'America's Bitter Pill' Makes Case For Why Health Care Law 'Won't Work'

Transcript

TERRY GROSS, HOST:

This is FRESH AIR. I'm Terry Gross. What are the odds? While reporting on the rollout of Obamacare, Steven Brill got an education in being a patient. He was diagnosed with a life-threatening condition that required heart surgery. This was not long after he'd written a special report for Time magazine, investigating the inflated charges in hospital bills. After winning a National Magazine Award for that report, he ended up with pages and pages of his own inflated and confusing hospital charges. Now he's written a book about the political fights and the medical and pharmaceutical industry lobbying that made it difficult to pass any health care reform and led to the compromises of the Affordable Care Act, which enables millions more people to afford health insurance but also adds new layers of bureaucracy and many confusing new regulations. Brill is a journalist who also founded Court TV, American Lawyer magazine, 10 regional legal newspapers and Brill's Content magazine. He teaches journalism at Yale.

Steven Brill, welcome to FRESH AIR. After writing your Time magazine story about the cost of health care and why individual items cost so much, you got very sick. You were diagnosed with an aortic aneurysm that required heart surgery. So this was as you were in the middle of researching your current book "America's Bitter Pill." What are some of the things that you learned about the difference between being a patient and being a journalist when it comes to health care?

STEVEN BRILL: Well, the first thing I learned was something that you and I probably can appreciate on an intellectual basis but not on an emotional basis, which is that a patient in the American health care system has very little leverage, has very little knowledge, has very little power. Now I knew that, I'd written it, and as I was completing the reporting of the book, literally on the last day for enrollment into the Affordable Care Act on the exchanges on March 31, I was told that I had this heart problem. And actually, I didn't get very sick at all, I was feeling completely fine. But I was just told that I had this bubble on my heart, which would show no symptoms at all, but it just had a 15 to 17 percent chance each year of bursting and if it did, I'd be dead before I got to the operating room.

So there I was, you know, a reporter who had made hospital presidents and hospital executives and health care executives and insurance company executives, you know, sweat because I asked them all kinds of questions about their salaries and their profit margins and now I was, you know, lying on a gurney in a hospital in real fear of my life. And at that moment, I wasn't worried about cost, I wasn't worried about, you know, a cost-benefit analysis of this drug or this medical device. I wasn't worried about health care policy. And it drove home to me the reality that, in addition to being a tough, political issue because of all the money involved, health care is a toxic, political issue because of all the fear and the emotion involved.

GROSS: Are there things you previously, as a journalist, might have thought of as being unnecessary in terms of health care and too expensive that now seemed really worth it to you?

BRILL: Well, it's not a question of whether if you're stepping back and saying well, is it worth it, that you sort of make a different kind of an analysis. It's just that when you're a patient, when you're in pain, when you're in fear, you don't make that analysis at all and you don't want anyone to make that analysis. This is a matter of pain versus no pain, life versus death, and if a doctor says you need, you know, two blood tests today just to be sure, you say fine. You know, if I need five, I'll do five. If I need 10, I'll do 10. If I need two x-rays of my chest after I have open heart surgery, you know, that's OK with me. Whatever you say, I will do because I am terrified.

GROSS: So for your Time magazine story, you'd studied seven people's bills and did a line-by-line analysis of how the charges were computed and why they were so high. What was your bill? What was your total bill?

BRILL: The total bill for the surgeon, the hospitalization, the test and everything was approximately $190,000.

GROSS: How much of that did you have to pay?

BRILL: Of which I paid - I think I paid probably 12,000 of it. I exhausted the deductible on the policy that my wife and I had. And once I paid the 12,000, I was indifferent to all the costs because I was paying zero. Once I achieved, you know, my maximum out-of-pocket, as they say, you know, nothing mattered to me.

GROSS: OK, so you write that you got 36 different first-class envelopes from UnitedHealthcare, which was your insurer, and each had an explanation of benefits - one of those papers that says this is not a bill, but it tells you everything that you were expensed for.

BRILL: Right.

GROSS: So each had an explanation of benefits for a separate treatment related to your surgery or one for a prescription drug or for each lab test done outside the hospital, one for each doctor, one covering your main hospital bill. So when you got these explanations of benefits, did you immediately know how to read them? 'Cause you'd done a whole story about this. Like, you were a pro in how to analyze these bills.

BRILL: Well, I'm supposed to, you know, I think of myself as a fairly well-educated person. I have a law degree from Yale, and, as you point out, I'd been writing about this stuff and reading this stuff for a long time. And I couldn't understand most of those, you know - for starters, it's hard to understand why you get 36 different first-class envelopes with 36 different pieces of paper from the same insurance company on the same day. That tells you something about the efficiency of the health care industry right there.

But then as you open each envelope, they're as completely unintelligible to me as they are to you and as they are to everyone listening, but better yet, they're also unintelligible apparently to the people who write them. I got to do what is, you know, probably a reporter's dream and probably something a lot of our listeners would love to do, which is I took one of those explanation of benefits which said amount billed - zero, amount insurance company paid - zero and in the third column said amount you owe - $154.

GROSS: (Laughter) Makes no sense.

BRILL: OK, so it makes no sense. But here's what I got to do. I had scheduled, as part of the reporting for my book, an interview with the CEO of UnitedHealthcare, the largest health insurance company in the United States and my health insurance company, as it turns out. So I went out to Minnesota to interview him and asked him all kinds of questions about what he thought the impact of the Obama health reforms was likely to be. And at the end, I took that explanation of benefits out of my suit pocket and said, you know, I'm wondering if you could do me a favor, could you explain this to me? Amount billed - zero, amount insurance company paid - zero, amount you owe - $154. How can I owe $154 if nothing was billed? And he looks at it, and he looks at it and looks up at me and says, I could sit here all day and I couldn't explain that to you. I have no idea why they sent this to you. And I said, well, aren't you they?

GROSS: (Laughter).

BRILL: And he said, well, yeah. He said, I just can't decode it, I'm at a loss. And then he sort of - he took a breath and then he thought of another way to explain it. So he said, well, you know, New York state regulations - which is where I live, in New York state - New York state regulations I think require us to word it exactly that way. That's what it must be. And I said to one of his aides, who was, you know, nervously sitting there taking notes while this interview was going on, I said, would you mind just, you know, sending me those regs when you have a chance. And he got even more nervous because he knew there were no such regs. And sure enough, he sent me a regulation from the State of New York Insurance Department - the only statement of which was that explanations of benefits are supposed to be sent in a clear manner so that the average layperson can understand them, which wasn't quite what had happened. So here's the CEO of the largest health insurance company in the United States unable to explain the most basic communication that his company provides to its customers.

GROSS: Did you pay that $150?

BRILL: No. I mean, I wouldn't even know how to pay it. Who would I write the check to? Amount billed was zero.

GROSS: And what - did you get subsequent EOPs and bills saying, hey, you owe that $150...

BRILL: No. It just sort of - it obviously was some kind of mistake.

GROSS: OK.

BRILL: But these mistakes happen all the time to people.

GROSS: And you spend so much time on the phone. And a theory many of us have is that the health insurance companies intentionally make some mistakes, thinking you don't have the time to make those phone calls. And, probably, you don't even have the time to examine the bills that carefully, and you'll just assume you don't understand it. So you'll pay what you're told.

BRILL: Right. Well, now, I'm going to say something that's going to get you and your listeners angry maybe.

GROSS: OK. Try me.

BRILL: And that is that the insurance companies are not really the bad actors in this movie. The insurance companies are, in many ways, like us. They pay health care bills. And the culprit here and the reason that the Affordable Care Act doesn't work - is not going to work - is that nothing has been done to curb the marketplace of exorbitant bills and exorbitant profiteering on the part of hospitals, medical device makers and, obviously, the drug companies. And the insurance companies are as much the victim of that as we are.

Now, they're terribly managed. I mean, again, you know, the CEO of the largest company can't even explain, you know, what his bill means. You know, they're incompetently managed. They're not very nice people when you get them on the phone, but they're sort of stuck in the same ditch we're in, which is being forced - unlike the payers for health care in any other developed country on the planet, being forced to pay uncontrolled, exorbitant prices and high profits that are generated by nonprofit hospitals and by drug companies and medical device makers. So, in that sense, I kind of feel sorry for them.

GROSS: OK. Let's look at some more charges on your hospitalization bill. And let's, specifically, start with what you were charged for the surgery and the eight-day stay in the hospital. You say that was a total of $149,872.50. Do I have that right?

BRILL: But who's counting? Yes.

GROSS: (Laughter) But who's counting? So $20,992 of that was for use of the operating room during your six-and-half-hour operation. Does that seem like a reasonable charge for you? It's very - I assume it was a kind of high-tech surgery. We're talking open-heart surgery.

BRILL: Yeah, but, you know, let's just step back for a second. There are two ways to look at this. The first way to look at it, which is certainly the way I was looking at it the morning after my surgery and the morning eight days later when I walked out of that place a healthy person, is that those people saved my life.

So, in that sense, would I beg, borrow and steal or insist that my insurance company beg, borrow and steal to pay for all of that? Yes. Were the people there, you know, highly professional, highly skilled? Did they care a lot about me? Yes. So, in that sense, it's reasonable. If it had been $249,000, I guess I would have thought it was reasonable. In the sense that if you step back the way I did as a reporter and look at the economics of health care in the United States, it's absurd.

That nonprofit hospital makes a lot of profit. The executives are highly compensated. The people who sell all the equipment that is in that operating room have humongous profit margins. The drugs that I was given - the prescription drugs that I was given have humongous profit margins. And we have done nothing in this country, unlike every other country in the free world, to control that, because we have lived with the illusion that health care can be a free market. One of the hospitals that I write about in the book - the MD Anderson Cancer Center in Houston - had an operating profit - the year that the patient I wrote about, who was stopped downstairs from getting his first cancer treatment because his check didn't clear - they had an operating profit margin of 24 percent. That's an incredible profit margin. And yet, they're thought of as a nonprofit, you know, charitable organization. They do great work. They save lives. But, you know, everybody involved, except, actually, most of the doctors and the nurses, is making a ton of money.

GROSS: My understanding of that is that hospitals spend a lot of money on people who come into the emergency room and then maybe get admitted, who don't have health insurance. So, they're basically charity cases that the hospital takes on. And the money for that has to come from someplace. What's your understanding of that?

BRILL: Well, two things. First of all, hospitals spend a lot of money on charity care for people who come into the emergency room, and then they spend still more money on lawyers and bill collectors hounding those people and suing those people into bankruptcy. Sixty percent of the personal bankruptcies in the United States are the result of health care bills. And it's not like, you know, people wander into the emergency room because they want to get something for free. You know, nobody does that voluntarily. This is their health we're talking about.

Second, the Affordable Care Act really changes that because a lot of those people are now insured. So one of the reasons the American Hospital Association - the hospital's lobby - supported Obamacare, was because Obamacare created so many new paying customers for them who would now be able to pay so they wouldn't have to sue them to collect on their bills. They would now show up with insurance. So the hospitals are doing much better. The for-profit hospitals are reporting record profits as a result of Obamacare. And the nonprofit hospitals are typically, believe it or not, more profitable than the for-profit hospitals.

GROSS: If you're just joining us, my guest is Steven Brill, and his new book is called "America's Bitter Pill: Money, Politics, Backroom Deals, And The Fight To Fix Our Broken Healthcare System." Let's take a short break, and then we'll talk some more. This is FRESH AIR.

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GROSS: This is FRESH AIR and if you're just joining us, my guest is journalist Steven Brill - author of the new book "America's Bitter Pill: Money, Politics, Back-Room Deals, And The Fight To Fix Our Broken Healthcare System." And it's a story of all the deals that enabled the Affordable Health Care Act to be passed. And it's also an analysis of what works and what doesn't work with Obamacare. You write in your book that a lot of people blame doctors for the high cost of health care, but you don't think doctors are responsible for that. And so I want to talk about doctor's fees. Let's take a look, first, at your bill again from when you had the open-heart surgery. Your surgeon's bill was $19,500, which it was an over six- hour surgery and a difficult one and your life was saved. So, first, I want to tip my hat to your surgeon and thank him for saving your life and for doing a good job. But does that seem like an especially high amount?

BRILL: Well, let's remember, this particular surgeon, you know, they keep stats in New York on the success rate of these kinds of operations. And he's in the 99.9-tenths percentile. So he not only succeeded with me, but he's, you know, he's one of the best of the best. The second is, as I recall, his bill was $19,000, but the insurance company, their discount reduced that bill to something, like six or $7,000.

GROSS: Oh.

BRILL: So...

GROSS: What's the point of that? I never understand that. Why is the billing number so high if they know they're not going to be...

BRILL: So you'll feel good about your insurance. So you'll feel great about your insurance.

GROSS: Seriously, is that why?

BRILL: Yeah.

GROSS: Did it make you feel great about your insurance?

BRILL: Well, look at it this way - so suppose you have a co-insurance of 20 percent. So you get a bill from a doctor, you know, for a surgery like this and let's keep the math easy. So let's say the bill was for $20,000. And then let's say the insurance company's pre-negotiated discount for doctors in the surgery group where he practices brought that down to $10,000. Then, since you're only paying 20 percent, you pay $2,000. So you look at the bill and you say, oh, my god, I got $20,000 worth of surgery for $2,000 - thank god I have insurance. So that sounds like a pretty good deal. Now, in the case of this doctor, it is a good deal, but when your hospital, as I point out in the book, is billing you $77 for a box of gauze pads that you could buy at, you know, Walgreens for two-and-a-half dollars - if that - and you're getting a $77 bill for it, and then you see that your insurance company got a 50 percent discount off of what's called the chargemaster price - the $77 price. Well, a 50 percent discount off of $77, if you're still paying 38-and-a-half-dollars for a box of gauze pads, it's not such a great deal.

GROSS: You saw a lot of different doctors in a lot of different specialties when you were in the hospital, and you think some of that might not have been necessary.

BRILL: I don't know.

GROSS: You don't know, right. OK. You don't know. But you...

BRILL: But that's actually the larger point, which is, we never know. And we rely on doctors to make those judgments. But, to come back to your question about, you know, my surgeon, of all the ills in the healthcare industry, if you sort of stuck them up, you know, that would be pretty far down my priority list. For example - you know, the fact that, you know, you can be a salesman selling CAT scan equipment that hospitals don't need in, you know, Southern Connecticut and you can make two or $300,000 doing that each year or that you can be a hospital administrator in Pittsburgh making $5 million a year - the fact that my surgeon might make, you know, seven or $800,000 a year, which is, you know, the equivalent of a senior associate at a Wall Street law firm, that doesn't keep me up at night. That guy is saving two or three lives a day and he might be making what a junior partner or senior associate doing debentures at a Wall Street law firm makes. That is not one of, you know, the great scandals in our society.

GROSS: Steven Brill will be back in the second half of the show. His new book is called "America's Bitter Pill." I'm Terry Gross and this is FRESH AIR.

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GROSS: This is FRESH AIR. I'm Terry Gross. My guest is journalist Steven Brill, author of the new book, "America's Bitter Pill: Money, Politics, Backroom Deals, And The Fight To Fix Our Broken Healthcare System." It's a follow-up to his 2013 Time magazine cover story investigating inflated and incomprehensible hospital bills. While reporting on the rollout of the Affordable Health Care Act, he became a patient. He was diagnosed with an aortic aneurysm and required open-heart surgery. He's recovered now. Let's get back to our discussion about the Affordable Care Act.

The pharmaceutical lobby supported the Affordable Care Act. What did they get...

BRILL: As well they should.

GROSS: What did they get from it, and what did they insist on?

BRILL: Again, what they got - what everybody got - and the reason the Affordable Care Act passed was all the businesses that employ, you know, tens and hundreds of millions of dollars worth of lobbyists in Washington - the pharmaceutical companies, the medical device makers, the hospital industry, the people who, you know, who make CAT scans and MRIs - you name it - they all got a lot more new, paying customers - because if more people have health insurance, that means more people can pay into the system. So there are more people who will be, you know, who will get a prescription for Celebrex, and their insurance companies will pay Pfizer the same money that my insurance company paid. So, you know, that's a great deal.

You know, basically what Obamacare did was a very good thing. It gave tens of millions more people in this country the opportunity to have health care. And it's - you know, it's a longtime national disgrace that we're the only developed country where tens of millions of our citizens can't get health care. So what Obamacare does is it gives tens of millions of people the opportunity to get insurance coverage. That's the good news.

The bad news is that the way it does is it is it provides them with subsidies that taxpayers pay so they can get that insurance, or in the case of people who are poor, 100 percent subsidy by expanding the Medicaid program so that the taxpayers are paying for tens of millions of new customers to pay the same exorbitant prices in fees that everybody else has been paying and which makes health care in the United States roughly the equivalent of 16 to 18 percent of our gross domestic product, when all of our competitive countries - it's maybe 9 or 10 percent.

GROSS: So you explained how the pharmaceutical industry benefits from the Affordable Care Act - because so many people - so many more people now have benefits and can afford to buy medication...

BRILL: Right.

GROSS: ...Because it's all or partially covered. The pharmaceutical industry also lobbied against items that they did not want in Obamacare. What were the things they did not want to see in Obama care?

BRILL: So there are two or three proposals when it comes to prescription drugs that the pharmaceutical industry has resisted. One of them is - let's finance something called comparative effectiveness studies. We'll have, you know, a group of professional doctors, you know, with peer-reviewed studies, and they will look at drug A, which, let's say, is, you know, $100 a pill, versus drug B which is $10 a pill. And they'll report objectively if drug B at $10 a pill is as effective as drug A at $100 a pill. The pharmaceutical industry fought that and got that defeated.

The second piece was - let's let the biggest buyer of drugs in the world, Medicare, negotiate the price that it pays for those drugs. The pharmaceutical industry fought that, and as a result the law continues to be that Medicare has to pay the pharmaceutical industry whatever they say their wholesale price is for drugs plus an additional 6 percent. That's how it stayed.

So the third piece of reform on the drug side was - let's let people buy drugs in Canada. If they come from, you know, the exact same supply pipeline, the same drug in the same packaging, why can't they, you know, do mail-order sales into Canada? And that would just kill the industry in the United States because the dirty little secret is that the exact same prescription drug in the United States is typically 40 or 50 percent less in Canada, in the United Kingdom, in France, in Germany, in Australia, in every other country in the world, because every other country in the world controls the price of monopoly drugs. And all drugs, if they have a patent, have been given a monopoly by the government. And usually when the government gives someone a monopoly, it regulates the price - not so with prescription drugs in the United States.

GROSS: Would the drug companies say, therefore, Americans are doing more to support the drug research than other countries are because we have a bigger - there's a bigger profit margin here? We pay higher prices.

BRILL: Well, that's one of their arguments, which is the very high profit margins that drugs earn in the United States is necessary for the research and development that creates products that save people, not only in the United States, but around the world. Now, the answer to that, first, is the math doesn't add up. If you look at the financial reports that these companies file with the SEC and with other regulatory bodies, their expenses on research and development in no way justify the profit margins that they're taking. That's the first point. But the second point is I don't remember who signed the United States up to support research and development to help, you know, patients in Japan and Germany and France and England. Why don't, you know, we even out all the prices?

GROSS: If you're just joining us, my guest is Steven Brill on his new book. It's called "America's Bitter Pill," and it's about the behind-the-scenes negotiations that led to the Affordable Care Act - the deal-making behind the Affordable Care Act. And it's also about what that means in terms of the pricing for health care now. Let's take a short break, and then we'll talk some more. This is FRESH AIR.

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GROSS: This is FRESH AIR. And if you're just joining us, my guest is Steven Brill. His new book, "America's Bitter Pill," is about all the backroom deals that led to Obamacare, how Obamacare was only passed after all these deals were made, both in Congress and with the medical industry, with the insurance industry and so on. And nearly two years ago, he had an article in Time magazine that was actually the full edition that was about pricing. And it examined seven people's medical bills and tried to figure out, why are the prices so high? Who is making the profits?

In terms of the deal-making that enabled the passage of Obamacare, you write that Republicans who had always opposed the right of Americans to buy drugs through Canada and have that paid for by their health insurance companies, they actually launched a plan to try to block some of Obamacare or block all of it by supporting the liberal position of allowing Americans to buy drugs from Canada and having that paid for by their health care company. And that the whole goal of supporting the liberals in that was to get the pharmaceutical industry to block Obamacare.

BRILL: Exactly.

GROSS: So that a way of defeating Obamacare was to support liberal Democrats in wanting Americans to buy cheaper drugs from Canada and have their health insurance company pay for that.

BRILL: Well, that's right because they knew it would be shot down. It was, you know, a completely cynical play. And, you know, let's step back and sort of look at the big picture. What I think most Americans don't understand about Obamacare is Obamacare is a Republican policy position. Obamacare is slightly more conservative than a plan that Richard Nixon proposed in the '70s to head-off a Ted Kennedy plan that was much more liberal. Obamacare is more conservative than Romneycare.

So imagine the Democrats' surprise when they sort of finally relent through Senator Baucus in the Senate and write a bill that basically, you know, kind of throws in the towel on decades of Republican opposition to more liberal plans and throws in the towel, and says, all right we're going to go along with the Republican plan. We're going to do Romneycare for the country. And the Republicans still oppose it, and oppose it vehemently. And oppose it by taking measures like the one you've described where they actually say, well, we'll write an amendment into the bill that if it passes people will be allowed to buy drugs from Canada. And we know that if that's - that if that amendment is sitting in the bill, the all-powerful pharmaceutical lobbyists will get enough Democrats and Republicans to oppose the bill that the whole thing will go down in flames.

And let me just, you know, stress something here; the lobbyists - you know, this is a nonpartisan sport. The lobbyists were just as influential on the Democrats when Obamacare was being written as they were on the Republicans. The most obvious example is there's nothing of any substance in this bill about medical tort reform. And any expert who ever has looked at this dispassionately will tell you that the lack of tort reform is what allows hospitals and doctors either the reason or the excuse - you can take your pick - either the reason or the excuse to over test in the emergency room, to order many more lab tests than are necessary, to order MRIs or CAT scans whenever anybody comes in and says they have a headache. Tort reform is nowhere to be found in Obamacare.

GROSS: You're very critical of the Obama administration in terms of the bureaucratic administration of Obamacare and all the problems that the administration had with the website when it was launched as an example of that. And you write that you knew something was wrong when you asked different people, well, who's in charge of administering Obamacare, and you got seven different answers - seven different people were mentioned as the person who's administering it. So what did that tell you?

BRILL: Well, I was going to do another big Time story about the triumphant launch of Obamacare because I thought it would be, you know, all these, you know, people in government, you know, the law's been passed, and then in October of 2013 it was going to launch. And I thought I'd write sort of the inside tick-tock of how they pulled it off. And as I started my reporting during the summer, as you mentioned, I began with the innocent question of, OK, who's in charge of this thing? And I got, you know, seven different answers. And I remember coming, you know, back to New York that night from Washington after reading my notes and telling my wife, well, this story is not going to work because they're not going to launch.

And I think, again, the reason I did this book is I think in every respect, this whole saga of Obamacare - the politics of it, the bitter, you know, partisan politics of it, the lobbying and in this case the challenge of governance - all are emblematic of what's really eating away at our country. The incompetence in the White House - you know, we can agree or disagree with the president on his policies, on his goals, on his aims - but there have never been a group of people who more incompetently launch something, and it's principally because the people in the administration who knew it was going wrong went to the president directly with memos, and in person and to his chief of staff and said, we need to bring people in from the outside to launch this. And the president was protected, mostly by Valerie Jarrett, from doing anything.

And I guess one of the really sadder aspects of this is that nobody who knew what was going wrong spoke out and still hasn't spoken out, even in the aftermath of the whole thing being a total bust and for at least a year discrediting the whole notion that government could actually run a program.

GROSS: So you're saying Obama was protected by his own people from knowing what was going wrong?

BRILL: He was protected, but - you know what? - at the end of the day he's responsible. He kept getting reports; he kept getting all these green lights on his laptop of all, you know, on a grid - everything's going great, everything's going great. Literally the night before the launch, on October 1, his chief of staff called a friend of his and said, we're going to knock your socks off tomorrow. Well, he was right about that. But, you know, the president, you know, whatever we can say about him on policy and on giving speeches, as a manager, he failed. He did not know what was going on in the single most important initiative of his administration.

GROSS: There are several challenges now to Obamacare. There's challenges in Congress, there's challenges in the courts. Of all the challenges to all or part of Obamacare, which do you think poses the biggest threat to the program now?

BRILL: I don't think ultimately any of those challenges are threats in the sense that it will be repealed. I think the big challenge, and the one I really try to focus on in the book, is that there's going to come a point - it's going to be, you know, in the next few years - where something is going to snap. We cannot pay for this. We cannot pay for this. It is great that more people are getting health care, but we cannot continue to be a country where health care prices are 40, 50, 60 percent higher than they are in every other country where the health care results are as good or better than ours. It's just unsustainable.

So the only ray of hope I have is that Obamacare will force changes in the cost structure just because there are going to be so many more people buying health care that we'll just have to change the cost structure. That was sort of the implicit expectation that Governor Romney had in Massachusetts, which is if we enact this plan and give more people health care, then when they have it we'll see that we have to do something about the cost, and we'll get the political will together to do that. The question is does Washington today, tomorrow, next year, in five years - even in the face of, you know, daunting healthcare costs - will they ever be able to summon the political will to do something about it?

GROSS: So we started our conversation by talking about your experiences as a patient and the bills that you got when you had open-heart surgery. So now being an expert on the history of Obamacare, on billing practices and on being a patient, if you could make one change what would it be?

BRILL: Well, it would be three.

GROSS: OK.

BRILL: You take the people who provide the kind of care that I saw firsthand in my own situation, and you put them in charge. You let them expand. You let major hospital systems expand, and you let them provide their own insurance. I'd rather buy my insurance from New York Presbyterian Hospital in New York or Yale New Haven because that's a brand I trust. And then you regulate them like crazy to make sure that they live up to their promises, and you control their profits. And at the same time, you regulate the cost of drugs, and you provide significant malpractice reform.

GROSS: Well, Steven Brill, thank you so much for talking with us.

BRILL: Well, I was glad to do it.

GROSS: Steven Brill is the author of the new book "America's Bitter Pill." You can read an excerpt on our website freshair.npr.org. Coming up, rock historian Ed Ward recaps the career of rhythm and blues singer Barbara Lynn, who had the hit "You'll Lose A Good Thing." Her recent album collects her Atlantic recordings. This is FRESH AIR. Transcript provided by NPR, Copyright NPR.