Steven Brill’s latest book, America’s Bitter Pill, is a frustrating mix of excellent history and muddled health policy analysis. The book is a very good addition to the literature on the history of the Affordable Care Act and by far the best reporting I’ve read on the bungled implementation of the federal health insurance exchange. But Brill’s analysis of why the ACA cannot reduce health care costs is naïve and confusing. Brill claims a few smart men on the White House “economic team,” including Peter Orszag and Ezekiel Emanuel, fought hard to push “game-changing” cost-containment into the ACA but were defeated by others who were less interested in cost containment.
That explanation is wrong on two counts:(1)There was little evidence in 2009, and little today, to support the claims by Orszag et al. that the methods they promoted would cut costs;(2) The ACA in fact contains most of what Orszag et al. fought for.What Brill unquestionably gets right is his conclusion that the ACA cannot cut costs.