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

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

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

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

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

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

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

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

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