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Sick The Untold Story of America Health Care Crisisand the People Who Pay the Price Jonathan Cohn 9780060580452 Books

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Sick The Untold Story of America Health Care Crisisand the People Who Pay the Price Jonathan Cohn 9780060580452 Books

My friend Jonathan Cohn has found a fantastic way to explain to somebody like me what’s wrong with Medicine in the US.

Every chapter of the book is the story of another patient in another city:

Gary Rotzler from Gilbertsville, NY, lost the medical insurance that came with his high-paid aerospace job when he was made redundant in 1993. He did find work, and did so very promptly, but not work that offered him medical benefits, because by the mid-nineties the aerospace sector was feeling the squeeze from defence cuts. His wife Betsy’s breast cancer went undetected and by the time it had metastacized to the spine there was little that could be done. Merely going through the motions of offering her the best possible care under the circumstances led Gary to personal bankruptcy and left him wondering if regular health care for Betsy would have allowed her to detect the cancer earlier, live longer and help Gary care that much longer for their three children. His and Betsy’s story demonstrates the slow-moving disaster that is unfolding across America in an age when neither employment is for life nor companies (or entire business sectors) can be expected to last for one’s entire career.

Janice Ramsey, a fifty-something realtor in Deltona, FL was a successful woman. After sending off five children to college she decided to work for herself; only then did she realise her diabetes made her uninsurable. After two years of looking for a plan (with applications to prove this) she was pleased to finally find a policy to suit her needs. Except American Benefit, that collected USD 365 per month from her to provide her this policy, was a scam, part of a third wave of insurance scams in the history of American medicine. Her story ends better than Gary’s when she eventually gets a realtor’s licence, which entitles her to insurance via a bank that offers it to realtors who work with it. But it highlights the plight of Americans seeking individual health insurance who happen to have a prior condition.

Elizabeth and Steven Hilsabeck of Lakeside, TX were lucky to have health insurance arranged through a prominent HMO because the hospital bills they ran from having premature twins were in the hundreds of thousands and their HMO picked up the whole thing. But when one of the two twins, their son Parker, was eventually diagnosed with cerebral palsy, their plan did not cover the USD 1000 per month of his physical therapy, because not only was there no proof it would work, but Parker had never walked before (duh!) and thus the therapy would be “habilitative” rather than “rehabilitative.” The couple lost their home to medical bills and also lost their marriage, but the story does have a happy ending of sorts, because Parker now walks. Jonathan uses this story as an opportunity to take the reader through the entire history of HMOs in America (It’s very interesting!) and to point out the main problem associated with the cover they provide, namely that they define upfront what you’ll get from them and that’s your lot: rather than say “we’ll take care of whatever it is you’ll get” it’s more along the lines of “here’s what we’ll treat and here’s for how long and good luck to you if something else happens.”

Next stop is Sioux Falls, SD, where Lester Sampson had retired after 30 years with his (and his father’s) employer, meatpacker J.P. Morrell, safe in the knowledge that he had a double safety net for his and his wife Audrey’s health: Medicare and access to enhanced medical coverage from his former employer, in part thanks to having foregone (USD 100 per month) higher pension payments in favor of investing in the best possible health plan. In 1991, the company was taken over by a conglomerate which cancelled the health plan. When the retirees sued, the court split down party lines and decided two-to-one in favour of the employer. Lester and Audrey lost their mobile home to their healthcare costs, but at least eventually found a way to get their hands on the drugs they needed through the VA and Medicare; other former employees were less lucky, leading even to a suicide. Jonathan uses this story as a springboard to take the reader through the depredations visited upon Medicare by Clinton and Bush 43.

Larger-than-life Ernie Maldonado came from Puerto Rico with 5 dollars in his pocket age 14 and eventually settled at age 55 in Lawrence County, Tennessee, where he established a successful auto painting business with his wife Wanda. A rough life of inhaling industrial fumes and exposure to lead from paint left Ernie battling neuropathy, atherosclerosis, poor lungs and diabetes, but Tenn Care had him covered, until in the 1990’s it was cut to the bone, ironically by a Democratic governor and former HMO founder and CEO, to help the State make its budget. Only five of Ernie’s more than two dozen medications continued to be covered by Tenn Care and he did not live long enough to make it through to the partial reversal of the healthcare cuts that followed.

Chicago is next on the map and the unlikely heroine here is Marijon Binder, who was dismissed from her order as a Catholic nun after 35 years of service when she decided to defy her superior’s instructions to return to California and remained in Chicago to continue taking care of an elderly volunteer, Eleanor, whose health had been deteriorating. When Marijon was hospitalized at the Resurrection Medical Center, a Catholic institution, following an incident that looked and felt a lot like a heart attack, but wasn’t, and despite having been admitted into an ER where a sign was clearly displayed, indicating care would be offered to all, the last thing she was expecting was a large medical bill. But that’s what she got. She appealed to her former colleagues who ran the institution, but to no avail. In contrast to most people who find themselves in her situation, she was educated and articulate. When the hospital’s case was heard in court (for Marijon simply did not have the funds to settle the bill), she might not have had the law totally on her side, but she won over the judge, by pointing out (among other things) that the costs presented to her vastly exceeded what the hospital would be charging her insurer (had she been insured). Others are not as lucky and Jonathan uses this chapter to take his readers through the proud history and current diminished status of Catholic hospitals in America.

From Chicago we’re off to the roughest neighbourhood in LA, where Tony Montenegro, an avid reader and aspiring accountant, moved from El Salvador to live his American dream. The story is told in medias res. It starts with Tony narrowly avoiding a car accident as his vision slowly goes away during his drive home from work. When he wakes up in the morning he’s totally blind. The cause is diabetes that he has refused to treat because he can’t afford the medicine. Jonathan details how health care for residents of the poorest parts of LA is no better than in the third world, with nearly half of the working-age adults having no health insurance, because the complex web of programs offering healthcare to the poor is quasi-impossible to navigate. While we’re at it, we also explore the Los Angeles County-University hospital, better known from the credits to TV show General Hospital, and its days-long waiting room queue. The point is made that this can’t be really be happening in the most advanced country in the world. At the same time, the story ends with Tony finding a workable solution for his healthcare needs, albeit at a point where it’s too late to restore his health, eyesight and ability to work to where it had been before he was diagnosed.

Denver is the last stop and the most heartbreaking story, that of Gina Doren, a former child abuse victim who was hospitalized with severe mental disorders shortly after giving birth to her son Kory. Her husband Ross was lucky to have a solid job as a teacher, with full health benefits for his whole family. But the point is made that mental illness has pariah status within the American healthcare system. Even Russ’s gold-plated healthcare benefits only allowed for a fixed number of days of hospitalization for mental health. After years of moving in and out of hospitals, with as many as three years of good mental health in a row, Gina deteriorated suddenly when her mom asked to see Kory more. When the fifty days of coverage ran out and Russ ran out of cash, she had to be admitted into a program that would only take care of her during the day. This gave her the opportunity (i) to get her hands on enough prescription drugs to overdose and (ii) allow the suicide attempt go unnoticed for longer than previous, unsuccessful attempts at her own life, much as this last, successful, attempt could well have been another “cry for help.”

So there you have it:

1. Tying medical benefits to employment is problematic in a world where people change jobs and companies last longer than a lifetime

2. Tying medical benefits to employment is problematic for the self-employed, who are essentially no different than the unemployed

3. Allowing insurers to turn away those with prior medical conditions turns on its head the whole concept of insurance, whereby the healthy pay for the ill. The converse, however, is equally pernicious because it presents the insurance industry with the problem whereby only the ill or potentially ill purchase insurance, while the provisionally healthy free-ride.

4. HMOs do reduce costs by cutting administrative costs, but competition eventually leads them to also restricting coverage.

5. States that once offered decent healthcare have had to curtail entire programs or else they won’t make budget, which they are not constitutionally allowed to do.

6. Charities that once offered decent healthcare have been forced to act more and more like the for-profit institutions they once supplemented, down to the seediest practices like overcharging the uninsured.

7. Parts of America are now offering healthcare that in some respects is of third-world quality

8. Mental health has pariah status in today’s American healthcare system.

What is to be done?

Jonathan believes the answer lies in universal coverage. He is not impolite enough to say “the rest of the civilized world does it that way, about time the US joined.” Instead he mentions that France, the UK, Germany, Switzerland and sundry Scandinavian nations all spend about half as much on healthcare as the US as a percent of GDP while delivering similar average results and fewer total failures.

And that’s QED as far as he’s concerned.

I hear you, Jon, but you need to do better than that!

The advocates of the current system are not really denying these stories, as much as they are saying a bunch of very different things. In no particular order:

1. All major medical advances in the world are still happening in the US. Like, yesterday morning, as I was finishing this book, came out the story that they have developed drugs that marshall the resources of the immune system to successfully fight lung cancer. This did not happen in France, the UK, Germany or Scandinavia, did it? It happened in the country where there’s serious profit to be made in finding new cures to illness.

2. Yes, at 17% or whatever the GDP proportion is that the US spends on healthcare, America is spending double than the UK give-or-take. But that’s because there’s tons of rich people in America and health is the ultimate good. The richer the rich get, the more they will spend on healthcare.

3. You can solve both the free-rider problem and the adverse selection problem by making healthcare mandatory for everybody, like you do for car insurance. This means everybody must buy it and everybody must accept to insure everybody, and it’s pretty much what Obamacare (Romneycare, call it what you like) can do.

Equally, there are arguments in favor of universal, government-supplied coverage that I was hoping to hear, but again didn’t. In no particular order, again:

1. There needs to be a central system that accumulates and aggregates all knowledge that relates to results. We cannot afford the balkanized knowledge about both medical procedures and the effectiveness of drugs under which we are currently operating.

2. There needs to be a minimum level of public health provision, from which we will all benefit, also via lower costs of having to deal with the ill in the future. With people switching jobs and plans so often in today’s economy it is impossible to expect private healthcare to provide this, the invisible hand cannot be entrusted with the provision of public goods.

3. While regular healthcare provision can carry on being privately delivered ad infinitem, anybody who has followed the “23 and me” saga, or reads Willem Buiter, will be exposed to the undeniable truth that sometime in the future we will all have a very good picture of what illness awaits us in the future. This entirely violates the concept of private provision of health insurance. Private companies will continuously jostle to insure the members of the public with the lowest expected future costs.

Ultimately, then, this is a book that appeals only to one thing: our sense of fairness. Is it right that the poor can’t pay for their healthcare and the unlucky in the middle class can see the savings of their lifetime disappear just as they are losing a loved one? Is it right that the American system resembles more the law of the jungle and puts the onus on the few sick rather than on the many healthy?

I concur with Jonathan that the answer is “no.” It’s not fair. It’s also very unfair in my view that the provision of health insurance is not subject to any laws like the Sherman Act (a fact that the book mentions very obliquely). But I equally know that this is a matter of opinion. Taste, if you like.

I would have liked to see him tackle more facets of the healthcare problem. Maybe in the next book!


Tags : Sick: The Untold Story of America's Health Care Crisis---and the People Who Pay the Price [Jonathan Cohn] on Amazon.com. *FREE* shipping on qualifying offers. America's health care system is unraveling. Every day, millions of hard-working people struggle to find affordable medical treatment for themselves and their families—unable to pay for prescription drugs and regular checkups,Jonathan Cohn,Sick: The Untold Story of America's Health Care Crisis---and the People Who Pay the Price,Harper,0060580453,Health care reform;United States.,Medical care, Cost of;United States.,Medical care;United States.,Consumer Health,HEALTH & FITNESS Health Care Issues,Health & Fitness,Health Care Delivery,Health Care Issues,Health Care Policy,Health care reform,HealthFitness,Medical care,Medical care, Cost of,United States

Sick The Untold Story of America Health Care Crisisand the People Who Pay the Price Jonathan Cohn 9780060580452 Books Reviews

This book covers the health care crisis in the United States by following the experiences of a number of middle class or poor Americans negotiating their way through the system after experiencing some sort of health care catastrophe. Knowing that every other advanced economy country and many developing countries already have had universal health care for decades ought to exasperate every American that we still don't have universal health insurance in the US. The book was written before the Affordable Care Act passed into law, but things haven't improved far enough under the ACA, except for very low earners who before couldn't find affordable coverage at all. Americans can still be ruined financially if they have the misfortune to suffer a catastrophic health care event. That isn't acceptable. Cohn intersperses his accounts of the misadventures of his subjects dealing with the health care system with clear explanations of the various aspects of American health care that lead to waste and very high costs.
I obtained Sick as an e-book after viewing a recent interview with the author. The book traces the development of modern health insurance from the 1920's, when hospital care began to be unaffordable, to the time of the book's publication around 2007. Although this is a big topic, Sick is very readable--it explains without graphs or statistics or excessive historical detail.

Jonathan Cohn explains the origins of many of the systems we have heard of--Medicaid, HMO's, co-ops, "managed care," block grants, S-CHIP, Health Savings Accounts and more--some of which came and went, while others were poor solutions to problems caused by prior "solutions." He focuses on why we moved from one trend to another--the answer frequently relating to costs and politics rather than public benefit.

Sick is liberally illustrated with the heartbreaking true stories of people who suffered because of the many failures of our profit-based system--parents who lost children, people who were handcuffed and marched into courtrooms over medical debt, even a former nun who was refused charity care by a Catholic hospital.

Oddly, many people believe the uninsured or the indigent get care when they truly need it. The book concludes with many examples of those who lost coverage they believed was secure, and of a "safety net" with big holes. One of the saddest was the suicidal woman denied in-patient care, whose husband, who had exhausted his benefits and his savings, was told "We're a business."

Cohn's bias is for universal health care which equates to a system regulated by government in the public interest. He makes a good case for it. So far we have tried everything else. Maybe it's time to acknowledge that our for-profit system works poorly, if at all, for too many of us.
My friend Jonathan Cohn has found a fantastic way to explain to somebody like me what’s wrong with Medicine in the US.

Every chapter of the book is the story of another patient in another city

Gary Rotzler from Gilbertsville, NY, lost the medical insurance that came with his high-paid aerospace job when he was made redundant in 1993. He did find work, and did so very promptly, but not work that offered him medical benefits, because by the mid-nineties the aerospace sector was feeling the squeeze from defence cuts. His wife Betsy’s breast cancer went undetected and by the time it had metastacized to the spine there was little that could be done. Merely going through the motions of offering her the best possible care under the circumstances led Gary to personal bankruptcy and left him wondering if regular health care for Betsy would have allowed her to detect the cancer earlier, live longer and help Gary care that much longer for their three children. His and Betsy’s story demonstrates the slow-moving disaster that is unfolding across America in an age when neither employment is for life nor companies (or entire business sectors) can be expected to last for one’s entire career.

Janice Ramsey, a fifty-something realtor in Deltona, FL was a successful woman. After sending off five children to college she decided to work for herself; only then did she realise her diabetes made her uninsurable. After two years of looking for a plan (with applications to prove this) she was pleased to finally find a policy to suit her needs. Except American Benefit, that collected USD 365 per month from her to provide her this policy, was a scam, part of a third wave of insurance scams in the history of American medicine. Her story ends better than Gary’s when she eventually gets a realtor’s licence, which entitles her to insurance via a bank that offers it to realtors who work with it. But it highlights the plight of Americans seeking individual health insurance who happen to have a prior condition.

Elizabeth and Steven Hilsabeck of Lakeside, TX were lucky to have health insurance arranged through a prominent HMO because the hospital bills they ran from having premature twins were in the hundreds of thousands and their HMO picked up the whole thing. But when one of the two twins, their son Parker, was eventually diagnosed with cerebral palsy, their plan did not cover the USD 1000 per month of his physical therapy, because not only was there no proof it would work, but Parker had never walked before (duh!) and thus the therapy would be “habilitative” rather than “rehabilitative.” The couple lost their home to medical bills and also lost their marriage, but the story does have a happy ending of sorts, because Parker now walks. Jonathan uses this story as an opportunity to take the reader through the entire history of HMOs in America (It’s very interesting!) and to point out the main problem associated with the cover they provide, namely that they define upfront what you’ll get from them and that’s your lot rather than say “we’ll take care of whatever it is you’ll get” it’s more along the lines of “here’s what we’ll treat and here’s for how long and good luck to you if something else happens.”

Next stop is Sioux Falls, SD, where Lester Sampson had retired after 30 years with his (and his father’s) employer, meatpacker J.P. Morrell, safe in the knowledge that he had a double safety net for his and his wife Audrey’s health Medicare and access to enhanced medical coverage from his former employer, in part thanks to having foregone (USD 100 per month) higher pension payments in favor of investing in the best possible health plan. In 1991, the company was taken over by a conglomerate which cancelled the health plan. When the retirees sued, the court split down party lines and decided two-to-one in favour of the employer. Lester and Audrey lost their mobile home to their healthcare costs, but at least eventually found a way to get their hands on the drugs they needed through the VA and Medicare; other former employees were less lucky, leading even to a suicide. Jonathan uses this story as a springboard to take the reader through the depredations visited upon Medicare by Clinton and Bush 43.

Larger-than-life Ernie Maldonado came from Puerto Rico with 5 dollars in his pocket age 14 and eventually settled at age 55 in Lawrence County, Tennessee, where he established a successful auto painting business with his wife Wanda. A rough life of inhaling industrial fumes and exposure to lead from paint left Ernie battling neuropathy, atherosclerosis, poor lungs and diabetes, but Tenn Care had him covered, until in the 1990’s it was cut to the bone, ironically by a Democratic governor and former HMO founder and CEO, to help the State make its budget. Only five of Ernie’s more than two dozen medications continued to be covered by Tenn Care and he did not live long enough to make it through to the partial reversal of the healthcare cuts that followed.

Chicago is next on the map and the unlikely heroine here is Marijon Binder, who was dismissed from her order as a Catholic nun after 35 years of service when she decided to defy her superior’s instructions to return to California and remained in Chicago to continue taking care of an elderly volunteer, Eleanor, whose health had been deteriorating. When Marijon was hospitalized at the Resurrection Medical Center, a Catholic institution, following an incident that looked and felt a lot like a heart attack, but wasn’t, and despite having been admitted into an ER where a sign was clearly displayed, indicating care would be offered to all, the last thing she was expecting was a large medical bill. But that’s what she got. She appealed to her former colleagues who ran the institution, but to no avail. In contrast to most people who find themselves in her situation, she was educated and articulate. When the hospital’s case was heard in court (for Marijon simply did not have the funds to settle the bill), she might not have had the law totally on her side, but she won over the judge, by pointing out (among other things) that the costs presented to her vastly exceeded what the hospital would be charging her insurer (had she been insured). Others are not as lucky and Jonathan uses this chapter to take his readers through the proud history and current diminished status of Catholic hospitals in America.

From Chicago we’re off to the roughest neighbourhood in LA, where Tony Montenegro, an avid reader and aspiring accountant, moved from El Salvador to live his American dream. The story is told in medias res. It starts with Tony narrowly avoiding a car accident as his vision slowly goes away during his drive home from work. When he wakes up in the morning he’s totally blind. The cause is diabetes that he has refused to treat because he can’t afford the medicine. Jonathan details how health care for residents of the poorest parts of LA is no better than in the third world, with nearly half of the working-age adults having no health insurance, because the complex web of programs offering healthcare to the poor is quasi-impossible to navigate. While we’re at it, we also explore the Los Angeles County-University hospital, better known from the credits to TV show General Hospital, and its days-long waiting room queue. The point is made that this can’t be really be happening in the most advanced country in the world. At the same time, the story ends with Tony finding a workable solution for his healthcare needs, albeit at a point where it’s too late to restore his health, eyesight and ability to work to where it had been before he was diagnosed.

Denver is the last stop and the most heartbreaking story, that of Gina Doren, a former child abuse victim who was hospitalized with severe mental disorders shortly after giving birth to her son Kory. Her husband Ross was lucky to have a solid job as a teacher, with full health benefits for his whole family. But the point is made that mental illness has pariah status within the American healthcare system. Even Russ’s gold-plated healthcare benefits only allowed for a fixed number of days of hospitalization for mental health. After years of moving in and out of hospitals, with as many as three years of good mental health in a row, Gina deteriorated suddenly when her mom asked to see Kory more. When the fifty days of coverage ran out and Russ ran out of cash, she had to be admitted into a program that would only take care of her during the day. This gave her the opportunity (i) to get her hands on enough prescription drugs to overdose and (ii) allow the suicide attempt go unnoticed for longer than previous, unsuccessful attempts at her own life, much as this last, successful, attempt could well have been another “cry for help.”

So there you have it

1. Tying medical benefits to employment is problematic in a world where people change jobs and companies last longer than a lifetime

2. Tying medical benefits to employment is problematic for the self-employed, who are essentially no different than the unemployed

3. Allowing insurers to turn away those with prior medical conditions turns on its head the whole concept of insurance, whereby the healthy pay for the ill. The converse, however, is equally pernicious because it presents the insurance industry with the problem whereby only the ill or potentially ill purchase insurance, while the provisionally healthy free-ride.

4. HMOs do reduce costs by cutting administrative costs, but competition eventually leads them to also restricting coverage.

5. States that once offered decent healthcare have had to curtail entire programs or else they won’t make budget, which they are not constitutionally allowed to do.

6. Charities that once offered decent healthcare have been forced to act more and more like the for-profit institutions they once supplemented, down to the seediest practices like overcharging the uninsured.

7. Parts of America are now offering healthcare that in some respects is of third-world quality

8. Mental health has pariah status in today’s American healthcare system.

What is to be done?

Jonathan believes the answer lies in universal coverage. He is not impolite enough to say “the rest of the civilized world does it that way, about time the US joined.” Instead he mentions that France, the UK, Germany, Switzerland and sundry Scandinavian nations all spend about half as much on healthcare as the US as a percent of GDP while delivering similar average results and fewer total failures.

And that’s QED as far as he’s concerned.

I hear you, Jon, but you need to do better than that!

The advocates of the current system are not really denying these stories, as much as they are saying a bunch of very different things. In no particular order

1. All major medical advances in the world are still happening in the US. Like, yesterday morning, as I was finishing this book, came out the story that they have developed drugs that marshall the resources of the immune system to successfully fight lung cancer. This did not happen in France, the UK, Germany or Scandinavia, did it? It happened in the country where there’s serious profit to be made in finding new cures to illness.

2. Yes, at 17% or whatever the GDP proportion is that the US spends on healthcare, America is spending double than the UK give-or-take. But that’s because there’s tons of rich people in America and health is the ultimate good. The richer the rich get, the more they will spend on healthcare.

3. You can solve both the free-rider problem and the adverse selection problem by making healthcare mandatory for everybody, like you do for car insurance. This means everybody must buy it and everybody must accept to insure everybody, and it’s pretty much what Obamacare (Romneycare, call it what you like) can do.

Equally, there are arguments in favor of universal, government-supplied coverage that I was hoping to hear, but again didn’t. In no particular order, again

1. There needs to be a central system that accumulates and aggregates all knowledge that relates to results. We cannot afford the balkanized knowledge about both medical procedures and the effectiveness of drugs under which we are currently operating.

2. There needs to be a minimum level of public health provision, from which we will all benefit, also via lower costs of having to deal with the ill in the future. With people switching jobs and plans so often in today’s economy it is impossible to expect private healthcare to provide this, the invisible hand cannot be entrusted with the provision of public goods.

3. While regular healthcare provision can carry on being privately delivered ad infinitem, anybody who has followed the “23 and me” saga, or reads Willem Buiter, will be exposed to the undeniable truth that sometime in the future we will all have a very good picture of what illness awaits us in the future. This entirely violates the concept of private provision of health insurance. Private companies will continuously jostle to insure the members of the public with the lowest expected future costs.

Ultimately, then, this is a book that appeals only to one thing our sense of fairness. Is it right that the poor can’t pay for their healthcare and the unlucky in the middle class can see the savings of their lifetime disappear just as they are losing a loved one? Is it right that the American system resembles more the law of the jungle and puts the onus on the few sick rather than on the many healthy?

I concur with Jonathan that the answer is “no.” It’s not fair. It’s also very unfair in my view that the provision of health insurance is not subject to any laws like the Sherman Act (a fact that the book mentions very obliquely). But I equally know that this is a matter of opinion. Taste, if you like.

I would have liked to see him tackle more facets of the healthcare problem. Maybe in the next book!