Abstract
Considering the book’s title, prospective readers might expect that Rosemary Gibson and Janardan Prasad Singh have written about the disagreements and tactical maneuvers involved in the enactment and implementation of “Obama’s reform.” However, the battle over health care that the authors describe began before Barack Obama’s presidency and will probably continue long afterward. They see the combatants as the powerful interests that continue to fight for their own economic and political gains in health care, even as patients lose from unsafe care and high costs.
This book is an indictment of the president, the political parties, and the “medical-industrial complex” for pursuing selfish interests at the expense of patients and citizens. It is organized into five parts. Part 1 describes the deals made by Obama and the Democrats with health insurers, pharmaceutical manufacturers, hospitals, and physicians to secure support for a major expansion of health insurance. Part 2 criticizes the Affordable Care Act (ACA) for failing to put enough emphasis on reforming health care, rather than health insurance. It blames the American Medical Association’s Relative-Value Scale Update Committee for undermining the availability of primary care by “fixing” Medicare prices in favor of specialty care, and accuses hospitals of choosing “financial gimmickry” instead of reengineering for safety, quality, and efficiency. Part 3 draws parallels between greed and excesses in health care, and the recklessness that brought down the financial industry in 2008. Part 4 paints a picture of America’s descent into bankruptcy, should it fail to slow the growth of Medicare and other health care spending over the long term. Part 5 offers “Ten Steps to More Affordable Health Care.” Here, the authors warn about lobbying efforts to eliminate the Independent Payment Advisory Board, “the only meaningful part of health care reform to directly rein in Medicare spending.” They also elaborate on alternatives to lawsuits for compensating patients harmed by medical errors, and the need for larger investments in identifying and prosecuting health care fraud.
Gibson’s and Singh’s biggest complaint about “Obama’s reform” is apparently encapsulated in the title of Part 2, namely, “How Health Care Reform Did Not Reform Health Care.” Indeed, that would be an appropriate title for the entire book. The authors acknowledge a number of provisions in the legislation that move in the right direction (refusing to pay for preventable hospital readmissions, bundling payments, the Patient-Centered Outcomes Research Institute, public investments in information technology, uniform electronic standards for public and private insurers, state experimentation with alternatives to lawsuits for compensating patients harmed by errors, and increased funding for antifraud efforts), but they argue that the ACA does not deal with the central failure of the health care system in the United States. This failure, they write, is its reliance on a business model that is driven by volume and the “addiction” of the medical-industrial complex to ever-increasing revenues, an addiction that must be financed by ever-increasing health insurance premiums, ballooning government deficits, tax increases, and bankrupting out-of-pocket costs.
According to Gibson and Singh, the White House and Congressional Democrats could have used the leverage of thirty-two million new customers to negotiate more affordable care for the American public. Instead, industry players were treated as if they were doing a favor for Americans when, in fact, the deal did them a favor by giving them 10 percent of the US population as future customers. (p. 36)
However, to suggest that Obama and the Democrats passed up an opportunity to win it all—big cuts in spending on health care for insured Americans and expanded coverage for the uninsured—is wholly inconsistent with the overwhelming power of the medical-industrial complex that the authors decry in their book. As it was, “Obama’s reform” was enacted by the narrowest of voting margins.
“We wrote this book for the American people,” the authors explain in the introduction. “They are the only special interest we represent.” What Gibson and Singh do not explain is why they absolve the American people of any responsibility for making informed, reasoned judgments about health care in their roles as patients and voters. The book is too quick to excuse Americans for being stampeded by falsehoods such as the myth about “death panels” in the ACA, when ultimately the power to stand up to deeply entrenched interests and win the battle over health care resides only in the American people.