It’s even worse than we think

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Steven Brill was working on a book-length expansion of his widely read Time magazine article on health-care expenses when the story got very personal: an aortic aneurism put him in the hospital for eight days in 2014. The cost: $197,000.

Therein lies a key insight of this dizzying book: the Affordable Care Act (ACA) passed in 2010 represents—by far—the most comprehensive attempt in the country’s history to control health-care costs and provide coverage for tens of millions of uninsured citizens. And yet, as too many Americans have experienced, the continually rising cost of caring for ourselves has reached a stratospheric level that feels beyond the reach of any legislation.

Brill assigned himself the herculean task of telling how the ACA came to be, which ends up being a guided tour to its shortcomings and even perverse results. The law is so complex, and assembled by so many competing hands, that essentially no one understands it in its entirety. Moreover, the compromises needed to ensure its passage all but guaranteed that its implementation would be chaotic, whether it’s red-state governors refusing to expand Medicaid or a website that infamously could not be accessed by millions looking for coverage.

Given the enormous portion of America’s economy that is tied up in health care, it is nearly impossible to pass any legislation that might threaten the profits of its powerful factions. The motivations behind the ACA may have been largely noble, but the creation of the bill became an orgy of self-interest. Trial lawyers seem to have convinced then–Senate majority leader Harry Reid not to include a provision limiting the ability to sue doctors for malpractice, which could have saved some $70 billion. A proposed soft-drink tax to fund insurance was removed when the soda industry hammered down on Max Baucus, who drafted the legislation.

Partisan politics also added dysfunction. Once Republicans decided on uniform opposition to the bill, every Democratic vote became crucial—and every Democrat had a pet issue or industry to protect. Seasonal workers, for example, are not counted as full-time employees eligible for coverage because Michael Bennett was protecting Colorado’s ski resorts and Barbara Mikulski Maryland’s crabbers. The proposed tax on medical devices was cut in half, as a sop to the Senators from Indiana and Minnesota, where many device companies are located. “It was a retail sale, one by one, requiring the [draft bill] to grow every day, quickly becoming a monstrous document,” Brill writes.

Passing the bill, while a remarkable achievement, did not end the headaches. Thousands of questions had to be answered, from the very large—how exactly would insurance exchanges work?—to the minuscule: was it appropriate to tax smokers, and if so how much? The thicket of federal bureaucracy did not lend itself to effective decision making. Even the simplest rules had to pass through a five-step approval process, including the final word from the Office of Management and Budget, which “often took months to move drafts of regulations off its many desks,” Brill writes.

And the ultimate snafu was technological. The healthcare.gov site, Brill reminds us, was “intended as the backup for states that did not build their own.” But that ended up being a majority of states, and the site was probably doomed from the start. The contractor, a Canadian-based company called CGI Federal, had a spotty record and was never properly integrated into the various government databases and departments needed to make it work. Perhaps not surprisingly, the original $93 million contract, Brill notes, “would later become $293 million.” When tens of thousands of visitors descended upon the site during its 2013 launch, its malfunctions were so serious, Brill reports, that the White House came very close to scrapping it altogether and starting over.

Through it all, Brill functions like a nonfiction Dickens, jumping from Congressional corridors where deals are cut to emergency rooms where seemingly normal procedures force real-life Americans to fork over surreal sums. In one case, a northern California man died less than two years after he had been diagnosed with lung cancer in 2011; his wife was hit with bills totaling $902,452.

The ACA, as Brill points out, has had salutary accomplishments. The percentage of uninsured Americans has dropped precipitously; millions of Americans are no longer denied insurance because of preexisting conditions; and employer-provided health care need no longer shackle most adults to jobs they otherwise dislike. And overall costs are not rising as fast as they once did (a trend not entirely attributable to the ACA). But they are still rising, and America’s health-care spending as a percentage of gross domestic product is still the highest in the world. Being insured is preferable to its opposite, but for tens of millions of Americans monthly premiums are punishingly high and gaps in coverage can still bring on economic peril. Brill ends with the grim conclusion that the threat of an economy bankrupted by medical costs may provide the only impetus to meaningful change.

It is worth remembering that other countries with national health-care systems, such as the United Kingdom, needed to make significant adjustments after their plans were introduced, and so perhaps the ACA can be incrementally improved. Still, the unmistakable lesson of America’s Bitter Pill is that the political costs of any genuine reform are enormous; very few presidents or Congressional leaders will ever have enough clout to take them on successfully.