Hospital City, Health Care Nation: Race, Capital, and the Costs of American Health Care (Politics and Culture in Modern America)

“The problem is much worse than most Americans understand. It is not simply a matter of replacing private insurance with a public system.”

“Hospitals are a key source of the U.S. health system’s excessive costs relative to other countries.”

Guian McKee’s encyclopedic analysis of the range of special interests that would be harmed by health care cost reduction calls for antacid. Hospital City, Health Care Nation: Race, Capital, and the Costs of American Health Care shows us why reformers have been unable to overcome powerful hospital and other healthcare lobbyists to enact meaningful system-wide reforms. “Where a person lives and how much they earn affects where they are treated and the quality of care they receive.”

Sparing the reader some of the economic wonkiness, market failures, and consumers lacking complete information, he postulates that higher prices Americans pay for health care are because the providers can get away with it. No one has been able to effectively challenge that pricing power and since the Affordable Care Act of 2010, hospital power has consolidated further. Competition has not served as a check on inefficiency, and the promotion of this theory is frequently foisted on the public by elected officials. U.S. health care is indelibly tied to the history of capitalism since the 1960s. The Hill-Burton Act enforced Jim Crow provisions in health care disparities, reinforcing segregated care.

This dense treatise focused much of the text on Johns Hopkins in Baltimore, revealing how the expansion of the hospital completely obliterated African American housing not just once, but multiple times.

In the current trash talk of electoral politics, the inference is that the idea of national healthcare was hatched by the Democrats, often referred to as socialists, but were promoted by everyone from Goldwater to Nixon. Medicare was a goldmine for hospitals and represents a compromise on Barry Goldwater’s Better Care bill. Originally it was to cover the poor and seniors, but powers that be grifted from the low-income folks, deigning it a handout. And it wasn’t until 1970 that medically needy people were afforded Medicaid.

Although McKee gets into the tall weeds of minutiae, The Hospital Metropolis chapter provides a good summary of healthcare reform issues. Robert Heyssel’s clarity on the mission of Hopkins Health Care is a perfect rallying cry for national healthcare. “I happen to believe that to move in the direction of a system of accessible, quality, efficient, equal as far as possible and economical care for everyone—regardless of former or present status, regardless of socio-economic status, regardless of place of residence, or of color—should be our goal as a medical center as well as the goal of the nation.”

In the chapter, Hospital City and the National Health Insurance Struggle, McKee does yeoman’s work explaining the trajectory for ever increasing hospital costs due to inefficiencies in care delivery and poorly aligned incentives from policymakers. This is the chapter where he shows Nixon’s push for national health insurance, with three components: free care for the poor, with subsidies for those with higher incomes, and National Health Insurance Standards (mandates for employers). Unfortunately, he promoted cuts in Medicare to fund care for the poor. Ultimately Watergate killed this healthcare reform moment. And nearly 50 years later the U.S. remains the most expensive nation on earth for health care while lacking a national healthcare plan.

McKee’s Hospital City, Health Care Nation pulses with “yikes” moments as he unravels the gordian knot of national health policy and its adverse effects on those subject to American health care. Yet his chapter on Maryland’s Health Services Cost Review Commission should be a standard for all states, for it continues to have the lowest hospital costs in the nation. Maryland’s “all-payer cost-control model”  works. It is here that McKee’s analysis sings clearly outlining three aspects to an effective state model for cost control.

Though academic in nature Hospital City, Health Care Nation pulses with political intrigue, who knew Ted Kennedy torpedoed President Carter’s national health plan? And then spent the rest of his life trying to get his own national health plan passed. Obama’s Patient Protection and Affordable Care Act was the first major healthcare act since Medicaid was created.

For policy analysts and policymakers there is so much to like about this book, an exceptionally thorough and mostly readable treatise on the history and current state of dissonance in U.S. health care.