Rage Against American Healthcare

Abstract

Rage Against American Healthcare Laura Marsh (bio) Our Malady: Lessons in Liberty from a Hospital Diary by Timothy Snyder Crown, 2020, 192 pp. Medicare for All: A Citizen's Guide by Abdul El-Sayed and Micah Johnson Oxford University Press, 2021, 368 pp. To fall sick in the United States is to undergo a unique rite of passage. Each sick person discovers the ordeal of trying to get a diagnosis, of attempting to access treatment, and of being extorted every step of the way—of realizing that we do not, in fact, have a healthcare system. Beliefs that the healthy can hold lightly no longer make sense—the belief, for instance, that health insurance will provide. The sick soon learn that insurance, even "good" employerprovided insurance, does not protect them from outrageous bills, and that paying through the nose is no guarantee of timely, humane, or even competent care. In order to get medical treatment, Americans have to deal with one of the most opaque industries in the world. The 28 million people who do not have health insurance are locked out of affordable care almost entirely. The 50 percent of Americans who get insurance through their employers have little say in the coverage they end up with: the employer chooses the plan, or sometimes a couple of different plans; most employees will never see how any of this is decided, despite the fact it will determine which doctors they can see, the monthly premiums they'll pay, and the deductible and out of pocket costs that will hit them if they get really ill. Beyond insurers, the providers themselves—hospitals, doctors' offices, pharmacies—are exceptionally secretive. Most doctors' offices cannot tell a patient before they get a treatment how much it will cost; even the doctor can only know that once they send out the bill. That's because there are no set prices for procedures. Every insurer negotiates their own rates with every provider and passes on a portion of that rate to the patient. That means not only that the cost of care is impossible to predict or plan for; it also means that patients can't "shop around" as they might in a functional market. You can't shop around when there are no prices to compare. The bills themselves are notoriously difficult to understand, with lists of often unrecognizable charges. A single visit to the ER may occasion one bill from the hospital itself, plus separate bills from individual doctors and labs. And if you arrived by ambulance, a service that is often not covered by insurance at all, that will be billed separately too. The patient has a full-time job—on top of being sick, they also have to spend hours coordinating, haggling, and sometimes pleading with each of these entities. It's the patient's job to find the right doctor, to research and locate a facility that offers [End Page 187] Click for larger view View full resolution Billing envelopes litter the floor of a shuttered hospital in rural Missouri. (Michael S. Williamson/Washington Post via Getty Images) the care they need, to check who is in network or out of network, to chase down test results and schedule follow-up care. Although we talk about a "healthcare system," the many facilities that provide care are separate companies that have limited communications with one another. Americans spent $812 billion in 2017 on the administrative costs of healthcare—more than the entire U.S. military budget that year—but there is, remarkably, no one at the doctor's office whose job is to guide the patient smoothly through their treatment. When the historian Timothy Snyder fell ill at the end of 2019, the dysfunction of American healthcare nearly killed him. In his recent book Our Malady: Lessons in Liberty from a Hospital Diary, he recounts a pattern of neglect in his visits to hospitals over a single month, as his symptoms are dismissed, his medical history goes ignored, and his condition worsens. The disaster of his illness and mistreatment is the starting point for a short, livid set of reflections on healthcare in the United States and how its failures make us...