on our healthcare which is the entire economy of France. We have skyrocketing costs without patient health improvements and the only returns on the cost are the ones rigging the system and padding their pockets with outrageous profits. There are several issues that have led us to this dire state and they are the following:

1. Monopolized healthcare systems: their stranglehold on the market allows them to bully insurance networks into paying large sums which completely destroy the finances of the under-insured or the uninsured. Non-profit status allows them to dodge payroll taxes, compensate their CEOs at private-like salaries and invest in curbside appeal for their hospitals to help with their optics to keep patients coming.

2. Monopolized private insurance: their ability to act unilaterally and stop reimbursement whenever it is not profitable.

3. Pharmaceuticals and their patent evergreening: by adding another methyl group to an old drug, they can re-patent it and charge whatever they would like. And the generic market doesn’t mean generics are cheaper. Generic drugs can be taken over and prices can go up.

4. Medical manufacturers cartel-like hold on their products and pricing: There’s like three or four major medical device manufacturers and they do whatever they want with pricing and are HEAVILY involved in bedside patient care

5. Contracting upon subcontracting within a hospital system: many hospitals contract services out like lab work, pathology, anesthesiology ect and these companies charge whatever they want and they can be out of the patient’s insurance network.

6. Out-of-network costs: these creep up on patient’s out of nowhere when they get their bill

7. Doctors: clueless doctors not knowing costs, profit-seeking doctors setting up exploitative practices and ethically questionable ownership relationships.

8. Unbundling of care: everything now costs something including the $50 cotton gauze included under your bandage.

9. Lack of price transparency: patient’s should also have FINANCIAL consent to anything before they have treatment or procedures.

10. Price elasticity. Hospitals employ strategic pricing which creates insane pricing volatility. Upcoding of medical diagnoses and nickel and diming everything that is done to a patient to extract as much profit as possible.

11. Exploiting resident doctors: residents are underpaid for their labor. Of course this is not equivalent to a different profession being underpaid because residents become full attendings who eventually have higher salaries. The point is that resident labor is very profitable for hospitals because they receive government stipends for having residents that they may not use all to pay their residents. And why do they need the stipends when they have plenty to pay their CEOs and make their lobbies look pretty?

12. The AMA is an out-of-touch, rent seeking body of bureaucrats who lobby for their own bottom line. The AMA no longer has the patient's interests at heart. It acts like a type of senate with extremely unbalanced representation between medical specialities ensuring that sub-specialties like ENT or urology are better compensated than other specialities like internal medicine or psychiatry. The AMA has many, many revenue streams of which only 25% is made up from physician membership. To be clear: I am NOT a member of the AMA and I never will be.

13. Many more reasons I don’t have the time or energy to enumerate so you should read this book.

The amazing thing about American Sickness is that the author spends several chapters offering solutions, many of which are about educating yourself as a patient. Ask for an itemized bill, every time. Ask if some of your care is contracted out and if those contracts are within your insurance network. Ask if your doctor has ownership in a surgery center or anything else they are referring you to. Not for profit hospitals should lose their status if they can afford to pay their CEOs more than private companies. We need stricter regulations on drug patents. Medicare should be expanded to the young. Medicare is MORE efficient than private insurance. Medicare spends 98% of its premiums for medical care and only 2% for administration which is way way different when it comes to private insurance. The ACA was mostly a gift to private insurance but there were helpful provisions that can be built upon. The author offers many many more solutions that you really should check out yourself.

This is a phenomenal read. As a doctor, I HIGHLY recommend you read this and educate yourself about the catastrophe of the American healthcare industrial complex.

[John · Rating 3 out of 5]

I read this book because my colleague and Goodreads friend Divu raved about it -- and I can see why. This book collects up evidence across many domains of healthcare to explain why care is so expensive, sub-optimally delivered, and sometimes low quality in the United States. The book is essentially muckraking of the finest sort.

The first half is devoted to what is wrong, and discusses insurance, hospitals, physicians, drugs, devices, services, billing, fake non-profits, conglomeration, the subordination of care to new business models, and the ACA.

Her discoveries are shocking. I was a bit surprised that in this book, the insurance business is almost the least of our worries. The most troubling chapters were those on doctors and the AMA, hospitals, and on drugs (big pharmaceutical companies). The problem with doctors can be summed up in one fact. In the early 90s, the official pledge for the American College of Surgeons said:

I promise to deal with each patient as I would wish to be dealt with if I were in the patient's position and I will set my fee commensurate with the services rendered.

I will take no part in any arrangements such as fee splitting or itinerant surgery which induces referral or treatment for reasons other than the patient's best welfare. (p. 55, emphasis by the author)

By 2004, these bolded ethical limitations were removed. Across all medical disciplines, many doctors now exploit the destruction of such promises and conduct various kinds of billing chicanery that would make Charles Ponzi blush.

Over and over again, medical businesses conduct the grossest kinds of self-dealing and obviously dishonest manipulation of the system for their own gain. A key summary of the book's finding is in a table of "Economic Rules of the Dysfunctional Medical Market," with entries such as: "1. More treatment is always better. Default to the most expensive option," and, "7. Economies of scale don't translate to lower prices" (p. 8). There are eight more.

The second half of the book explains how you, the patient, can engage and resist these forces. Basically, you have to be super-aware of every detail of your care. Example: She advises, for instance, that you take note of every single person who visits your hospital room, and find out why they're there. Why? Because someone dropping by for a 5-minute check-in may bill you for a consult.

This is good stuff, but it is also the problem with the book. According to the author, the only person who can help herself out of this mire is the patient. (And there's a lot of truth to that.) But who has time for this? No one. That is the problem with healthcare today: it is essentially an incoherent and contradictory space that makes no sense. Why become an expert in your own care when the system's reaction to your situation is essentially random?

The book reads like a gigantic list, first of the problems, then of the solutions you personally can exercise.

So where is the holistic solution? Unfortunately, it's only here piecemeal. It's there alright: The problem is with lobbying at the federal level. Our representatives are essentially bought. There is a new afterword to the paperback edition that rightly attacks Trump and the GOP, but it's not just them: Even a cursory browse through https://www.opensecrets.org will tell you that the Democrats are almost as in hock to big pharma, the AMA, insurance, and the hospital networks as the Republicans. Rosenthal is not very vocal in summing it up -- that the whole system stinks, and there needs to be massive regulation and restructuring of the industry, and only political semi-outsiders like Elizabeth Warren would ever be able to articulate how to do it. I mean, let's be real. The existing leadership has very little to offer because they're employed by the system.

In short: I do recommend the book. But the solution is to transform healthcare tout court. If you want to learn how to do that, read T. R. Reid's The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care.

[Mary Greist · Rating 4 out of 5]

Well written expose of our healthcare system

As a physician who practiced 35 years and recently retired, I have seen first hand much of what the author describes. It is extremely well researched and well written. It should be required reading for all law makers. Some of the possible solutions discussed seem like bandaids. The only solution I see is a single payer system.

[Yun · Rating 4 out of 5]

An American Sickness is the most eye-opening book I've read so far this year. It takes the reader through how insurance, hospitals, doctors, big pharma, and medical device manufactures, among others, all prey on the system and the patients to wring every possible cent of profit from American healthcare. Though it is the ill and the poor who suffer immediately from this, really every person who pays taxes is subsidizing this greed in the end.

The book is divided into two parts. The first part, which covers the first two-thirds of the book, takes a detailed look at all that is going wrong with the American healthcare system. The second part contains suggestions for what people can do to push back and combat these wrongs. For such a dry topic, this book was surprisingly easy to read and digest, partly due to the copious amount of real-life examples.

A word of warning though: the greed detailed in this book is often hard to read and swallow. For example, medical devices are not subjected to the same rigorous FDA regulations that drugs are, so patients are the ones who suffer when devices implanted into their bodies fail because they haven't gone through adequate testing. Another example is that doctors can employ extenders, so that if you are in surgery, you can be billed at full price by both the overseeing doctor as well as his assistant. Another example shows drug companies exuberantly raising prices year after year, and paying off other drug companies to not manufacture a generic so that they can retain their monopoly.

My one complaint about this book is that it didn't go far enough in talking about how we can fix the system. Every other developed country in the world is better off in terms of healthcare than we are. I want to know more about how they are able to achieve that, but the book only touched upon some of those points instead of providing a more thorough juxtaposition of how their system works versus ours.

There is so much wrong with the American healthcare system that I'm not sure we can ever as a country pull ourselves out of the mess that we've landed in. The entire system is fundamentally broken. At times, reading this book made me feel sick. I can't believe we've come so far from patient-first healthcare to a world now where profit is king. The currently profit-driven healthcare isn't sustainable, and the country is already buckling under its tremendous cost. Though this book doesn't provide all the answers, it does help me better understand what is happening to healthcare in the U.S., and what I can do as an individual in a vast system.

[Scott Rhee · Rating 5 out of 5]

One would think that, given the fact that we are living in the wealthiest nation on Earth, we would also have the best healthcare system in the world. Sadly, this is not the case. Depending on which study one looks at, the United States consistently comes in around dead-last in every ranking, with the exception of “Country that spends the most on hospital landscaping” or “Most money spent on erectile dysfunction drug commercials”.

Those post-modern shiny new hospital facilities and medical centers popping up everywhere in the country paint a pretty picture about our national healthcare, but it’s all a subterfuge and a lie, hiding a slow-metastasizing cancer eating away at our country’s health. The diagnosis is an easy one. It’s late-stage capitalism.

There are three services that never should have been treated as a business: education, religion, and healthcare. Today, all three fields are money-making industries, and, not surprisingly, all three of them are failing miserably in this country. Thanks to capitalism, we now have one of the worst education systems in the world, churches that have seen rapidly-dropping memberships and patronage in the past ten years, and a healthcare system that cares more for making money than it does helping the sick.

Elisabeth Rosenthal’s “An American Sickness” may be thick with information, but her pedigree as both a journalist (22 years as reporter for The New York Times and currently editor of Kaiser Health News) and medical doctor (MD from Harvard Medical School and has worked as an ER physician) gives the book intellectual weight and credulity.

This book is worth reading if only as a brief historical overview of the American healthcare system and how it came to be the multi-billion dollar industry it is today. It wasn’t always a for-profit industry tied inextricably with insurance companies and pharmaceutical companies.

Indeed, health insurance was a grand idea before it became the monster it is today. Started at the turn of the 20th century as a way for people to afford hospital stays, which even in the early 1900s could be costly, health insurance was a simple system in which everyone chipped in a monthly payment (50 cents a month, or $6 a year) for a service that they hoped they would never have to use. At first, school teachers were the only segment of the population to benefit from insurance, but before long the kitty was open to everyone. By 1939, three million people were involved, and the system was given the name Blue Cross Plans. They were non-profit.

Eventually, for-profit insurance companies started sprouting up in competition with Blue Cross and Blue Shield, co-partners and the only non-profit insurers on the market. Sadly, Blue Cross/Blue Shield was unable to keep up with the bigger, better (and more expensive) insurers. Today, what few Blue Cross/Blue Shields remain bear little resemblance to the non-profits they once were. All of them are, today, for-profit companies.

Hospitals, once thought of as places that catered to everyone’s health needs, are now deluxe buildings with state-of-the-art technology and architectural designs that are showcased in magazines. Replete with green-spaces, five-star restaurants, and the most charming contemporary accommodations, hospitals now cater to only a small segment of the population: the rich.

You’re basically screwed if you’re poor and uninsured nowadays, as a simple one-night hospital stay could cost you upwards of a few thousand dollars, and that’s being conservative. And don’t bother trying to get a line-item bill of charges. Assuming they give you one, you probably won’t understand it anyway.

Medical billing has become such a ridiculous quagmire, it has actually opened up a quite lucrative cash-cow industry. Medical schools now offer specialists in “coding”, which is nothing more than being able to read and write in the confusing language of medical billing. Everything from colonoscopies to X-rays to using a tissue has a specific code number, and those code numbers correspond to prices that are never fixed and always changing. Hospitals set the market price for services. They can literally charge you $400 for using the bathroom, and there’s nothing you can do about it.

The unhealthy marriage of hospitals, physicians, and Big Pharma adds more problems to an already-horrible situation that most Americans face. Big Pharma is a multi-billion dollar industry, and don’t be fooled into thinking that just because they are manufacturing and marketing drugs that might help people that they actually give a shit about helping people. If, by “helping people”, you mean “taking as much money from sick people to ensure that they live a little bit longer so they can give more money”.

Today, the sad and disturbing truth is that many doctors, most hospitals, insurance companies, and Big Pharma have a vested interest in keeping a majority of Americans sick and repeat customers. They don’t want cures or treatments that actually mitigate people’s illnesses because that’s bad for business.

The good news, according to Rosenthal, is that there are good doctors and hospitals out there. There are also good politicians, like Senator Bernie Sanders, who continue to fight the good fight in advocating for universal healthcare. Thankfully, views on universal healthcare---once thought to be a dreaded form of (gasp!) socialism---are turning around. Even Some Republicans are beginning to see the light.

In the second part of the book, Rosenthal offers several chapters of ideas on how to fight the system. Steps as simple as adamantly asking for line-item bills after hospital stays or asking doctors, upfront, how much insurance will pay for a particular treatment and what will be out-of-pocket. Most hospitals or doctors will say that they can’t legally give out information. They are lying. Rosenthal advises people to not be afraid to, occasionally (and if the situation isn’t life-threatening), threaten doctors and hospitals to go elsewhere. Nothing terrifies a doctor or hospital more than to lose customers.

“An American Sickness” is absolutely required reading for anyone with a dog in the race of living and staying healthy in the United States. Namely, all of us.

[Wen · Rating 4 out of 5]

This is certainly a very provocative book. I am more than a light user of the U.S healthcare system, and have personally experienced a fair number of ordeals described in the book; even I was shocked by case after case of “runaway” patient bills being cited.
There are three major and mutually dependent factors in any healthcare system: quality, cost and accessibility. The author Elisabeth Rosenthal primarily tackled one of them: cost.
If we compare the dysfunctional U.S healthcare system as a sick patient, Rosenthal spent 2/3 of the major portion of the book giving the symptoms, e.g. exorbitant patient bills, wasteful medical procedures, transparent pricing, etc.… and her diagnosis, the focus of the system pivoting from health and science to profit-making in the last quarter of a century. Hospitals, doctors, drug and medical device companies, with the assistance of consultants, trade associations, lobbyists, politicians, etc.…have all been shamelessly seeking to gain bargaining power and circumvent regulations in order to squeeze out more juice from the system for themselves and their stakeholders. And the losers: tax payers and patients. In this part Rosenthal did a thorough job exposing the inner work of the rigged system, the role played by each party and their motivations.
Then she used the rest of the book to suggest treatment options. She gave suggestions, some I found quite useful, for patients to cope with the current system and minimize financial damages, She went on to proscribe ways to overhaul the entire healthcare system.
I agree that simplifying the system, i.e. collapsing some of the middle layers of the supply chain, could reduce the numbers of mouths to feed, and result in cost savings. But how will the savings be distributed? how much of the savings would be passed on to us patients? The recently announced so-called vertical merger between CVS (drugstore) and Aetna (health insurer) and between Cigna (health insurer) and Express Scripts (pharmacy benefit manager) both ostensibly aimed at this very purpose. As the country now only have two major drugstore chains and five major health insurances as a result of prior industry consolidations, these two mergers could also give rise to further concentration of bargaining power at the expense of tax payers and the patients.
I don’t believe any sweeping healthcare reform would be possible without the overhaul of our more dysfunctional political system. To me universal healthcare, as ideal as it is, could only be feasible at the state level, if at all.
On the brighter side, incremental improvements are happening under our noses. Mostly driven by technology. For example, My Chart, a mobile app, now connects me directly with two of my most frequently used healthcare providers. I can schedule appointments, get refills, message doctors, view my lab results, and so on at my own convenience. Technology will be the key enabler of price transparency and patient comparison shopping. Moreover, artificial intelligence and big data analytics will help improve the quality of the diagnoses, design more personal treatments, and indirectly lower the cost.
I'm really curious about the universal healthcare in UK, Canada, and other countries. Will look for books on the topic.

[Melissa · Rating 5 out of 5]

If you are lucky every year you’ll stumble across one or two non-fiction books that are so on topic for the current discussion with both tons of useful and informative examples and lots resources and ideas to move forward. This is the book to read this year! It details, in easy to understand ways, how the US healthcare system has spun so far out of control, as well as some common sense solutions to slowly start nudging it back on track.

[Zack · Rating 5 out of 5]

really good write up on an overly complex system. This book is really well sourced and approachable. A lot of the content would be funny if it weren't so tragic

[Natalie · Rating 5 out of 5]

I do most of my reading from the library and rarely buy books or reference them after the fact - I'm seriously considering buying this one.

I work in the healthcare industry and am familiar with some of the practices that impact my corner of the healthcare world. But even though I consider myself to be someone more knowledge than the average American, a lot of what I read just blew me away. As discussion of our healthcare system is at the forefront, we ALL need to understand the financial motivations of the industry so that we can better evaluate some of the nonsense or counterproductive "solutions" put before us by elected officials and industry. When we are swayed by carefully crafted sound bites into support things that are against our best interests, or discouraged from fighting them, we are actively making the system worse in many cases.

Beyond an insightful political analysis, the most valuable part of the book were the solutions that are offered in the last section. In addition to helping us push the system to make necessary reforms, she also provides great tips for navigating your healthcare encounters in the meantime. How to pick an insurer or provider, how to protect yourself against obscene "out of network" charges, how to spot providers who make an appearance solely so they can bill for the privilege, where to get lab work and X-rays at the most reasonable cost, how to negotiate when you need to, and many more. And most of all, what are your rights as patients and who to push back to make sure those rights are respected. Until we get meaningful change, we can all use these tips to make the system work better of us and hopefully avoid surprise out of pocket charges.

Get this book. Read this book. Use this book to support system-wide reform. Follow it's tips when consuming healthcare. You'll be glad you did.

[Gerald Hilton · Rating 5 out of 5]

I thought I knew quite a bit about the healthcare system, because of having some chronic health issues. However, I quickly learned that my experiences were either to narrow in scope, or too old to really know our healthcare system. I knew that our system ranked as one of the worlds' worst, for providing quality healthcare to the citizens it's suppose to serve. This book not only shattered any preconceived thoughts of what I thoughts were redeeming values in the system Americans call a "healthcare" system. It also explained why, and the many, many problems that are inherent in it.
Therefor, I am writing this review, (something I rarely do) In hopes that many more people will read this book and not only understand how to reduce the cost of this system in their own lives. And to take any action they can politically, to make major changes for improvement.
This book is extremely well researched and written. Using real peoples stories to bring the problems to light. As well as making it easy reading. I found this book both very enlightening and a book that I wanted to keep reading to find out what else I didn't know. As well as enraging me to know our government has shown very little concern for the basic welfare of it's citizens.

[David Marshall · Rating 5 out of 5]

My 80s-something mother-in-law gave me this book, because she wants her children to have the best tools available to navigate the dysfunctional American health care system. It's a excellent read, diagnosing the illness in the first two thirds of the book, and providing, if not a cure, and least a set of therapies for coping with the sickness in the last third. It dissects the interrelated disease organ by organ, the: 1) insurance companies, 2) hospitals, 3) pharmaceutical industry, 4) doctors, 5) medical equipment manufacturers and suppliers, 6) billing companies, etc. The book is worth the price just for all the links in the reference section in the back of the book to help patients educate themselves and take action to avoid health care abuse and overcharging. Everybody who pays money for their own health care should read it, and those who don't as well. This book is truly a gem.

[Book Shark · Rating 5 out of 5]

An American Sickness: How Healthcare Became Big Business and How You Can Take It Back by Elisabeth Rosenthal

“An American Sickness” is an outstanding expose of what ills the American healthcare system. Dr. Elisabeth Rosenthal takes the reader on an eye-opening journey that covers a wide spectrum of abuses that end up costing the average American. This insightful 412-page book includes eighteen chapters and is broken out by the following two Parts: Part I. History of the Present Illness and Review of Systems, and Part II. Diagnosis and Treatment: Prescriptions for Taking Back Our Healthcare. ​

Positives:
1. A thoroughly-researched, well-written book.
2. A fascinating an utmost important topic in the skilled hands of Dr. Rosenthal. Her medical and journalistic background is ideal to write such a book. It’s an expose of the American healthcare crisis.
3. A very engaging prose. No holds barred here, Rosenthal relentlessly exposes the ongoing medical extortion in America and does so by breaking it down by categories.
4. This was a highlight fest for me; consider the following quote that captures the essence of this book. “Faced with disease, we are all potential victims of medical extortion. The alarming statistics are incontrovertible and well known: the United States spends nearly one-fifth of its gross domestic product on healthcare, more than $3 trillion a year, about equivalent to the entire economy of France. For that, the U.S. health system generally delivers worse health outcomes than any other developed country, all of which spend on average about half what we do per person.”
5. There are two main themes covered thoroughly in this book: first, the transformation of American medicine in a little over a quarter century from a caring endeavor to the most profitable industry in the United States. Secondly, sound advice to keep healthcare affordable and government fixes.
6. Provides a list of the economic rules of the dysfunctional medical market and makes recurring references to it throughout the book. “More treatment is always better. Default to the most expensive option. A lifetime of treatment is preferable to a cure.”
7. Provides a historical look of the evolution of health insurance. “Between 1940 and 1955, the number of Americans with health insurance skyrocketed from 10 percent to over 60 percent. That was before the advent of government programs like Medicare and Medicaid. The Blue Cross/Blue Shield logo became ubiquitous as a force for good across America. According to their charter, the Blues were nonprofit and accepted everyone who sought to sign up; all members were charged the same rates, no matter how old or how sick.”
8. How hospitals take advantage of the public. “Hospitals tend to have more high-priced legal counsel than cash-strapped cities. In addition to avoiding property taxes as well as federal, state, and local payroll taxes, hospitals can issue tax-exempt bonds for building projects. They can collect tax-deductible donations (a boon when a big donor wants to underwrite a new wing or hand over a valuable piece of art to adorn a lobby).”
9. Strategies that physicians use to gouge the public. “The doctors sign up with insurance plans, but the centers themselves do not participate in any insurance networks, so the facility fees are not constrained by insurers’ negotiated rates. That allows them to bill $40,000 to $50,000 for what Dr. Zapf called “a simple surgery” like a bunion removal, when the standard office fee would be $3,000 to $4,000.”
10. The power of lobbyists exposed. “At one point, Medicare declared that anesthesiologists could not bill for supervising more than four operating rooms at once. It briefly decreased payment for each subsequent room, but lobbying undid the plan.”
11. How pharmaceuticals get their licks in. “Brand makers take out weak patents, generics makers challenge them, and the brand makers answer back with an objection. Under Hatch-Waxman, that objection alone sets off a mandatory thirty-month halt in the FDA’s consideration of the generic entrant.”
12. How medical device manufacturers extort the public. “He vowed to use only the older, cheaper valve and urged his colleagues to do the same. American Medical Systems parried by raising the price of the older valve by $1,300 so that it was no longer more cost effective.”
13. Ancillary services intended to take advantage of the public. “A 2012 article on Medscape, a Web site for physicians, urged practices to offer tests and ancillary services to counteract insurers’ stingier reimbursements, in order not to “miss out on a lot of opportunities.””
14. The use of contractors to further gouge the public. “Highly skilled coders have contributed to higher costs for patients, because the salaries of this new layer of professionals and their years of education are reflected in our medical bills.”
15. A look at the perversion of a noble enterprise. “Collectively, the medical industry has become the country’s biggest lobbying force, spending nearly half a billion dollars each year.”
16. Healthcare as pure business. “Our healthcare system today treats illness and wellness as just another object of commerce: Revenue generation.”
17. How the well-intentioned Affordable Care Act has been taken advantage of. “Even the well-intentioned provisions that managed to survive the tortuous congressional negotiations over the ACA have been in practice diluted and perverted, as providers find ways to maximize revenue by gaming its rules.”
18. Provides practical strategies that can be implemented to make American medicine better and more affordable. “Fee schedules and national price negotiations. A sonogram of the heart costs anywhere from $1,000 to $8,000 in the United States. The 2014 negotiated fixed price in Japan and Belgium was under $150.”
19. Provides useful information on how to control doctor’s fees.” Ask key questions. Who else will be involved in my treatment? Will I be getting a separate bill from another provider? Can you recommend someone in my insurance network?”
20. Key advice to limit hospital bills. “First consider each hospital’s general safety record: Does the hospital protect its patients from errors, infections, and injuries?”
21. Provides many helpful tools in the appendices.

Negatives:
1. My only major criticism is the lack of visual supplements to complement the excellent narrative. Charts, graphs, diagrams would have added value.
2. No formal bibliography.
3. I can see where well-intentioned professionals in the field may be upset to be thrown in with the moochers of the industry. The book’s emphasis is on the sickness not on the many noble people in the industry.

In summary, this is a must-read book. It’s a classic expose of an American industry that went from being a noble profession of healing to a predatory medical industrial complex. Dr. Rosenthal does not hold back any punches and lays out the ills of the American medical industry and also provides useful advice. I highly recommend it!

Recommendations: “The Healing of America” by T.R. Reid, “America’s Bitter Pill” by Steven Brill, “Unaccountable” by Marty Makary, “The American Healthcare Paradox” by Elizabeth Bradley and Lauren A. Taylor, and “Ending Medical Reversal” by Vinayak k. Prasad and Adam S. Cifu.

[Ericka Clou · Rating 4 out of 5]

Everyone read this book!! It's about the medical and pharmaceutical industries, and it was written by a doctor. It's not a liberal or conservative book. It's the most educational and relevant book I've read all year.

[Stephen Simpson · Rating 2 out of 5]

Very mixed book on a controversial and extremely important subject.

First, the negatives.

If you want to play a game of "Logical Fallacy Bingo", this should be your go-to book. Sorites fallacy, false authority, appeal to authority, false dichotomy, false equivalence, McNamara fallacy, onus probandi, proof by assertion, begging the question, cum hoc ergo propter hoc, furitve fallacy, argumentum ad lapidem, appeal to consequences, ipse dixit, straw man, and so many more... Honestly, this book should be a required textbook for logic and rhetoric classes (and not in a good way).

I also found repeated factual errors. One example (repeated a few times in the book) - FDA advisory committees DO NOT have the power/authority to approve or reject drugs or devices, they simply make non-binding recommendations (which the FDA often, but not always, and does not have to go along with).

Last and not least was the tone - from self-righteous to mocking to strident, it actually undermined many of the arguments (appeal to fear / appeal to emotion).

All of that said, there WERE positives.

The author was quite thorough in listing out the many and varied sources of rising health care costs, and did a very good job of explaining/illustrating how many of these sources reinforced each other to send costs spiraling higher. I also really liked the time and attention given to the role of hospitals; the impact of consolidation and a shift toward for-profit models.

All told, I'd say this is not a must-read. The anecdotes are fine for rabble-rousing, but there are just too many flaws in the author's arguments and too few coherent solutions (and there are much better books discussing potential solutions to the issue of high health care costs).

[Ariel ✨ · Rating 4 out of 5]

It's hard to know how to rate this book. Every time I opened it up, I got a stomachache. I thought I knew what people meant when they told me, "Insurance companies are evil!" and, "Big pharma is evil!" but it went way beyond my wildest ideas about the human propensity for evil and selfishness.

Dr. Elisabeth Rosenthal first focused on big-picture issues, then narrowed in on individual bills and medications to give us a better idea about how these issues play out in real time. I thought she spent a little too much time focused on a few individual cases when there was so much to learn about the business of healthcare and the bigger picture, but other readers may disagree.

This is an essential text for understanding health care in the United States. I'd love to see her write more about the potential benefits or pitfalls of Medicare for All. A quick search brought up a few opinion pieces for the New York Times! I'll definitely be keeping tabs on what she has to say about health care moving forward.

[Tanmay Jadhav · Rating 4 out of 5]

The long ass title is quite self explanatory.

The book is basically a compilation of stories and history that systematically dissects how the healthcare industry has evolved to be something quite different today than what it was even 50 years ago.

The book dives right to the start of the money epidemic in 1950s and builds itself around the different directions of capitalization it took. Pharma, Biotech, Specialized consultations and orthopedic surgeons earning a 7 figure income by just doing Arterio Venous shunting ( something usually done by a nephrologist or surgeon) and playing the insurance system codes.

The book is quite a boring read if you pick it up with little conviction but if you want a glimpse into the backstage of the industry, this is your fix. Being a Harvard trained doctor and moving onto journalism allows the author to appeal from the best of both worlds. This particular feature adds a lot of character and originality to this book.

I still don't know what I'm supposed to do with all this information but i do know for a fact that this may help you decide the place and role you want to play in the industry, or if you want to play that game at all.

In conclusion, I would say that for someone in the medical field looking for answers on why we operate the way we do today and why the NHS is a herald and India still a hot spot for medical tourism, this book is all you need to start off with.

For someone looking for creative ways of making money in medicine, i think this book should give you a lot of inspiration as well.

Lastly, i must warn you about the hate you may develop for the events and doctors that are described in this book. It's not something you can ignore but i urge you to look beyond that and try to explore between the line about the subconscious motivations and generations of capitalism that have led to today's reality.

I have a copy of the book, if anybody would like to borrow.

p.s. I think i'm done with non fiction for a while. I think i'll pick up some Plath next.

[Janet Newport · Rating 5 out of 5]

A real eye opener. I just wish I had read even half of this 5 years ago.

The appendix was very helpful and worth the price of this book many, many times over.

Thank you Dr. Rosenthal.

PS I very rarely read non-fiction straight through....tend to put the book down to read something more entertaining and then return to it.....it can take me a month or two to finish something like this.
This was an exception to my normal reading of non-fiction. I did read it straight through. While the first section of the book was mostly in anecdotal, and the second part was more self-help steps a patient can take, I found to to be compelling and easy to read/understand.

[Reid tries to read · Rating 2 out of 5]

My main flaws with this book are that:
1) it gets too bogged down in the minute details of its real life anecdotes and therefore often misses the forest for the trees. The real life stories there book uses should supplement its overall theoretical framework, and if I were to re-edit it I would have it structured so that it starts with an overall issue (I.e health insurance is broken) then use real life scenarios as evidence. Instead it usually starts a chapter off with a real story (Joe paid 100x more for a knee replacement than he would have if he lived in Sweden) and then devotes large chunks of the chapter to thoroughly going through the details of this story rather than focusing on more on the structural forces which caused Joe to pay so much for his stupid fucking knee.
2). The book fails to connect all its various strands of America’s medical-industrial-complex together (I.e big pharma, medical insurance, hospital fees, the medical device industry, etc ) in a satisfying or all-encompassing way because it gets bogged down by a pro-market, neoclassical frame of view.

According to the author here are the 10 golden rules of American healthcare:
1) More treatment is always better, and healthcare providers will tend to default to the most expensive treatment while they’re at it
2) A lifetime of treatment is preferred to being cured
3) Amenities and marketing are more important that good care
4) As technologies age, prices tend to rise rather than fall
5) Patients aren’t offered a robust amount of competing choices; they stuck buying American
6) More competitors vying for business often drives prices up
7) Bigger providers don’t translate to lower prices (contrary to the macroeconomic assertion that ‘economies of scale’ reduce production costs and therefore the cost of commodities) because they use their economic weight to tilt markets in their favor
8) There is no such thing as a fixed price for any type of procedure or test, and the uninsured always pay the highest prices
9) There are no standards for billing. You can be billed for any and everything
10) Prices will always rise to whatever the market can bear (what does this mean btw? Am I wrong in thinking all market prices are whatever the “market can bear”? What is an example of price being higher than the market can bear and why couldn’t the market bear it?)

This book claims “Health insurance is the original sin of the medical industrial complex”. I’d argue that any system that requires someone to pay to keep themselves alive and relatively healthy is the “original sin”, but even still health insurance plays an inseparable role today in maintaining America’s broken healthcare system. Originally, health insurance was only meant to help workers recover compensation lost due to sickness or injury keeping them out of work, while also keeping charitable hospitals afloat and able to maintain themselves. Health insurance became widespread once the government incentivized businesses to provide it by giving them tax rebates/subsidies for doing so. From the 1940s to the mid 1950s, the amount of insured Americans skyrocketed from around 10% of all Americans to 60% of all Americans. Once medical insurance became widespread, it became the main goal of profit chasing hospitals/doctors to make profits through insurance payouts. From 1967 to 1983 Medicare insurance payouts to hospitals increased from $3 billion to $36 billion. The book gives a real life example to demonstrate how widespread health insurance has led to booming profits: someone receives care for some shit that at one facility that costs around $1900 a pop. However, if this same person changes facilities just a few miles down the street the price for their care goes up to around $100,000 a pop. This occurred even though both facilities were providing the same service, which was simply mixing medicine, providing nurses, and giving the person a room to stay in for three hours. The only real difference was the facilities. The reason the insurance agrees to pay exorbitant prices at some places, even though they could easily pay less somewhere else, is because it’s simply easier for them to do so. The facilities charging the insanely higher rates to the insurance are generally much bigger clients who also have teams of lawyers and negotiators in place to jockey and jostle with insurance companies over fees. It’s easier and safer for the insurance to pay the trumped up fees than it is for them to lose these clients. Insurance then makes this money back, and then some, through raising the costs of premiums (amount you pay to your health insurance per month), deductibles (an amount that must be paid for covered healthcare services before insurance begins paying), and co-pays (also a set amount of money, but it's a fixed fee attached to certain covered services). Simply put, hospitals and other service providers have millions of dollars to spend on teams to fight insurance in order to maintain their profits, while the average person does not. This is why, once something is covered by insurance, its price tends to rise. The book gives an example of how, in many locations, physical therapy used to cost around $100 for somebody before it became covered by insurance providers; once the insurance companies pay for the PT, the price of the therapy shot up to $500 a session. Insure will brag to you that “you saved 96% on your stay!” without mentioning that this price was already heavily inflated just due to it being insured.

Inflated insurances payouts resulted in the cost of hospital stays increasing by 150% from 1997 to 2012. Because of this, the average hospital visit in America costs around 10 times as much as it would in Australia or Spain, which are countries whose healthcare systems provide similar quality healthcare results to America’s. Since it is hard to know how much a given surgery or procedure actually costs (like what should the price of an appendix removal be? What about being injected with a steroid?), this helps hospitals to set their own prices as high as they can. The entire process of insurance-backed price inflation snowballs into a positive feedback loop: as hospitals make more money, administrators and people with business degrees (AKA the money managers) start gaining more power within the hospitals and multiplying in number. As this happens they start implementing ways to raise profits over any other concerns, leading to hospitals recommending the most expensive treatments and services to their clients. Doctors are then financially incentivized by the higher ups (through bonuses and such) to ‘up code’ and provide more expensive treatments/care. An example of upcoding is classifying a patient filling out a questionnaire as a “health needs assessment” which is a billable charge. Injecting someone with steroids can be charged as ‘surgery’, and then further charged by using an ultrasound to “guide the needle”. Even though using such devices is completely unnecessary due to how easy the procedure is, the financial incentive to do so outweighs any practical reasons not to. Insurance companies don’t really fight such practices (although often they will try and fail to audit hospitals) because they can easily be undercut by smaller, more desperate insurers who are often raked over the coals by the hospitals.

If you are uninsured and ever go to the hospital you are basically fucked. Hospitals charge patients who are uninsured about 2.5 times higher than those that are. This almost certainly puts the patent in debt, often because they literally have no choice but to accept whatever the hospital is offering or possibly die. Professional debt collectors, who make their profits off of commission, are then hired out by the hospitals to basically loan shark uninsured patients until they’re drained of all funds. Hospitals also use residents as cheap labor to do grunt work like draw blood and change IVs, which they justify as “training”. In 2013, a study estimated that the average resident costs a hospital around $120,000 (including salary) to maintain, but federal subsidies usually cover about $100,000 of this. The work these residents do generally translates to a value of around $200,000. The profitability of residency therefore speaks for itself, which is why, between 2003-2013, the total number of residents grew by 20%. This growth of residency has occurred despite the passage of legislation all the way back in the 1990s intended to curtail the number of residents and the subsidies hospitals receive to train them. Organizations such as the American Hospital Association (AHA) have been able to lobby Congress to allow the practice to continue to grow. This book doesn’t explain how this lobbying has been so effective, which is why Richard Lachmann’s “First Class Passengers on a Sinking Ship” is essential reading.

The pharmaceutical industry is another pillar of the American medical-industrial-complex. Most modern pharmaceutical firms grew out of 19th century small businesses who sold unreliable potions without quality controls. In 1906, to regulate these small tonic/elixir makers, congress passed the Wiley Act (AKA the Pure Food and Drug Act) to monitor and regulate drug safety. Since most of the drugs back the didn’t actually do anything, the Act’s focus was more on preventing them from harming people rather than making sure they actually functioned as advertised. In 1938, the Wiley Act was replaced by the Food, Drug, and Cosmetic Act, which required government regulated testing before drugs could be marketed. For the first time drug manufacturers were required to prove to the young FDA that they were both safe and effective. Here is where a modern loophole was born: drugs had to be proven to both safe and more effective than doing nothing at all. This has never been refined, meaning that drugs today do not have to be compared to other drugs in terms of their efficacy. Drugs of similar/lesser qualities can therefore populate the market without being tested against each other. Pharmaceutical companies use this loophole to create drugs of lesser quality to those that already exist, then take over the market by outspending their opponents on marketing (btw drug advertising is banned in pretty much every developed country not named the United States of America) and legally bribing doctors to prescribe the drug. In 1980, the Bayh-Dole Act was passed to allow businesses to patent and commercialize inventions developed under federally funded programs, further reallocating funds from the working class into the pockets of drug companies. By creating a drug enforcement system characterized by strong patent protections and weak price controls, the United States became the global hub for drug manufacturing. By the early 2000s global drug makers spent over 80% of their money in the U.S. Today, the number of patents registered for the same drug have ballooned from an average of 2.5 in 1990 to 3.5 in 2005. By changing small, inconsequential parts of a drug or its production process, pharmaceutical companies can use patents to prevent other companies from being allowed to use their drug formula, thus inflating the prices of drugs (which that should already be public goods but aren’t thanks to the Bayh-Dole Act). This is why the pharmaceutical industry has grown twice as fast as the rest of the economy since the 1990s.

A final major pillar of our failing healthcare system is the medical device industry. Americans pay way more for medical devices than the rest of the world. Although it only costs about $350 to manufacture a hip or knee implant, the price to receive a hip or knee implant is usually around $36,000 in America; defibrillators cost people around $40,000 even though their actual parts consist of just a battery, some wires, and pads. The medical device industry is controlled by an oligopoly of a few massive producers/cartels. For most devices customers only have the option of buying from 1 of these conglomerates. For example, if you want a knee replacement in America your only options are to buy from either Stryker, Zimmer Biomet, DePuy Synthes, or Smith & Nephew. These corporations work together in groups like AdvaMed or the Medical Device Manufacturers Association (MDMA) to lobby congress and insure little to no new taxes or substantial price controls get placed on them. Device manufacturers have also used their muscle and take advantage of legal loopholes to more likely get their devices classified as class 2 by the FDA rather than class 3. This means that their devices go through a much less rigorous and scrutinous testing process by the FDA (the FDA spends around 20 hours evaluating class 2 devices vs 1200 hours evaluating class 3 devices). This results in devices being sold on the market with very little testing done, including not even being tested on animals or given clinic trials before being put into humans. Medical devices today are therefore much more dangerous than they should be.

Since profit is the overriding goal of the healthcare industry, funding does not go to “cure” research, as permanent cures aren’t as profitable as temporary ones. Take insulin for example. Most “advances” in fighting type 1 diabetes are just different ways to administer insulin (ex: different injectors, more fancy pumps, etc), whose price continues to skyrocket, while research towards actual cures must be crowdsourced. Instead of spending money on research, the healthcare industry as a whole spends around $500 million annually lobbying congress (more than any other industry). The industry itself, at its very base level (I.e at the sites where you actually get care from), is dominated by monopolies or cartels. There are virtually no competitive markets in America when it comes to healthcare services offered by hospitals. This is why, as far back as 2014, there was a historical number of hospitals mergers (95 that year), and this practice only continues to fester, leading to less competition and more monopolies as time goes on. As power and market share concentrates in fewer conglomerates and competition is squeezed out, these monstrosities can negotiate more effectively with insurance providers. They also tend to over test patients, while there are studies which show less independent hospitals leads to more inpatient death, suggesting that not only do these conglomerates over-treat/over test, but the treatments they give are often ineffective.

The book the fails to really give any reasonable suggestions on how to completely overhaul this system. It immediately concedes that the solution of single payer health insurance (AKA the government provides health insurance to everyone, and those who want more than what government insurance offers can opt out and pay for more expensive, but much smaller/less powerful private insurance firms) and socialized state-run healthcare is impossible in America today; it doesn’t really say why, as the book never gets into the actual nuts and bolts of healthcare under capitalism (again read Lachmann). It then provides completely half-assed solutions such as “ask your doctor to provide you with concrete data on how much each service they offer will cost you”. Yeah good luck with that.

[Elizabeth · Rating 5 out of 5]

In an era of unprecedented scientific advances—lifesaving drugs, transplant technologies, immunotherapy—medical treatment is more successful than ever in combating disease; however, patients are simultaneously watching the American healthcare system move in the opposite direction, growing ever more expensive, inefficient, and frustrating. Although the United States annually shells out more than $3 trillion on healthcare, our country generally delivers worse health outcomes than developed countries which are spending half on average what we do per person. If all that money isn’t improving our medical care, then where is it going?

In An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, journalist Elisabeth Rosenthal analyzes key factors which have distorted our medical system into one incentivized by profit rather than good health or science. While she skillfully digs into the various industries—insurers, pharmaceutical managers, and more—which are responsible, this illuminating book ultimately emboldens us—the patients—to protect ourselves from the tangled mess that is American healthcare.

Rosenthal chooses not to sugarcoat any of the glaring severities within our sprawling healthcare system, a decision she is uniquely positioned to uphold. Her background as a Harvard-educated emergency physician, former healthcare reporter for the New York Times, and current editor-in-chief of Kaiser Health News gives her the subject matter expertise and investigative skills to create a thorough breakdown of U.S. healthcare. This well-researched book draws its evidence from an array of sources: reputable journals, such as The New England Journal of Medicine; reports from government agencies like the CDC and FDA; and interviews with physicians, scholars, and patients across the country. Rosenthal deftly weaves together all this information to craft a condemning account of profiteers in the healthcare system.

To document American medicine’s shift away from patient-centered, evidence-based care, Part 1 of An American Sickness focuses on the broader scope of healthcare history. This book provides concise explanations of how each sector, from insurance companies to hospitals to doctors to drug manufacturers, has evolved to take advantage of the economic rules governing our medical market. In Part 2, Rosenthal offers recommendations of effective personal and political changes we should implement, encouraging us to be more cognizant patients who expect greater discussion with our doctors and insurance providers about treatments, particularly their costs.

Though the sheer barrage of numbers presented page after page in this book can desensitize the reader to these outlandish treatment costs, Rosenthal reminds us that this type of scenario has very real, harrowing consequences for everyday citizens. Two decades ago, doctors and medical workers might have tried to determine an affordable payment for a given treatment. Nowadays, they turn patient accounts to billing services and collection agencies—by 2014, half of overdue debt on American credit reports was a result of unpaid medical bills. Rosenthal ominously repeats that “the uninsured pay the highest prices of all.”

Despite being stocked with essential insight into how we should best navigate our healthcare system, An American Sickness is still a dense read. Rosenthal’s medical training occasionally reveals itself when she provides detailed descriptions of treatment mechanisms for diseases like HIV/AIDS, hemophilia, and Type I diabetes. Thus, familiarity with human diseases and treatments will likely make this material easier to digest. The constant healthcare lingo (HMOs, bundled payments, RBRVS, etc.) can also be overwhelming. Rosenthal provides a beneficial glossary of some common terms in the appendices, but you may still struggle to remember every detail of the intricate business economics and health policy regulations within each chapter. Nonetheless, you should not shy away from using this book as a resource to familiarize yourself with our healthcare system sooner rather than later. Keep in mind that you have been and will continue to be a part of the same medical system as the patients who shape Rosenthal’s narrative.

Regardless of future discoveries in disease prevention and treatment, people will not reap the rewards if we don’t figure out an effective method of providing basic access to affordable, quality healthcare. Rosenthal does not advocate for any single solution to solve the numerous problems within healthcare; however, this book equips you with sufficient knowledge of the currently exploited loopholes in governmental healthcare policy so that you have a fighting chance of making necessary changes. With our lives on the line, take the wealth of information and advice in An American Sickness to heart so that we can all start making healthcare work for, not against, us.

[Leah · Rating 5 out of 5]

Grrrrrrrrrrrrrr

[The Pfaeffle Journal (Diane) · Rating 4 out of 5]

An American Sickness is a frightening book as it lays out how dysfunctional the US medical system has become.

Overall, CMS projected that total health care spending for 2016 reached nearly $3.4 trillion, up 4.8 percent from 2015. According to CMS, U.S. health care spending is projected to reach nearly $5.5 trillion by 2025. The agency attributed the increase in large part to the United States' aging population and rising prices for health care services.
According to the report, national health care spending is projected to outpace growth in the United States' Gross Domestic Product (GDP) by 1.2 percentage points. As a result, CMS estimated that health care spending will account for 19.9 percent of GDP by 2025, up from 17.8 percent in 2015.[1. CMS: US health care spending to reach nearly 20% of GDP by 2025 ]

Rosenthal lists of 10 Economic Rules that she sees govern the Dysfunctional U.S. Medical Market.

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

Through out the book she refers to these rules, as she educates on out of network fees, facility fees, old drugs that become exorbitantly expensive for no other reason than profit. Tests, Electronic Medical Records, pharmaceuticals, billing codes have all become a way to ease more money out of us with not relate improvement in medical care.

The book is overwhelming in its look at the current medical system in the United States, the Republicans want to cut back on both private and government insurances, telling us that we need to shop around for the best price (which isn't always possible) and totally impractical with the current system. While health care might be more readily available in say Marin County, California health care may be very limited in say Bonner's County, Idaho.

It is a fascinating book, for me it made it all the more clear that a single payer system would be best. That getting sick in this country is scary, I don't really see the suggestions for taking back our medical system working out any time in the near future. I do not trust politicians to be doing what is best for patients, business interests will always come first. Despite what Raul Ryan keeps telling us Medicare is not going broke today or tomorrow and there are methods to fix it.



This review was originally posted on The Pfaeffle Journal

[Bonnie Brandt · Rating 3 out of 5]

There was a lot of good information in this book and I do mean a lot. This is a very long book. I work in the healthcare field and even though it made me feel a bit like a prostitute I appreciate the information.

The fact portion of the book, about the first two thirds, was better than the solutions part. I found a lot of the solutions to be a little simplistic and ignorant of the realities of not only healthcare, but the real world and human nature.

For instance, I work in a hospital lab. She says that it's very simple to ask your doctor to send your blood work to a commercial lab. That is absolutely not the case. This may be because I live in a rural area. She says hospital labs charge much higher prices for the testing which is partly true, but it is for a reason AND partly due to the existence of commercial labs.

When you have chest pain and you go to the hospital, blood gets drawn and sent to the lab. Dozens of tests are run on very expensive analyzers. These obviously can't be sent to a commercial lab because we need to know ASAP if you're having a heart attack. So your hospital lab still needs the really expensive equipment so that you can know if you're having a heart attack before you die from it.

The more tests commercial labs drain off from the hospital labs, the more it drives the test prices up because we have to have the staff and the analyzers and the infrastructure to get critical results when they're needed. When all of the less critical stuff goes away to another lab, we still have to have all those thing in place for the now greatly reduced number of tests that we're doing AND they still need to pay for themselves, so the prices go up, way up.

Many of her suggestions were about the over ordering that doctors here do as compared to doctors in other countries. The implication was that it's because they're trying to make more money or because they just don't know about the costs. While those things may be true, she doesn't discuss the role of the American consumer. We want answers... now! If I have a rash and go to the doctor and he tells me to wait a couple of weeks and then come back if it doesn't get any better, I'm not happy. I want tests, and a diagnosis, and a prescription before I walk out the door. Otherwise it's been a waste of my time and my money and now I have to live with whatever's going on.

With the pharmaceuticals, even though a lot of it makes me sick, we have to look at this and an individual rather than a statistics basis. Perhaps medicines are developed that are less effective and cost more but that's a statistical representation. If a medication doesn't work for you it doesn't matter that it works better for most people, it didn't work for you. Thank goodness here may be another medication the doctor can try. There are also side effects and cross-reactions from different medications.

Academic solutions are always easier than real world solutions. But that is where things have to start sometimes.

[W. Whalin · Rating 5 out of 5]

A Significant Book for Every American

Subtitled, “How Healthcare Became Big Business and How You Can Take It Back” is a new audio book and I heard it cover to cover. Elisabeth Rosenthal has an MD from Harvard but also spent 22 years as a medical reporter for the New York Times. The writing and storytelling in this book is compelling along with thorough research and multiple interviews and sources of information.

The first section of this book tells the story of how medicine and healthcare became a huge business. The examples are pointed and as a reader your anxiety grows with each chapter. You learn the focus of healthcare has turned from providing excellent patient care and health to making money at the expense of the patient. With pointed and specific illustrations, you learn how the costs of healthcare have spiraled out of control—especially compared to other countries.

The second section gives the details for every American to become proactive with their healthcare, save money and hopefully change the system. Rosenthal provides detailed information such as when you check into a hospital, there are multiple pages of release forms you sign. One of those clauses will say that you are responsible for any expenses your insurance does not cover. Rosenthal suggests you add the words “as long as the expenses are within my insurance network.” Without this addition, the patient can incur incredible personal expenses. It’s just one small example of the valuable content in this book.

I learned a great deal from AN AMERICAN SICKNESS. The detailed websites and resources in the Appendix are a resource I plan to use over and over. I highly recommend this book.

[Fred Forbes · Rating 4 out of 5]

We spend 2-3x times what the rest of the world does on healthcare and cover fewer people and with worse results. The probable fix is some sort of single payer system like those used in the rest of the developed world but in the meantime, this book by a Harvard educated MD can help provide you with some defensive measures. Our system has evolved over the last 25 years from a caring, patient oriented system, mainly non-profit to a commercial business enterprise at all levels. Remember the Super Bowl ad with the fighting toe with a blob of fungus on it? The "cure" comes in vials costing $450 to $650 and if you had to treat all your toes, the total bill would come to $20,000 over the recommended time period. What the ad fails to mention (and is not required to) is that the 20% cure rate is no better than a $20 tablet docs have been using for years. (We are one of only two countries in the world that allow drug ads, New Zealand being the other). Know why hospitals are buying up physician practices? So they can claim the doc is hospital affiliated and raise his charges by 35-100% for facilities fees, even if he doesn't move from his current office. The system is a horror show and this book does a great job on explaining it and how it got that way.

[Barbara (The Bibliophage) · Rating 5 out of 5]

If healthcare in the United States frustrates you, this is the book for you. It alternately made me furious, sad, and empowered me to ask a thousand more questions of my various providers.

I’m sure my own experiences assisted in understanding the context and content of the book. Living with chronic illness necessitates a great deal of medically-related learning. But even if I didn’t have this background, I would have found Rosenthal’s book understandable. She tells patient stories throughout, which bring the realities into stark focus.

All in all, I found this to be a meaningful book that isn’t just bitching about healthcare gone wrong. It’s about finding solutions, both on a grassroots and systemwide level. It was extremely well worth my reading time.

Full review at TheBibliophage.com.

[Drew · Rating 2 out of 5]

too long; too technical... A very thorough read about the subject; The author has a negative outlook on the current healthcare system. And, I feel that she does not give both sides to the equation. She reports on most stories saying something to the effect that the healthcare system is a business and patients get the short end of the stick. I wish I could of heard a more balanced view. Maybe, she could highlight on some of the positive aspects of healthcare: such as the access, high quality, and etc. Plus, I think this book encourages Americans to be cynical about the current system.

[Steve Nolan · Rating 4 out of 5]

Pretty comprehensive overview of the American healthcare system. Some crazy anecdotes of people getting screwed and crazy prices for ridiculous things.

Does a great job showing that it really isn't one single thing that's turned the whole system upside down - it's a bunch of individual parts all individually trying to maximize profits. (At the expense of people!)