Book Review: An American Sickness by Dr. Elisabeth Rosenthal
An American Sickness: How Healthcare Became Big Business and How You Can Take it Back is undeniable proof that the American healthcare system is morally bankrupt and requires massive reforms.
The privatization of economic sectors is typically rationalized via the argument that selling off public resources increases efficiency and therefore positive outcomes across the board. That these greater efficiencies disproportionately reward the richest and luckiest participants, and this is as true in the healthcare arena as it is in the purchasing and reselling of wine, is seen as an inevitable and excusable function of the greater freedom which facilitates market-based growth. Even though this increases inequalities and widens the gulf between those with pre-existing access and those without, the fact that anyone can technically participate and enjoy the fruits of an uneven economic system by striking it rich justifies the inequality of opportunity—“nothing is stopping you from making good on the same on-paper equality of opportunity as I did,” the unlucky capitalist aspirant might be told. No matter how unrealistic or purely theoretical this liberalizing freedom might be, it is said to satisfy the goal of deregulation, decentralization, and privatization of even life-saving goods and services if it exists in concept, or more accurately, if it said to exist. Under this same logic, the existence of a lottery which is technically available to everyone would by itself justify the existence of massive, undeniably deadly inequalities of the kind that we are increasingly witnessing as a direct result of the US healthcare industry.
The brutality brought about by these massive inequalities is only limited by the extent to which the masses will tolerate it—imagine a population of 100 in which only one or two members are lucky enough to have access to lifesaving healthcare. The other 99 or so members might decide to rise up, necessitating the “sharing” of resources and the creation of something resembling a public healthcare system. Imagine instead if only 20 had access, or 50—would the remaining sufferers have the ability to pool together their resources and fight the injustice to secure their access to medical care? Does might make right in this case, and if not, what is the normative difference between 10 people being left out in the cold and 99? This is the vision of a world without a functioning healthcare system which reflects a universal right to life: it will inevitably result in some sort of calculus which will see vulnerable members of society cast aside and ignored, or worse, pressured into accepting assisted suicide or continued intolerable suffering out of nothing more than economic concerns (in this case, the ability of the rich to keep the lion’s share of of the wealth, which will be euphemized with concepts of scarcity and the idea that there are naturally insufficient resources to go around anyway).
An American Sickness compellingly traces the development of this morally bankrupt logic as it grew to pervade the entirety of the US healthcare system, from ambulance rides to private health insurance to prosthetics to prescription medication to hospital stays to doctor visit copays. The avarice and underhanded mendacity underpinning the actually very inefficient systems she analyzes are summarized by ten economic rules, which she refers back to repeatedly throughout the text (page 8):
Economic rules of the dysfunctional medical market:
More treatment is always better. Default to the most expensive option.
A lifetime of treatment is preferable to a cure.
Amenities and marketing matter more than good care.
As technologies age, prices can rise rather than fall.
There is no free choice. Patients are stuck. And they’re stuck buying American.
More competitors vying for business doesn’t mean better prices; it can drive prices up, not down.
Economies of scale don’t translate to lower prices.
There is no such thing as a fixed price for a procedure or test. And the uninsured pay the highest prices of all.
There are no standards for billing. There’s money to be made in billing for anything and everything.
Prices will rise to whatever the market will bear.
Rosenthal proceeds to dismantle the market’s claim of efficiency in every aspect of modern healthcare, through numerous examples of the very complex, opaque privatized medical bureaucracy resulting in confusion (more than 80% of hospital bills contain errors, yet around two thirds of bankruptcies in the US are due to medical bills), denial of care, financial ruination, and generations of frustrated, suffering victims. No part of the industry is left unexposed, and she sites many examples of unjust treatment, with many of the stories seeming almost unbelievable.
Much has been written about the superiority of the public healthcare systems in terms of all conceivable criteria, from infant mortality to life expectancy—monetizing and therefore restricting access to necessary goods and services would seem at its core an inappropriate and cruel idea, consigning millions to early grave for the crime of being poor in a system which requires the existence of a massive underclass to function as intended, notwithstanding the unfulfilled and unfulfillable promise of equality of opportunity which amounts to nothing more than rote lip service to justify extravagant lifestyles. A powerful argument would be needed to alter this logical perception; the market would need to prove itself efficient on a level which would not only satisfy the “rising tide raises all boats” promise of unregulated economic growth but would guarantee that fewer would be left without access than in a government-run system (that it is both efficient and fair). However, the historical lack of proof that any such rising tide benefits anyone but the already well-off as well as the internal contradictions of the American healthcare model which are so revealingly cited by Rosenthal very handily put the lie to this rationalization. An American Sickness is a powerful document in the argument against healthcare privatization and its popular rhetorical history, which can be summarized as a series of shady backroom deals which carved up and exploited a once-equalizing, functioning system and which only ever appeared to benefit the average consumer, with leaps and bounds in technology rightly taking most of the credit for improvements in outcomes. The “logic” of the market is in reality one of rudderless, lazy avarice, devoid of coherent logic outside of that which ensures that the rich and their allies will continue to reap disproportionate rewards while everyone else is cast aside.
The labyrinthine and unaccountable bureaucracy of the medical industry is a reflection of this shadowy devolution fueled by political favors, right-wing orthodoxy, and victim-blaming, and it is a relatively new development rather than a historical given, paralleling the rise of neoliberalism in the postwar era which oversaw the selling out of other essential goods and services as well (see for another compelling example of universally disastrous privatization of water services throughout the world). It didn’t have to be this way, and for a long time, it wasn’t. Recent events continue to move the US toward widespread denial of care for underlying economic reasons which are periodically given a moralist sheen by right-wing campaigners, such as occurred with the recent Supreme Court rejection of Roe v. Wade, which has already resulted in horrifying outcomes in several states with restrictive laws:
But sometimes, evidence is an expression of grief or even rage. A recent journal article, “Maternal Morbidity and Fetal Outcomes Among Pregnant Women at 22 Weeks’ Gestation or Less with Complications in 2 Texas Hospitals After Legislation on Abortion,” contains such evidence.
To understand this article, you need to know that any number of complications can threaten a pregnancy, such as rupture of the bag of water around the baby, preterm labor, or heavy bleeding. When those complications arise before 22 weeks of gestation— before the age of viability when a fetus can live outside of a uterus—the standard of medical care is to offer a patient termination of pregnancy as an option. Women who continue pregnancy in these situations take on significant risks to their own health, and because of the early gestation, the chance for a healthy baby is very, very low.
However, in September 2021, Texas adopted two measures, S.B. 4 and S.B. 8, which instituted punitive actions against anyone providing abortion. These laws took effect before the Supreme Court decision ended Roe v. Wade. And all of a sudden, termination of pregnancy became impossible in Texas unless and until there was an “immediate threat to maternal life.”
The journal article, published in the American Journal of Obstetrics and Gynecology, describes the experience of two large Texas hospitals over a period of eight months following that legislation. The authors, who care for patients at those hospitals, describe how their hospitals managed 28 women who presented at less than 22 weeks’ gestation with serious complications following the ban on abortion.
Without the ability to offer abortion to their patients, all 28 women were managed expectantly. This is a medical way of saying that they waited for something terrible to happen. That wait lasted, on average, nine days.
During that nine days of waiting, here is what was achieved for the babies: 27 of the patients had loss of the fetus in utero or the death of the infant shortly after delivery. Of the entire cohort, one baby remained alive, still in the NICU at time of the journal article’s publication, with a long list of complications from extreme prematurity, including bleeding in the brain, brain swelling, damage to intestines, chronic lung disease. and liver dysfunction. If a baby survives these complications, they often result in permanent, lifelong illnesses.
During those nine days of waiting for an immediate threat to maternal life, here is what happened to the women of that cohort: Most of them went into labor, or had a stillbirth, which meant the medical team could then legally intervene and empty the uterus. Fifty-seven percent of those pregnant women had some sort of complication, and for about a third of them, it was serious enough to require intensive-care admission, surgery, or a second admission to the hospital. One of the 28 patients ended up with a hysterectomy, which means she will never carry a pregnancy again. The authors of the article estimate, based on their pre-September practice, that about half of those maternal complications would have been avoided if immediate abortion had been offered as a choice. But of course, post-September in Texas, these women didn’t get a choice.
Even the American Medical Association has recently issued guidance to doctors to break the law and continue to offer abortions (to conscientiously object to fascist overreach into the bodies of women, in effect), arguing that government interference with the health of patients is reckless and unnecessary.
This is sound, morally consistent advice, and a brave enough statement, but what if none of these brave doctors are nearby and an expectant mother needs to have an abortion performed? What recourse do these women have, given that not all (or indeed most) can simply pack up and move to another more civilized state which favors health and bodily autonomy over emptyheaded moralizing? Another instance of the kind of conscientious objection which will soon be necessary: Planned Parenthood has begun to offer mobile abortion services within abortion-legal states:
Since the U.S. Supreme Court decision in June overturning the abortion-rights precedent Roe v. Wade, Cooper says thousands of patients have been flocking to the organization's clinic in southern Illinois after their states enacted prohibitions on the procedure.
"I didn't think that other states' [abortion rights] would be overturned so quickly," she says. "Because of that we've seen a huge uptick, quicker than we thought we were going to see, in the last few months."
As a result, Planned Parenthood officials say they wanted to find a way to expand capacity and make it easier for patients in states with abortion bans to reach them. Many struggle to get time off work, find child care, and cover the costs of traveling long distances for appointments.
Planned Parenthood's new clinic on wheels will have to operate within Illinois, where abortion remains legal, but will be able to travel closer to other state lines.
Inside, the clinic is equipped with two examination rooms - including small exam tables and ultrasound machines. It's one of just a few such units nationwide that are set up to provide abortions.
The implications of the AMA’s statement reach far beyond abortion though, and leads to the question: if the law can and should be broken in order to save a life, why is there a price tag on healthcare to begin with, if this results in denial and avoidance of medically necessary care? This inhuman logic—that some can justifiably be left to die for this reason or that outside of necessary self-defense against an attacker—can be turned around to apply to the architects and gatekeepers of scarce medical care, validating, for example, armed robbery of lifesaving drugs to preserve one’s life or that of a loved one. If the capitalists can conceptualize and enforce de facto (effectively privatized or market-based) restrictions to the universal right to life in the name of nothing more than personal profits, what is to stop any of us so deprived from doing whatever is morally necessary to secure treatment, aside from the law, which is both malleable and distinct from a moral calculus. Just because it is legal to force us to die so that hospital owners can purchase another yacht, does not make this morally justified. We are past legalism outside of a few notable cases (in excusing the actions of police and US soldiers, mainly), but the US healthcare system depends on it to function without interruption.
Rosenthal shifts her focus in the second part of the book, advocating for a grassroots approach to reforming the healthcare system by holding doctors and healthcare administrators accountable. From the epilogue:
No one player created the mess that is the $3 trillion American medical system in 2017. People in every sector of medicine are feeding at the trough: insurers, hospitals, doctors, manufacturers, politicians, regulators, charities, and more. People in sectors that have nothing to do with health—banking, real estate, and tech—have also somehow found a way to extort cash from patients. They all need to change their money-chasing ways.
To make that happen, however, we patients will need to change our ways too. We must become bolder, more active and thoughtful about what we demand of our healthcare and the people who deliver it. We must be more engaged in finding and pressing the political levers to promote the evolution of the medical care we deserve. (Page 329)
In the absence of a potential top-down revolution in American healthcare (which is not forthcoming, especially in the wake of Obamacare, a gift to the insurance industry which only kicked the can down the road—see pages 19-20 and 235-238), this “patient rebellion” approach is the best chance to force a system change, though with the violent and disproportionate opposition to the ACA on the right (who without basis warned of “death panels” and long wait times), even a minor movement toward universalizing healthcare from the people would be met with predictably alarming responses. This is a theme of right-wing opposition to would-be democratizing reforms in general—even a token leftward shift elicits outlandish responses which the centrist Democratic Party is more than happy to cite as a justification for inaction, their genuine deep-seated goals (such as they are—many Democratic politicians are also bankrolled by the insurance industry) rendered immaterial by their history of repeated capitulation and failure to represent the actual will of the people. Though it may be unlikely, the absence of any genuine healthcare stewards in the government and any real, established reformers with appreciable momentum leaves the task of establishing accountability to the patient and the particulars of their own grievances by default. This is an inevitably piecemeal, scattered, and largely directionless revolution though, and ultimately a self-interested effort by patients stuck with egregious bills and denials of care, who will be less likely to find themselves in a position (let alone healthy enough) to mount a powerful case for healthcare reform beyond their limited scope unless represented in a class action suit. In doing so, they will face a wealthy bureaucracy which, as Rosenthal notes repeatedly throughout the book, have successfully lobbied to stymie even well-organized efforts to increase patient access to affordable care (see especially chapter 4, The Age of Pharmaceuticals). They will face the well-paid politicians who represent this industry, who will be all too happy to use their offices to smear these victims as undeserving and greedy, drains on the system who want something for nothing. If even the undeniable statistical superiority of socialized healthcare systems is insufficient to bring about such change, what hope does a beaten and impoverished grassroots movement have? Can we count on the good nature of organizations such as Planned Parenthood (not without its violent detractors) to provide a sort of underground railroad for healthcare access? This presumes a compliant and conscientious police force, as well as the ability to freely travel to access healthcare, two very significant uncertainties in an increasingly Balkanized US (see also medical tourism to countries with significantly cheaper procedures, which is done by millions of Americans each year).
The American healthcare system as it currently exists is a boondoggle which functions only to enrich its overseers at the expense of employees and customers alike. Unlike with hedge fund liquidations though, more than money is lost: these costs are deadly rather than merely fiduciary—with only a few intermediaries, the well-compensated heads of insurance companies and hospital networks (many of which are named by Rosenthal) profit directly from human misery. This legitimates in turn the infliction of misery upon them in the service of ensuring that everyone has access to life-saving care. This misery can be easy, or it can be difficult, and this choice is up to the elites—the system has unfairly endowed them with great power over others, and it is their responsibility to use this power to ensure that violence is not visited upon vulnerable individuals or upon them in turn. If they are not willing to “go quietly” in the form of relenting and paying their fair share into the system (an amount which would still leave them with considerable wealth in any system likely to exist in 21st century America), they are morally liable for forcible wealth redistribution, potential indictments, and worse.
Sadly, the more likely outcome is the continued devolution of the public good in the United States. The rich will continue to amass ever greater riches by parasitizing healthcare as they do other industries, citing increasing aggregate misery brought about by climate change and environmental destruction (which they are responsible for, of course) as an expedient rationalization for maintaining or broadening the current arrangement and lowering our moral consideration of those who are unable to pay via a “desperate times” hardship excuse. Billions will die premature deaths from lack of care on top of food insecurity, exposure to natural disasters and weather anomalies, and pollution, with the elites who put us here the last to suffer. These deaths will be swept under the rug as they already are, chalked up to bad luck or bad lifestyle choices. If this suffering is not sufficiently minimized or waved away forcefully, the resulting revolution might be bloodier still.
What, in the end, is the point of living in a society? Is it not to avoid such nasty and brutish outcomes in the first place?
In the final analysis, An American Sickness is a compelling history of the development of America’s grossly inefficient and deadly privatized healthcare system and the lie that this process was driven by any kind of coherent or just evolution. In every respect, from point of care to aftercare and billing, the current arrangement was molded by bad actors interested only in maximizing profits at the expense of everyone else, which includes almost everyone reading this review who has struggled to pay for a procedure or avoided seeking medical care or preventive maintenance in the hope that nothing goes wrong, as in the case of expectant mothers in Texas. The elites are rapidly enshrining this enforced act of gambling with one’s life in the country’s legal system, devaluing the inherent worth of human life in the process. It is a game of Russian roulette for the vast majority of us.
The future is going to be brutal. Only through organization of the kind Rosenthal favors, in the form of mutual aid, popular protest, and circumvention of the law first and then open rebellion and violence against those who would restrict access second, can the underclass hope to secure anything resembling a livable arrangement. We could presently state the obvious: that it would be better to avoid this outcome while we are still able. This is by now a rote exercise in platitudes, though. On this issue as well as climate change, the time for action is almost certainly well in the past. We are in the palliative stage of our civilization, in which our primary concern should be preparing for the fast-arriving catastrophes to safeguard what remains of our physical and mental well-being. An American Sickness provides a great starting point for a broader conversation about potential replacements for this deadly boondoggle.