Скачать или смотреть [Review] The Hidden History of American Healthcare (Thom Hartmann) Summarized

The Hidden History of American Healthcare (Thom Hartmann)

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These are takeaways from this book.

Firstly, How employer based insurance became the default, Hartmann explains that the defining feature of United States healthcare was not inevitable. During the New Deal and postwar years, national health proposals from Franklin Roosevelt and Harry Truman faced a coordinated opposition campaign from business groups and the American Medical Association. While those efforts stalled, World War II wage controls created a loophole that allowed firms to offer health benefits to attract workers. When the tax code excluded those benefits from income, employer based insurance hardened into the national norm. Early nonprofit plans like Blue Cross gave way to commercial carriers that competed by avoiding sicker people rather than by improving care. The result tethered coverage to employment and economic cycles, leaving those who lost jobs exposed. Hartmann argues that this path dependence crowded out more equitable models and built a fragmented system of private risk pools, rather than a universal risk pool. He underscores how this choice still shapes access, affordability, and negotiating power across the entire sector.

Secondly, Nixon, HMOs, and the rise of managed profit, A pivotal turn arrives in the 1970s with the HMO Act and the normalization of investor owned healthcare. Hartmann details how managed care was sold as a way to control costs and coordinate services. In practice, financial incentives to deny or delay care expanded, and administrative complexity ballooned. The Reagan era intensified deregulation and antitrust laxity, fueling consolidation across insurers and hospital systems. Payment reforms like prospective payment and diagnostic related groups pushed hospitals to maximize billable codes and throughput. Private equity later targeted emergency departments, anesthesiology, and specialty clinics, optimizing revenue through surprise billing and facility fees. Hartmann links these trends to the rapid growth of Medicare Advantage and other privatized channels that skim public funds while narrowing networks and adding friction to care. The chapter shows how public programs were not expanded as public goods but increasingly outsourced to financial intermediaries, embedding a profit first logic in the core of coverage for seniors and low income groups.

Thirdly, Pharmaceutical power, patents, and price extraction, Hartmann devotes sharp attention to drug pricing as a case study in policy engineered scarcity. He walks readers through patent evergreening, pay for delay deals, and exclusivity periods that extend monopoly control far beyond the spirit of innovation rewards. Pharmacy benefit managers sit between manufacturers and insurers, extracting rebates that often fail to reach patients at the counter. Congress barred Medicare from negotiating drug prices for years, which amplified list prices and shifted costs to taxpayers and patients. Examples like insulin and EpiPens illustrate how life sustaining products can see repeated price hikes unmoored from research costs. Hospital formularies, group purchasing organizations, and opaque supply chains further obscure true costs. Hartmann argues that these structures turn illness into a revenue stream by design, not accident, and he outlines reforms such as public manufacturing of essential generics, compulsory licensing for abuse of monopoly power, and direct price negotiation to re anchor markets around public health rather than shareholder value.

Fourthly, Race, class, and the politics of division, One of Hartmanns central claims is that racial politics repeatedly blocked universal care. He recounts how segregationist lawmakers fought national health insurance to avoid integrated hospitals and clinics. Even Medicare and Medicaid required civil rights enforcement to desegregate facilities. Later, block grants, work requirements, and narrow eligibility rules kept safety net programs thin and stigmatized. In the modern era, many states refused Medicaid expansion, leaving coverage gaps concentrated among low income workers and communities of color. Hartmann connects these choices to broader patterns of environmental inequality, redlining, and labo