Book Review: The Hospital by Brian Alexander

I recently finished reading the book titled The Hospital: Life, Death and Dollars in a Small American Town by Brian Alexander. The premise of the book is very interesting. It takes a detailed look at a hospital in rural America, Bryan, Ohio to be specific. The book touches on the challenges a small-town hospital from a financial and clinical perspective as well as the population health and economic challenges faced in a small, rural rust belt area. The book combines statistics with personal perspectives from the hospital’s CEO and CFO to the local patients and community leaders.

Overall, the book does a nice job of highlighting some of the challenges. Smaller hospitals have less purchasing power than larger hospitals. The economic base and insurance coverage of individuals in poorer areas makes hospitals have more financial challenges. A poor economy means that more individuals are unemployed/underemployed which leads to worse health behaviors, more depression and more chronic disease. The book’s strength’s are highlighting these challenges as exemplified based on the events that occur in a single hospital.

Where the book strays is towards the end where the author basically complains about the entire health care system and does not highlight really any positives or tradeoffs that need to be considered when considering changing such a system. The solution is basically to start over.

Well, you could blow up the entire crazy structure and start over. The United States could create a a national health plan, proposed over a hundred years ago. The government could go into the drug business to manufacture drugs that had gone off patent. It could regulate drug prices, especially for drugs that had been created with the help of taxpayer research money. It could shorten patent protection and ban copycat patents. Medical school costs could be slashed, especially for general practitioners and family practitioners. Hospitals could be funded with grants, and in return charge patients nothing: many hospitals, including CHWC already received most of their income from the government.

In short, the solution is to just cut costs and have the government run everything. Reducing patent rights for pharmaceuticals would cut costs, but in the long-run would be problematic as there will be fewer drugs. Cutting medical school costs will be tricky as well; when the quality of education decreases, will the care that patients do get suffer. Also, if patients aren’t being charged for services, who will pay? Typically hospitals aren’t deciding patient out-of-pocket costs, that is commercial insurers and governments. While this approach would reduce cost, it would greatly reduce innovation. Further the current federal government health care system–Medicare–already is adding 2% of GDP to the national deficit in 2022. In short, I am skeptical that just having the government run everything will be a promising solution.

Despite the challenges in terms of policy prescriptions, the book does provide an interesting take on the challenges of a small-town hospital and from that perspective is worth a read.

• Alexander, Brian. The Hospital: Life, Death and Dollars in a Small American Town.
  St. Martin’s Press. 2021, 320 pages.

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