...Two of the book’s more powerful insights have to do with matters of industrial or bureaucratic structure. The first involves the health delivery system. Many people tend to look with alarm at consolidation in the insurance industry, and they focus on insurance company lobbying power as the essential cause of rising ­prices. One of Brill’s critical insights is how consolidation in the hospital industry has actually decreased insurer power relative to provider power: Much of the rising cost of health care comes from overcharging by hospitals, not insurers... The second insight has to do with the structure of management within the government. Brill argues that the initial website rollout failed in significant part because the “Office” in charge was demoted to a “Center,” in order to protect it from Republican funding cuts. In a wonderful passage, he recalls taking the train to Washington and reviewing his notes, noticing that when he asked different people who was in charge of establishing the federal exchange, he got seven different answers.

Why should the world care about what you are doing? Everyone is going to get sick and I think being able to be taken care of in a humane and effective way is really important. Our current system does it really poorly. I’ll give you an example: diabetes care. There is a new stat that people use for diabetes, it’s called perfect care. If you are diabetic and your blood-sugar is in control, your cholesterol is in control, your blood pressure is in control, you are taking an Aspirin and you don’t smoke we call that perfect care. If we can get people to do those five things, we dramatically reduce complications like blindness and kidney failure. Do you know what percentage of people in this country, even in the best medical centers, get this perfect care? It’s often under 10%. It is embarassing and we need to change that. I read that you allow patients to come in as often as they’d like. Absolutely. How will you manage a repetitive user who shows up all the time? We want people to come in to our practice. Again we are primary care. Our goal is that people come to us and not to the ER. Hospitalization costs $17,000, while a visit to us costs $60 to $80. You can do the math. Part of our model is getting it away from the doctor having to do everything. Today I think we focus too much on the doctor. If we want to have people improve their health care, we need to wrap a team around them. And the key to that team is what we call a Health Coach. A Health Coach? We are looking for people who really care to help people, people who are engaging and ideally who are from the community. Ideally they’ve had some experience with the health care system, either from a personal illness or a family illness, so they get how frustrating it is and they understand personally how they help someone go through it, and that’s it, everything else, we can train.

Obamacare isn't by any means a perfect law and not everything in it is going right. The law powers a different insurance market in every state (plus the District of Columbia), so it is perfectly possible for Obamacare to be a success in California even as there are troubles in Minnesota. And there continue to be operational issues: there have been troubling revelationsabout web site security, and problems verifying the incomes of some enrollees. On the whole, though, costs are lower than expected, enrollment is higher than expected, the number of insurers participating in the exchanges is increasing, and more states are joining the Medicaid expansion. Millions of people have insurance who didn't have it before. The law is working. But a lot of the people who are convinced Obamacare is a disaster will never know that, because the voices they trust will never tell them.