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katharine whittemore

Recent books about health care in the US

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Some books have the worst timing. Take last year’s “Where’s the Birth Certificate?” which came out just before President Obama released his birth certificate. Or the flattering bio of Joe Paterno, in the works when Penn State’s Sandusky scandal broke, then painfully published this summer. Sadly, a great, even groundbreaking book had a similar fate. “Best Care Anywhere: Why VA Health Care Would Work Better For Everyone” (Barrett-Koehler, third edition, 2012) debuted in the winter of 2007—just as the Walter Reed Army Medical Center exposé hit. You remember the gist: mold inside the building, drug dealers outside, appalling neglect everywhere. Best Care Anywhere? Ouch.

Here’s the thing, though: Walter Reed is not a VA hospital. It’s run by the Department of Defense, not the Department of Veteran Affairs. This distinction was lost on me, and many others, too. Thankfully, author Phillip Longman, a senior fellow at the Washington Monthly, shook off all the snarky bad timing commentary swirling on the Internet. And he got his revenge; the book has had two more printings and become an inspirational must-read in reform circles. Ezra Klein, of the Washington Post, also calls it “among the most important social policy books” of the decade.

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Reading about American health care is such a code blue experience, I’m comforted by the hope beaming from “Best Care Anywhere.” But for context’s sake, let me bring you down before I bring you up. In America, health care is in thrall to two crises: one of the uninsured, one of the cost of care. For the last few years, we’ve heard more on the insurance side. The Affordable Care Act passed in 2010, the Supreme Court decided to uphold it in June, and the bill’s main points are these: Starting in January, 2014, the uninsured will have to buy health insurance or pay a penalty (which the Supreme court significantly characterizes as a tax). And insurance companies must cover you even if you have a pre-existing condition.

That all sounds fair. But honestly, no one knows if the numbers will work — and reforming insurance is only half the battle. If we don’t contain costs, we’re still sunk. So how bad are things? According to “Best Care Anywhere,” a third of all health-care spending is sheer waste. That’s a huge $700 billion a year. Democratic daydream: fix the problem, and use the savings for schools, infrastructure, and the environment. Republican daydream: give the cash back through tax cuts. Either way, let one stat be your window: Between 1999 and 2005, Medicare’s rate of growth in per capita spending was 29.4 percent. Want to know the equivalent VA figure? That would be 1.7 percent.

In the last 20 years or so, the VA has become a paragon of effective government bureaucracy (it wasn’t before, not by a long shot). We’re talking parallel universe here; it features highly coordinated care and a culture of pinpointing and fixing problems, all of this enabled by its comprehensive
VistA electronic health record system. Then there’s the smoking gun: the doctors are paid solely by (competitive) salary, so there’s no economic incentive to order extra fee-for-service tests. The VA is efficient, effective, and solvent. Bonus: it’s already government-run! So it can be duplicated on a wide scale!

I’m throwing around exclamation points because I also just read a flashy comic book (yes, a comic book!) called “Health Care Reform: What It Is, Why It’s Necessary, How It Works” (Hill and Wang, 2011). Part of a new wave of grownup graphic works that cheekily break down complex issues, it’s the least daunting way to dive into the issue, sort of Richie Rich Goes to the Hospital. Jonathan Gruber, an economics professor at MIT, and a big force in the creation of MassHealth, writes cleanly, and comic book artist Nathan Schreiber nails the imagery. The twin health-care crises, for instance, are a two-headed alligator. The waste in costs is sewage pipelines spilling dollar bills into a fetid lake. Medicare is a 1000-pound gorilla.

Armed with the basics, I turned to “Landmark: America’s New Health Care Law and What It Means for Us All” (Public Affairs, 2010) by the staff of The Washington Post. The explanations of the bill are cogent, but I admit I liked the inside-politics scenes even better. There’s Obama at a March 2007 campaign event, for instance, giving a lackaday answer to a question about health care (“I just whiffed up there,” he later admits) only to realize he needs to dig in like never before. The end result? “He will be remembered as the president who pulled off one of the most audacious legislative feats in nearly 40 years.”

The Post’s writers are also revealing about the long, failed history of universal health care. Teddy Roosevelt called for it in his losing 1912 presidential campaign. FDR almost attached it to his social security bill, but feared one would tank the other. Nixon came this close, but a little soupçon called Watergate got in the way. Then it was Bill and Hillary and Harry and Louise (remember those smarmy ads?) until Obama vowed to be the last president to tackle the issue.

“Health Care Reform and American Politics: What Everyone Needs to Know” (Oxford University Press, 2010) trods “Landmark’s” ground, but the authors, both political scientists, are more analytical. Lawrence R. Jacobs, of the University of Minnesota, and Theda Skocpol, of Harvard, theorize that Affordable Care may in time gain as much popularity as Social Security and Medicare. Then again, both of those programs passed with some bipartisan backing. The Affordable Care Act did not. The book also covers the various skanky deals cut (remember the “cornhusker kickback” of higher Nebraska Medicaid reimbursements to lure in senator Ben Nelson?) And there’s a mercifully clear timeline and glossary. Need a quick refresher on the Sidecar, Donut Hole, and Gang of Six? This is the book for you.

But let’s get back to righteous indignation. “How We Do Harm: A Doctor Breaks Ranks About Being Sick in America” (St. Martin’s 2011) was written in fire by Otis Webb Brawley, MD, the chief medical and scientific officer of the American Cancer Society (journalist Paul Goldberg also gets writer credit). Besides his chief duties, Dr. Brawley was also an oncologist at Atlanta’s huge “safety-net” hospital, Grady Memorial. As such, he has quite the war stories of how the poor and rich are treated, and pulls no punches with chapter headings like “Cadillac Care” and “A Wallet Biopsy,” each a chronicle of greedy doctors and Big Pharma colluding on the “perverse incentives that spread dysfunction through the health-care system.”

This last title is less in-your-face and, like “Best Care Anywhere,” sounds a few power chords of hope. It’s called “Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer” (Bloomsbury, 2007), and it’s by the excellent health care writer Shannon Brownlee. Most doctors are “paid for how much they do, not how well they care for their patients,” she writes. To be fair, they also try to avoid lawsuits by covering their bases, and we patients go right along in the name of “getting the best treatment possible.” What to do? Brownlee’s solution arrives by acronym: CARE, which stands for “coordination, accountability, electronic medical records and evidence.” How to implement this? We must mimic “the extraordinary achievements,” she writes, of the VA. Beautiful. Now if we can just get the timing right.

Katharine Whittemore is a freelance writer based in Northampton. She can be reached at katharine.whittemore@ comcast.net.
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