*** This review appeared in the November 2017 issue of BookBrowse.com ***

An investigation of the dangerous, expensive, and dysfunctional American healthcare system, as well as solutions to its many problems.

In the 1976 Academy award-nominated movie Network, newscaster Howard Beale tells his audience to rail against what their society has become. He says, "Things have got to change. But first, you've gotta get mad!…You've got to say, 'I'm as mad as hell, and I'm not gonna take this anymore!'" This could well be the rallying cry of Dr. Elisabeth Rosenthal's book, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back. I was angry by the end of the introduction and I challenge anyone who reads even a small portion of the book to feel differently.

Rosenthal states her premise in the first sentence: "In the past quarter century," she writes, "the American medical system has stopped focusing on health or even science. Instead it attends more or less single-mindedly to its own profits." She goes on to define the various parties involved in our healthcare system (insurers, doctors, hospitals, drug companies) and, using real-life examples and plenty of documentation, demonstrates how each has moved from a model dedicated to providing the best care possible to one primarily concentrated on the organization's bottom line – often to the detriment of the patient. Rosenthal informs her readers about abuses: how lobbyists have influenced government policies that benefit drug companies and insurers; how drug and device manufacturers skirt laws, take advantage of vagaries in regulations, and "game the system" to reap obscene profits; and how deceptive accounting practices lead to incomprehensible – and often inaccurate – bills that patients and insurers pay without question.

The book abounds with horror stories such as a woman with multiple sclerosis who's been driven into bankruptcy and poorer health because the medication that keeps her alive keeps getting more expensive, and the person who is in constant pain and can no longer walk because the manufacturer of her hip joint replacement used a loophole in regulations to avoid testing the device (the appliance "wasn't even put in a dog before it was put in humans.") The author also talks at length about the abuses heaped on the healthcare system by "Big Pharma," including their manipulation of patents to force people to purchase new drugs that are just as efficacious as older (but now deliberately unavailable) drugs (read how this is done, in the Beyond the Book); jacking up prices just because they can; and their spending billions of dollars a year on advertising that encourages people to insist on expensive treatments even if they're ineffective ("Ask your doctor if [insert drug here] is right for you!"). For example:

Jublia, a topical drug for toenail fungus approved in 2014, was advertised during the 2016 Super Bowl. A little bottle of the solution sells for between $550 and $650 and the full forty-eight-week course of treatment for all your toes costs over $20,000. But Jublia's cure rates are under 20 percent. Lamisil (terbinafine), a pill that does the same with a higher cure rate, costs under $20. Of course, that isn't mentioned in the ad.

The book becomes a litany of how the cards are stacked against patients, and it not only makes one angry but depressed and frustrated; by the end of the first section I personally felt rather hopeless and as if everyone in the medical industry was out to get me (or at least my life's savings).

Fortunately, Rosenthal also offers concrete suggestions on gaining more control over each part of the medical process. Under "Drug and Medical Device Costs," Rosenthal recommends learning all you can about the prescriptions you're taking. Some pills, for example, are a newer combination of two older drugs and you can save a significant amount of money if you're willing to take two pills instead of one. Also, check dosage; one person discovered after a huge increase in the cost of her prescription that it was considerably less expensive to purchase a higher dosage of the same medicine and cut the pill in half. The author goes on to write about "System Change" – concrete items we should be demanding from our lawmakers such as allowing the import of drugs from other countries and revamping the drug and device approval process. Also noteworthy are the appendices that include helpful tools such as links to price calculators for procedures and drugs; tools for vetting hospitals; and templates for letters protesting one's medical bills.

An American Sickness is truly a must-read book for every U.S. resident; it's incredibly eye-opening and informative, and has the potential for sparking reform given a wide enough audience. Rosenthal's crisp writing style makes the book eminently readable and even those not typically drawn to non-fiction will find it holds their attention. Book groups in particular will find lots of great fodder for discussion.

An American Sickness is a gripping, fast paced and revolting dive from 50,000 feet above into the morass of what passes for healthcare in the USA. Patients are barely tolerated in a system optimized to pass money from bank accounts to providers. The industry is mean, nasty and greedy, with worse results than comparable nations - for far more cost. Everything you feared is true, and there is much more in these 400 pages.

Because Rosenthal (an MD herself) was a columnist for the New York Times, she received thousands of contacts over the years. She researched them and they provide the vivid and shameful examples of financial abuse in the industry (with real names). She has distilled them into a perverse list of principles of US healthcare that explains everything and forms the backbone of the book:

1. More treatment is always better. Default to the most expensive treatment.
2. A lifetime of treatment is preferable to a cure.
3. Amenities and marketing matter more than good care.
4. As technologies age, prices go up rather than fall.
5. There is no free choice. Patients are stuck. And they’re stuck buying American.
6. More competition vying for business doesn’t mean better prices. It can drive prices up, not down.
7. Economies of scale don’t translate to lower prices. With their market power, big providers can simply demand more.
8. There is no such thing as a fixed price for a procedure or test. And the uninsured pay the highest prices of all.
9. There are no standards for billing. There’s money to be made in billing for anything and everything.
10. Prices will rise to whatever the market will bear.

As the American economy freefalls into dysfunction, doctors and nurses have become “independent contractors”, just like everyone else. They must look out for themselves first. Administrators are no longer senior caregivers but numbers people who must limit the poorly insured and maximize the profit on every square foot.

What becomes obvious is that the “market” system has failed utterly and completely. Health cannot be left to capitalists, be they doctors, hospitals or manufacturers. The rest of the western world and history are the proof: “If the March of Dimes was operating according to today’s foundation models, we’d have iron lungs in five different colors controlled by iPhone apps – but we wouldn’t have a cheap polio vaccine,” Rosenthal quotes Dr. Michael Brownlee. The incentives are all wrong.

An American Sickness is a public service. It gathers, for the first time I know of, the various scams used by the professions to jack up bills. It explains the why and the how of all those bills being so high. It is well organized, clear and it puts everything into perspective as part of a greater scheme. It identifies what to look out for, what to ask, and how to skirt the event horizon. Rosenthal provides really useful links and sample letters, because customers are all in this same situation – ignorant and powerless. I particularly like her examination of prices for the same procedures around the world. You can afford to have treatments elsewhere, because the costs are so much less, that you can throw in the travel – for two – and still come out well ahead. This book is worth far more than a month’s health insurance; it can save you a fortune, and give you back your life.

David Wineberg