America's Bitter Pill:

Money, Politics, Back-Room Deals, and the Fight to Fix Our Broken Healthcare System

By Steven Brill

Random House. 528 pp. $28

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Reviewed by Robert I. Field


Obamacare's story could form the plot of a gothic novel. Supreme Court Justice Elena Kagan called it "a never-ending saga" during its last trip to the court three weeks ago. The twists and turns, political intrigue, and cast of characters make for a narrative as engrossing as any work of fiction.

If only it were.

Steven Brill tells the epic tale lucidly and engagingly in Bitter Pill: Money, Politics, and Background Deals in the Fight to Fix Our Broken Healthcare System. It begins in 1912, when former President Teddy Roosevelt first raised the cry for universal health insurance. Over the following century, a parade of presidents heard the siren call of a legacy of guaranteed health coverage for all, only to fail in the face of strident opposition.

The debate took an important twist in the 1970s, when President Richard Nixon proposed a private market alternative to a government-run approach and launched a shift in thinking. In the late 1980s, the conservative-leaning Heritage Foundation developed the idea into a detailed plan that restructured the private insurance market around a mandate that every American maintain coverage.

Gov. Mitt Romney adopted it as the basis for his 2006 health-reform initiative in Massachusetts, which liberals love to call Romneycare. Its perceived success led Democrats to appropriate the central elements as the basis of Obamacare.

Brill makes much of the irony of Obamacare's origins in Republican, market-based ideology, with numerous reminders of the close links between the health-care philosophies of the two men who fought so bitterly for the presidency in 2012.

As we now know, Democrats' hopes that adopting a Republican plan would ease passage didn't quite work out. Republican resistance started as strident and became fierce and monolithic. The heart of Brill's story is the maneuvering to pass the law without a single GOP vote.

And then Ted Kennedy died. The Massachusetts senator's death lends the tale an irony of near-biblical proportions, as the Democrat's messianic voice for universal health care for nearly 40 years was stilled by a brain tumor just as redemption stood at hand. When Democrats lost their 60th Senate vote - needed to prevent a GOP filibuster - when Republican Scott Brown won a special election to fill Kennedy's seat, the strategizing became all the more intense, leading to much of the clumsiness and complexity of the law that emerged.

Still, the real sausage-making took place not over politics but over the deals with industry that ultimately made passage of Obamacare possible. Brill recounts in meticulous detail the negotiations between congressional Democrats, the Obama administration, and a variety of health-care industries that paved the way for their support. Each had much to gain from the millions of new purchasers of health coverage and users of care the law would bring. Each exacted a price for signing on.

And the drama continued to escalate. Brill's narrative is especially strong in recounting the website disaster that marked the launch of the law's centerpiece, the insurance exchanges. He provides an insider's view of the bureaucratic mismanagement that led to it and the unheralded heroics of a team of millennial technology geeks who came to its rescue.

To bring his inside-the-beltway saga closer to home, Brill weaves in stories of ordinary people caught up in the maze that is our health-care system.

There is the woman with a preexisting medical condition who must work a second job just for the health benefits; the couple left with crippling debt by their policy's coverage limit; and the woman who receives an incomprehensibly huge hospital bill that even a senior hospital executive could not explain.

He adds to the mix his own recent health-care encounter: emergency heart surgery. His experience vividly demonstrates how abstract policy issues take on a very different hue when one's own life hangs in the balance. Suddenly, no expense seems worthy of being spared, belying the dream that market forces alone can bring costs into balance.

The book's one weak spot is the prescription for change at the end. Brill calls for restructuring health care around large integrated systems, along the model of the Cleveland Clinic and the Geisinger Health System in Pennsylvania. This is hardly an original idea. In fact, Obamacare includes several provisions to promote that very goal, a point he fails to mention. His treatment of the approach is largely superficial and neglects some of the most significant pitfalls.

But this shortcoming does nothing to detract from the value of Brill's definitive account of Obamacare's gestation and birth, and the place of this saga in America's unique health-care history and politics. If you want to understand what Obamacare is, why we have it, and how it will affect us, this is the place to look.

Robert I. Field is a professor of law and public health at Drexel University and author of "Mother of Invention: How the Government Created 'Free-Market' Health Care." He anchors the Field Clinic health-policy blog, www.philly.com/fieldclinic.