Book Review: America's Bitter Pill

Brief Summary

In My Bitter Pill, Steven Brill details the Affordable Care Act (ACA) from its inception, through the depressing complexities of the lawmaking process and the fret-filled implementation. He introduces us to the personalities, interests, and alliances of the early authors of healthcare reform. We learn about the compromises that were needed to achieve the bill’s passage, and the obstructive dynamics in Congress that made compromise both impossible and essential. Brill traces how the failures of the most visible sign of the ACA, the Exchange portal, ran so far afoul of its goal, and introduces the nerdy heroes that saved the day.  

What was missing

The ACA was much bigger than just providing expanded coverage through the exchanges. While Brill acknowledges some of the extremely popular consumer protections that were included in the bill, I missed more recognition of various elements of the ACA that were less visible to the public. I don’t fault the author for this omission; these elements are less accessible to the mainstream reader, and covering all aspects of the ACA would require an impossibly long tome. That said, when Congress talks about overturning the ACA, there are a vast number of programs, protections, pilots, funding, and programs that would also cease.

My goal in reading this book was to fill in the pieces of a law that I was busy living through from an implementation vantage point. Instead, I found myself face to face with the challenges of the legislative process.

 My takeaway

I loved that Brill acknowledged the human side of healthcare and how the trade-offs in this industry are far more impactful than in virtually any other. He avoided the righteous platitudes that provide easy criticism without recognizing the true obstacles to alternatives.

I was one of thousands of healthcare industry warriors who were charged with transforming the ACA text into practice during the 2010s decade. I worked with a team who processed thousands of pages of regulation and then struggled to piece these rules into fruition with mismatched and outdated technology at health plans throughout the US. We experienced the thrills and misfires of the ACA all around the country – from navigator forums in rural South Carolina, to member-centered administrative challenges in New York City and the San Francisco Bay Area, to state legislative meetings in Wyoming and North Dakota, and risk adjustment infrastructure in Tennessee, Utah and Florida. Throughout, I believed that expanding coverage was a moral imperative, but I was also exasperated by the growing infrastructure and complexity we were creating.

Working with Democrats and Republicans throughout this process, I experienced a large gap between party politics at the national level. The know-how and commitment to goodness by people of all party affiliations who were implementing the regulations on the front lines was a stark contrast to the divisive language in the public sphere. It made me realize that the challenges were not party affiliations but politics itself. Reading this book strengthened my resolve that truly fixing healthcare will mean aligning with the unsung heroes in the industry who are ready to embrace the hard work of change. It will also mean working with those bringing skills, experience, and capital from outside the industry to drive change.

 Reducing healthcare costs for our country will mean reducing revenue for wealthy interests unwilling to let it go. The change we need will be resisted by those who benefit and also propelled by higher purpose.  

Recommend?  - Yes! It’s not too late to learn from the ACA

I was worried that reading this book so far past the enactment of the ACA would limit its relevance, but I was completely wrong about this. My goal in reading this book was to fill in the pieces of a law that I was busy living through from an implementation vantage point. Instead, I found myself face to face with the challenges of the legislative process. I am a strong advocate of universal coverage and believe that we have a moral imperative to do better than we currently are as an industry and for our country. After reading this book, when considering the ACA as a whole, I was left feeling wary of any government-driven solutions to our healthcare crisis and even more committed to radical collaboration as a path to change.

My Ratings

Engaging/Interesting - 4 stars - Although I was riveted, I’m not sure how much this detail would register with someone who wasn’t so deeply involved in the implementation of the ACA. I’m grateful for how deep Brill went with his explanations.

Compelling Purpose - 5 stars - In order to get healthcare right, we need to learn from past efforts to achieve universal coverage.

Relevance to Healthcare - 5 stars - Critical for anyone interested in industry-wide change. We all have opinions on the ACA – it’s best to be as informed as we can be about them.

Overall Recommendation - 5 stars - If you haven’t already read it, give it a read and then let me know what you think!


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Nancy Wise, Managing Partner, Spring Street Exchange

Nancy founded Spring Street Exchange because she wanted to be wholly free to work with like-minded individuals in striving to make healthcare how it should be, rather than the way it has always been. Her work in the industry has ranged from tiny, community-based nonprofit service organizations to billion-dollar insurers, and most things in between. She specializes in the intersection between big ideas and practical planning, which she believes can only be accomplished through radical collaboration and using a new set of tools. Her secret sauce is in leading strategic planning and visioning initiatives. 

Nancy has a master’s degree in Public Health and an MBA from the University of California at Berkeley and a BA in American Civilization from Brown University.  She is from both Pittsburgh and Alameda, CA, but now lives in Lexington, MA, where the shot was fired that was heard around the world.