In a piece in Washington Monthly, Phil Longman of Open Markets Institute highlights how monopoly power in health care compromises public health and threatens democracy in reviewing Brian Alexander’s new book, “The Hospital”.

Hospitals are among the most opaque institutions in American life. Few allow their doctors to talk to the press except in the hovering presence of “handlers.” Though they often employ cadres of “communications specialists” who pitch reporters with puff pieces, most are obsessed with keeping their finances and internal operations secret.

The first remarkable thing about Brian Alexander’s new book, The Hospital, is that he managed to pull off an exception to this seeming iron law of U.S. health care. He never explains exactly how, but in early 2018 he persuaded the CEO and board of a small, community hospital in rural Bryan, Ohio, to give him fly-on-the-wall access to their struggling institution—and complete freedom to write up what he witnessed.

For the next year and a half, Alexander attended long rounds of anguished and divisive strategy sessions. Administrators and board members fought with consultants and each other over how to bring in enough revenue to avoid having to shut down or sell out to a big hospital chain. As Alexander became embedded in the hospital’s day-to-day operations, he gained the confidence of harried doctors and nurses, as well as patients and their loved ones.

Alexander’s previous book, Glass House: The 1% Economy and the Shattering of the All-American Town, was about the economic decline of his hometown of Lancaster in central Ohio, so he had some advantages in penetrating Bryan’s tightly knit social networks. His career as a journeyman feature writer for publications like The Atlantic and Outside also left him practiced in capturing small but unforgettable details about the many different characters he met in Bryan. 

In one plot line, Alexander traces the tragic arc of a local man named Keith Swihart. When in his early 20s, Swihart faints while working on an assembly line at an auto parts factory. Diagnosed with type 2 diabetes, he often goes without the insulin his doctor prescribes because even with company-sponsored insurance he can’t afford it. Then, in the 10 years following the Great Recession, Swihart faces a series of layoffs and crappy jobs with ever-lower wages and ever-higher-deductible insurance. The grinding downward mobility leaves him and his family exposed to such high medical costs that they can’t afford even routine health screening. Swihart loses his wife to cervical cancer, which wasn’t caught until it was too late. Then, as a grieving widower and single dad, he winds up losing his eyesight and enduring an amputation in the hospital after complications from his poorly managed diabetes land him in the ER. 

But Alexander does not let the sad story end there; he also shows how the amputation affected the local pathologist, who was left to deal with Swihart’s discarded body parts. “Shannon Keil opened the cottage cheese tub containing Keith’s toes and part of his foot,” he writes. “Corruption had invaded the tissue, seeped into the bones, oozed its way up the metatarsals until they became pliable, decayed, and no longer able to support a man.” Alexander uses this image as a symbol for the entire U.S. health care system. “What a fucking failure,” he later quotes the pathologist as saying, explaining that she didn’t mean Swihart or the medical procedure, but the malevolent “forces” within our health care system and beyond “that had swept his toes into that small tub.” 

Alexander’s understanding of just what those forces are and how they operate beneath the surface of events is the second most remarkable thing about this book. While it takes talent and enterprise to go out into the hinterlands and bring back stories full of pain and pathos, plenty of literary journalists have done that. But Alexander also brings to his writing a deep understanding of the larger economic, political, and social trends that are slowly crushing the lives of the people he met in Bryan, and of people like them all over this country. In his telling, Bryan becomes a microcosm of American sickness in all its dimensions.

Read the full piece in Washington Monthly here.