Customer Reviews

Sick: The Untold Story of America's Health Care Crisis---and the People Who Pay the Price

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I can't recommend this book highly enough. At first glance, one might expect its structure to be gimmicky:

1. Interview someone who suffered because of our country's health-insurance system.
2. Zoom out from that person to explain the political and economic background to his or her suffering.
3. Zoom back in.
4. Repeat 2) and 3) a few times.
5. Move on to the next person and repeat from step 1).

Far from being a gimmick, I couldn't imagine a better narrative device. Jonathan Cohn combines the passion of a muckraking journalist with the erudition of a historian. His delivery is simple, unpretentious, and never cloying.

His conclusion is simple: health insurance as delivered by private companies doesn't work, because their incentive is always to cut services to the bone; the ideal hospital for an insurer is one that has no patients. The history of health insurance, as Cohn tells it, is the history of nonprofit corporations and idealistic doctors slowly getting replaced by for-profit corporations that destroyed the industry they were ostensibly meant to save.

Of course there's a way out; it's the way that every other industrialized nation uses, namely guaranteeing citizens the right to health care as a basic condition of citizenship. They spend far less than 16% of their GDP on health care, which is where the U.S. is today. The main obstacle to universal health care in this country is political. We overcame that obstacle in the Sixties and got Medicare and Medicaid; in Cohn's telling, they are models of efficient health-care delivery. (He says that surveys of the elderly, who are covered by these programs, find that they're more satisfied with their coverage than are young people in private insurance programs.) It will take a political change to bring us universal health care, but we've come close before. There's no reason we couldn't do it again.

Why this book is subtitled "The Untold Story of America's Health Care Crisis - And the People Who Pay the Price" is beyond me. Everyone has a story about the failure of our health care system or "non-system" and everyone is paying the price. Not only is it becoming more obvious by the day, almost every presidential contender is promising some kind of reform.

Jonathan Cohn of The New Republic has given us a number of revealing and disturbing case studies, each indicating system failure; and with each study he gives us some historical background as to how certain institutions - Medicare, Medicaid, managed care, employer-based health insurance, etc. - came to be. The historical background is good because is shows that there was no single policy or grand design behind our current mess; it is more a product of haphazard decisions made over a long period of time.

Let's look at some facts. America spends about $7,000 per capita on health care annually, about twice as much as the country in second place. Yet we are ranked 37th in health system performance, according to WHO. There is indisputably something very wrong.

Our system can best be described as a private, employer-based health insurance system. It started during World War II with the wartime freeze on wages. Companies started offering health insurance to attract and keep employees. And the rest, as they say, is history. Today we have Daimler basically giving away Chrysler because they have about $18 billion worth of health care liabilities. Every single worker is paying for about three retirees - and their families. Now, the only way Chrysler can keep employees is if they drastically reduce their health benefits.

So what's the author's solution? The first step in any serious reform would be to separate people's health insurance from their employment. Health insurance must be portable. The second step to any solution would be universal coverage. Everyone must be insured, those who cannot afford it must be subsidized.

There are two ways to get everyone insured: one is to make everyone buy private insurance, and the other is a single-payer system. The author leans toward a single-payer system as they have in France. One must remember a single-payer system is not "government-run" health care; hospitals and doctor's practices are still private, government is only the financing mechanism. Think of it as "Medicare for all." This is not an ideal solution, but it is better than our current fragmented system.

Private insurance is not working for two reasons: for one thing, it wants to shut out the sick and the poor - which is understandable since insurance companies are in the business of making money. The second reason is that administrative costs are about 30% - again, because they are in the business of making money. The administrative costs of a single-payer system are less than 2% - that would be Canada's. The problem with a single-payer system is that providers will tend to overprovide, since they know the government will pay for it anyway. To remedy this some controls would have to be put in place, such as strategically placed co-payments and deductibles.

The author is vague on how his modal of health care would work other than it being single-payer, and that there would be universal coverage. Critics may call it socialized medicine, which it is not, but with employee health care no longer burdening American business, capitalism would work more efficiently and more jobs would be created, or at least remain in this country. Under a single-payer system employers would be able to pay higher wages to cover what would be a higher payroll tax - yes, that would mean a higher FICA. Everyone would benefit from this system, except the insurance industry which would be missing their 30% of the $7,000 per capita in fees; but not to worry, they'll find other ways of making money. Single-payer insurance can save American health care, and it can save the country. This book does well in presenting the problem, but hesitates with the solution. Very good read, nevertheless.

The US health care system is not in good shape and this book suggests some of the reasons. 40% of US citizens with problems do not get care due to cost issues. Patient satisfaction is lower in the US than in Canada, the UK and many other countries with some form a national plan. The US spends more than any other country with worse overall results and lower rates of coverage in the population than any other industrial country. We spend less on preventive care as a percentage of expenditures than any industrial nation. In 2004, 35% of Americans believe that the US health care system needed fundamental rebuilding.

I could go on, but the clear FACT is that US health care is in bad shape and getting worse quickly for many, many Americans. What is the solution? A single payer system is a good start. Only those ideologically paranoid about government (anyone who still thinks that the current Administration in DC is doing a good job, that global warming is a hoax, and that abstinence only education works is probably in that camp) big pharmacy, big insurance, and affluent folks with good jobs and good insurance disagree. Creating competition on the basis of value (like reduced illness) rather than cost and risk shifting would be a second place to go.

Lots of countries have great single payer, national plans that do well. I have lived in some of these places (like Germany) and they are great. Most allow for supplemental and/or private plans at an extra cost (like Japan) but they provide a good base of care for all. Speaking of Germany, they pay about 35% of what we pay for drugs. Like I said, the current system works well... for big pharma!

Cohn's book give an excellent historical context for the problem. Greed, ignorance, narrow self-interest, and paranoid account for most of the causes. It is a bit short on solutions (look at Redefining Health Care by Porter and Teisberg) for a good start on that) but it is a good read, a tragic story, and an enlightening book.

Arguing that current American health care coverage policies continue growing woefully inadequate, Cohn's book relies on 'hard' statistics culled from the government and private sector itself. Layoffs, cumbersome 'pre-existing' condition rules and a conglomerate of other socioeconomic factors undermined America's ability to enjoy good quality of life.

He also includes sobering stories from and by people whose lives are damaged by lack of (adequate) health care insurance coverage. Their heart-wrenching stories, including from the family whose wife/mother ultimately succeeded in committing suicide just because she was unable to receive coverage and did not want to be a 'financial drain', contrasts starkly with the propaganda being put out by the multi-million dollar companies of smiling happy and secure Americans appearing to not care about much other than romping in fields. Seeing myself reflected in these testimonies, I found the book's 'personal touch' a powerful component because it defuses the lobby's ongoing contention that any healthcare reform would hurt 'ordinary Americans', when obviously it is the insurance industry themselves responsible for our current agony.

So, where are the flaws in this book if it starts out so strongly and advances a topic which is ever-more timely for so many Americans? For how passionately he argues against the current model, Cohn can't seem to provide detailed specifics on just what would be offer up Americans in comparison and how this alternative would work better than what currently exists. I came in on both the personal and political level wanting to like this book, and still agree with it's overall thesis, but feel let down that the author stopped 'prescribing' change just when it was getting to the really good stuff.

Granted, one can only see so far into the future on any one issue, but Cohn did not have to work from scratch on his pet issue. Because universal health care plans already exist in Europe, have gone on line in some American states, and vagueness dooms any proposed public policy to defeat, he inadvertently seals off the fate of his case after having argued for it. Having given the impression that he sincerely does believe in and want health care reform, I found this contradictory action troubling, Cohn already has me and other people on board; he just needs to revise this book to convince others that healthcare must be a fundamental right.

America's ever-present health care crisis makes this a still-necessary read for every one

Coming from a Scandinavian country, living in the US, and being a physician; this has been an interesting issue to me.

I think this book does a very decent job of clarifying some of the problems with having a for-profit-health care system. It does this through real-world examples of what happens to individuals caught up in the for-profit game. The examples are carefully chosen, and I think the author wisely avoids being overly sentimental or person-story oriented, but instead uses the examples for illumination of general points.

The hospitals, health insurers, and employers all need to make money, and ultimately, the only way to achieve that is for the customers (the potential patients) to pay, either directly or through taxation. In a for-profit system, there is a natural tendency for cost to go up, unless the users (patients) by free market principles can drive cost down by competition. Health care has not shown itself to be easily self-regulated by competition (save perhaps some simple, non-emergency surgical procedures), instead all the different players who want to make a profit will help cost spiral. The situation is exacerbated when cost spiraling is reflected in higher insurance premiums, which leads to fewer who can afford to partake, and the cost being shared by fewer.

One core question asked in this book is this: Why does the American health care cost 16% of GDP, more than twice that of the other Western countries. Many Americans think they have the best health care in the world. I wonder about that. At best, this is true for the 80% who are covered. Personally, I am also curious from a quality perspective. When all players, including the hospital owners and doctors are working for profit, the costs will have a natural tendency to go up. This means more tests, more procedures etc, which provides income for the providers (and expenses for the insurers who will try to defer that cost somehow). Costly malpractice suits probably also have something to do with the tendency to take tests 'to be safe'.

These tests and procedures may be way more costly than beneficial in a community perspective, and downright dangerous for some individuals. This is something a free-market healthcare may have difficulty regulating, since individual interest may sometimes do not coincide with the community perspective, but most importantly it can be very difficult for a layman to obtain the necessary information to make informed decisions with very complicated health care decisions; especially in case of emergencies.

Again, I think this book shows some of these dilemmas very well, with a balanced political perspective.


The only caveat I have with this book, is the lack of discussion about the one central problem facing all health care systems, regardless of whether run entirely privately, entirely by government or in some combination:

The inability of the health care system to measure its production.

Essentially all health care systems have one important similarity - all health care have to be paid for, either through direct taxes or indirect (health insurance premiums or a lower salary than could be the case if the employers did not have to provide coverage).

But, what are we producing in a health care system? This could vary vastly. Ideally we produce health. To do so, we make the highest quality decision about an individuals health issue at any given time. How do we measure the quality of all those decisions?

Quality in health care is difficult to define, and hinges on a large number of 'small' decisions, where what is right for one individual with a disease may not be right for another. The exact right dosage of a medicine, the combination, the length of a course of antibiotics, the length of observation time before an intervention, handling of complications, information to patient and relatives about the disease, cause, and prognosis, are all important aspects of quality (to name a few), yet we can barely measure them. Or, in some cases, the bureaucracy involved in actually measuring all the little nuances become prohibitively expensive.

Thus, although we are increasingly being able to measure cost, we are still (in any health care system I can think of) amateurs in actually measuring our production.

This is crucial, both since we should all care about getting the highest level of quality care possible and since what we should be willing to pay should match what we actually receive.


Anyway, I found this to be a timely book, helping me to better understand how the American health system works, how it got there (lots of good historical perspective), and some of the problems facing it now.

The book is excellent as far as it goes but the book stops just when it is getting started. The anecdotes are interesting and tragic. The author convincingly makes the case for universal health care but does not say how it might work, what it would cost or how it would be paid for. He claims that perhaps the best universal health care system is to be found in France. He does not give many details. One wishes he had included a detailed comparison of existing health care systems around the world say in Canada, Britain, France, Germany, Japan. He should write a sequel giving the needed analysis.

Jonathan Cohn, a Harvard grad, is a senior editor at The New Republic, contributing editor at The American Prospect and a senior fellow at the think tank Demos. He has also written for The New York Times, The Washington Post, Mother Jones, Rolling Stone, Slate and The Washington Monthly.

I found Sick to be an excellent primer on the U.S. health care system. The subtitle: the untold story of America's health care crisis - and those who pay the price, turns out to be the focus of this book (shocking, I know). I say this with a bit of sarcasm because of some of the reader reviews I've seen that either criticize Cohn for advocating for universal coverage (a topic he spends about 18 pages at the end of the book discussing) or for not throwing enough data, analysis and policy at the reader. This book is about average Americans trying to navigate a perverse and often baffling health care system.

Each chapter highlights a different city (from Boston to Deltona to Sioux Falls and Los Angeles) and a few of its inhabitants as they interface with doctors, hospitals, insurance companies and employers. Several reviews site the use of anecdotes as a weakness but I found them to be the just the opposite. Cohn's use of personal stories aims to engender empathy in the reader and it does so in spades. Each chapter also highlights a different aspect of the system from the history of employer-based health insurance to Medicare and Medicaid to the rise of managed care. The narrative switches back and forth between personal story to policy discussion, but does so in a way that flows naturally. Reviewer Abigail Zuger wrote of Cohn's style: "I suspect that committed policy wonks might find his analysis fairly basic, but for those of us without formal background in the area, it is a pleasure to have the whole drama laid out, act by act."

This book is neither a rant nor propaganda. Cohn is as objective as one can hope to be on the topic. Of the negative reviews I've read, I have yet to come across one that assails the author's investigations, analysis and ultimate portrayal of the health care system. Perhaps this is because Cohn devotes 53 pages to his sources and notes.

I highly recommend this book to anyone looking for a point of entry into the discussion of health care reform. This book has sparked my interest and has spurred me on to read more books on the subject.

The fact of the matter is that the US is the ONLY industrialized nation to treat healthcare as a purchased privelege, rather than a basic human right. The "Healthcare" system in the US is broken, and the truth is that millions men, women, and children are unable to access basic healthcare for the simple reason that they are poor. Furthermore, millions of WORKING americans do not have adequate healthcare coverage. But whether someone is working or not, if you believe that all humans have dignity and therefore entitled to basic human rights, then you must conclude that all americans deserve a quality of life that ensures basic healthcare. Marginalized populations, especially minorities, suffer disproportionately from the effects of being uninsured and the consequences of lack of healthcare. This is an issue of SOCIAL JUSTICE.

I doubt that anyone arguing against universalized healthcare is actually unisured. Only those who have the means to benefit from US healthcare voice their opinions against universal coverage.

Americans have some of the best doctors and healthcare in the world, IF you can access care. Furthermore, as Americans we have POORER health outcomes and spend MORE money overall on our healthcare system than other industrialized nations like Japan, Germany, France --nations that HAVE universal health coverage.

The privitized system of healthcare delivery has been an 80 yr. experiment that has FAILED miserably. It is time to consider other options.

Cohn has researched this issue for years, and this book presents the evidence as it is.

SICK by Jonathan Cohn is, thankfully, one of many books coming out these days about problems with our health care system in the United States. The style of the book is brilliant, since in the first eight chapters Cohn carefully examines various aspects of health care and uses case studies of people who fall through the cracks to illustrate problems that exist. As this book explains, we have excellent medical facilities in the U.S., but the terrible problem is that many people are denied consistent access to those facilities. Many of the people Cohn uses as case studies die because of lack of access. He provides enough detail about those people to make you see them as real people and thus to empathize with their plights, yet he also provides quite a lot of "technical" detail about health care. If, on the other hand, Cohn had focused totally on the technical aspects and policies, he would have lost everyone but the policy wonks. And if he had focused totally on personal stories, the book would not have been educational enough. Instead he strikes a very good balance between the two.

Another neat balancing act that Cohn performs involves solutions to our health care crisis. SICK mainly examines the situation with our health care system, and is not mainly about solutions. There are other books out there focusing more on that. Cohn deals with solutions only in the last chapter, which runs 17 pages. In that space, he clearly advocates a government-run universal health care system. He holds up France as a good model to emulate, where he says there is universal coverage, quick and easy access to care, and overall better results than we get. And yet the French pay far less than we do for health care, as does everyone else in the world! Cohn could have devoted more space to his proposed solution (maybe in a sequel?), but I believe his method of focusing on problems will convince more people of its prudence, since many Americans are opposed to more government intrusion in health care. Everyone who reads SICK must surely conclude that SOMETHING must be done to seriously reform health care in the U.S. If there is some better answer than government-run universal care, what is it, and why hasn't someone done it already? The burden of proof is on the nay-sayers.

Reform of the medical care system has been an ongoing debate in American society for many decades now, but renewed interest during the Presidential Primaries and Michael Moore's 2007 documentary film "Sicko" pushed the issue to the forefront of American politics. The resultant deluge of books on the topic have widely varied in terms of quality and what the author advocates as the solution to the problems inherent in the health care system. "Sick" was one of the first books out of the gate and is an unabashed polemic advocating for single-payer universal coverage offered by the federal government that takes a hard critical look at the existing system and particularly it's flaws, faults and drawbacks. Cohn paints a portrait of a system that is not only faltering, but is at times failing miserably. All of this has been documented almost ad nauseum elsewhere, but there is a clarity and cogency to Cohn's writing that helps to dramatize his arguments. And Cohn points out the flaws that exist in single-payer universal health care systems elsewhere, but makes a compelling argument that anything would be an improvement over our existing system. Cohn uses individual cases to illustrate the failures of the system and in doing so personalizes the argument in ways that many books fail to do. At the same time Cohn pulls back for the broader macro picture that helps to illustrate the broader benefits to the change he advocates.

But as with many of these polemics about the health care system "Sick" is either likely to re-enforce what you already believe or will fail to convince you to change your mind and rethink your position. Most Americans have already formed an opinion regarding health care reform or are downright fearful of change. Cohn seeks more to allay the fears of those resistant to change, but fear is a powerful emotion that the reasoned arguments of "Sick" may not be able to placate. While Cohn does make a compelling case for the single-payer universal health care approach it seems unlikely that enough Americans would be willing to embrace such a bold change as opposed to the more tepid and timid incrementalist changes. Furthermore, the complexity of the health care system in its present form is such that any drastic changes may have dire unintended consequences that may cause potential supporters to flinch. In the end Cohn makes a compelling case for his radical surgery as opposed to the tentative half-steps of reform. This is telling as there are few books out there touting reform of the existing system; clearly that tells you of the dysfunction that exists and only makes Cohn's argument that more persuasive. There also is no shortage of titles out there warning of what may come to pass if America goes the single-payer universal health care route, but most are not as well researched, as well written, or as persuasively reasoned as "Sick." Rather than appealing to fear and emotions Cohn appeals to the intellect and reason in a way that should persuade readers to reconsider their beliefs about single-payer universal health care coverage.