time magazine - january 19, 2015

THE SURPRISING SOLUTION FOR FIXING OUR

HEALTH CARE SYSTEM

BY STEVEN BRILL

J A N U A R Y 1 9 , 2 0 1 5

t i m e . c o m

WHAT I LEARNED FROM MY $190,000

OPEN-HEART SURGERY

on the cover: Time photo-illustration. Medical tray: Fuse/Getty Images

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BRIEFING

13 Verbatim

14 LightBoxA capsizing cargo ship is run aground near the Isle of Wight

16 World A deadly terrorist attack targets a satirical newspapers ofce in Paris

18 World Foreign-affairs col-umnist Ian Bremmer maps global conicts brewing for 2015

20 NationA new lawsuit revives a high-prole sex-crime case

22 Health Is the prevention of most cancers out of our control?

25 MilestonesBill Clinton remembers Mario Cuomo

COMMENTARY

30 ViewpointWalter Isaacson on building a safer Internet

THE CULTURE

60 BooksA survey of the best young-adult literature of all time, including Top 10 lists of the best books for preteens and tweens and recommendations from Gillian Flynn, Michael Lewis and more

Plus, novelist Meg Wolitzer on taking inspiration from Sylvia Plaths The Bell Jar

68 The Awesome Column Joel Stein tries out hosting Americas Funniest Home Videos

vol. 185, no. 1 | 2015

The U.S.s total health care bill for 2014 was $3 trillion, bolstered by fees for MRIs, CT scans and X-rays. Photo-illustration by Ann Elliott Cutting

FEATURES

34 Fixing ObamacareHow letting hospitals run their own

insurance companies can bring down health care costs for everyone by Steven Brill

44 Strange BedfellowsInstability across the Middle East has

prompted promising conversations among Israeli and Arab ofcials by Joe Klein

52 Marching On A timely lm brings Martin Luther

King Jr.s civil rights struggle in Alabama to the screen by Daniel DAddario

Plus: A review of Selma by Richard Corliss

TIME (ISSN 0040-781X) is published weekly, except for two issues combined for one week in January, May, July, August, September and December, by Time Inc. Principal Ofce: Time & Life Building, Rockefeller Center, New York, NY 10020-1393.Periodicals postage paid at New York, NY, and at additional mailing ofces. Canada Post Publications Mail Agreement No. 40110178. Return undeliverable Canada addresses to: Postal Stn A, P.O. Box 4322, Toronto, Ont., M5W 3G9. GST #888381621RT0001 2015 Time Inc. All rights reserved. Reproduction in whole or in part without written permission is prohibited. TIME and the Red Border Design are protected through trademark registration in the United States and in the foreign countries where TIME magazine circulates. U.S. subscriptions: $49 for one year. Subscribers: If the Postal Service alerts us that your magazine is undeliverable, we have no further obligation unless we receive a corrected address within two years. Postmaster: Send address changes to P.O. Box 62120, Tampa, FL 33662-2120. CUSTOMER SERVICE AND SUBSCRIPTIONSFor 24/7 service, please use our website: time.com/customerservice. You can also call 1-800-843-TIME or write to TIME, P.O. Box 62120, Tampa, FL 33662-2120. Mailing list: We make a portion of our mailing list available to reputable rms. If you would prefer that we not include your name, please call, or write us at P.O. Box 62120, Tampa, FL 33662-2120, or send us an email at [email protected]. Printed in the U.S.

David Oyelowo as Martin

Luther King Jr. in Selma, page 52

time January 19, 2015 1

6 time January 19, 2015

LIGHTBOX James Nachtwey was moved to become a photojournalist by the searing images of Americas civil rights movement, so his recent undertakingphotographing scenes on the set of Selma for Paramount (see one above)was stirring. There were moments when I felt I had traveled back in time, he says, yet many of the emotions that fueled the historical event were still very much alive. To see Nachtweys images, as well as a video interview with Selmas director and star (right), visit time.com/selma.

Please recycle this magazine and remove inserts or samples before recycling

Customer Service and Change of Address For 24/7 service, please use our website: time.com/customerservice. You can also call 1-800-843-8463 or write to TIME at P.O. Box 62120, Tampa, FL 33662-2120. Back Issues Contact us at [email protected] or call 1-800-274-6800. Reprints and Permissions Information is available at the website time.com/time/reprints. To request custom reprints, email [email protected] or call 1-212-221-9595, ext. 437; for all other uses, contact us by emailing [email protected]. Advertising For advertising rates and our editorial calendar, visit timemediakit.com. Syndication For international licensing and syndication requests, email [email protected] or call 1-212-522-5868

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Write to us

NOW ONTIME.COM

In an exclusive interview with

TIME.com, Ford CEO Mark Fields says the world is not yet ready

for self-driving carsdespite advances in

technology and a proliferation of newly announced options

from other automakers. Read more at time.com/

fordinterview.

Selma director Ava DuVernay, left,

and lead actor David Oyelowo

LIFE The Consumer Electronics Show, which this year featured Bluetooth-equipped baby paciers, has come a long way from its earlier incarnation as the International Gadget and Invention Show. See images from LIFEs coverage of the 1958 exhibition, including this foot-propelled hammock, at time.com/gadgets1958.

this weeks cover story marks the culmination of Steve Brills extraordi-nary journey through the landscape of American health care. He rst launched this expedition for the 2013 story that became one of our best-

selling covers, Bitter Pill, a riveting and often infuriating autopsy of hospital costs. In subsequent stories, he explored the terrain as a reporterbut took a harrowing detour as a patient, winding up in New YorkPresbyterian Hospital for open-heart sur-gery to correct a potentially deadly aneurysm.

Steves discoveries now come together in his new book, Americas Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System,from which this weeks story is adapted. The Afford-able Care Act, he argues, is a case study of a dysfunc-tional government trying to take on a dysfunctional health care system. The more I looked behind the point I made at the tail end of the rst Time articlethat Obamacare didnt seem to do much about all the pricing abuses I had identiedthe more I realized that this was the overarching story of how Washing-ton really works, he says. We have become a coun-try where money seems to govern almost everything in Washington, and those interests that enjoy the most power and money, often abusively, will be able to protect their positions.

His experience as a patient brought the vast, sub-merged forces in this debate to the surface: namely the power of fear and emotion when it comes to a health crisis. You can have a deep belief in the efciency of markets and still doubt whether your own health, or the health of someone you love, is suited to negotia-tion or bargain hunting. Steve proposes a solution that does not require a change in human nature or the current state of U.S. democracy. Let that be the start of the next national conversation: Now that coverage has been expanded, what would it really take to con-trol the costs?

Americas Bitter Pill

Nancy Gibbs, editor

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BECAUSE SOMEDAY

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THE TOP 100 PHOTOS OF 2014 TIMEs picks reected a wide spectrum of emotion, according to Today.com, including Derek Jeters jubilant leap after his game-winning last at bat at Yankee Stadium against the Baltimore Orioles (second row, right) and a haunting closeup of a young Afghan refugee (second row, left). BBC News, in particular, was taken by Massimo Sestinis astonishing aerial photo of migrants crossing the Mediterranean Sea in a jam-packed boat (top left): From a distance it looks like a sh, with colorful scales. But look closely and you see that it is a boatpacked so tightly with people looking up that you cannot actually see the boat ... like when a child sprinkles a piece of cardboard with glitter. Meanwhile, on MSNBC, panelist Ayman Mohyeldin called out a lighter entrythe now famous Oscar seleand debated the merits of seles with TIMEs Belinda Luscombe. Is it cheating to use a sele stick? he asked. To see the full list, visit time.com/photos2014

What You Said About ...TWIN SPACE PIONEERS A guys gonna go up in space for a yearwhy? asked Joe Scarborough on Morning Joe in a discussion of Times Dec. 29Jan. 5 cover story on an up-coming NASA mission that will send Scott Kelly into space for a yearthe

longest period ever for an Americanwhile his identical twin Mark is monitored at home on Earth. On Chicago radio, writer Jeffrey Kluger addressed the experiments possible physical and mental strain, including third-quarter effect, or the fatigue and depression that can set in before the end of such an arduous period of relative isolation. Readers were im-pressed. I salute both of these intrepid men, wrote Mike Moore of Warsaw, Mo. But Thomas McGugan of Jacksonville Beach, Fla., thought NASA could do better by the astronaut: I was shocked and a bit sad-dened to see the condition of Scott Kellys suit, includ-ing rust on the helmet lock ring and connectors that belong on a 63 Rambler.

RAND PAUL ON CUBA The Kentucky Senators Time .com essay celebrating the Obama Administra-tions recent moves toward engagement with Cuba sparked heated debatenot least between Paul and fellow GOP star Marco Rubio, who cri-tiqued Paul as a cheerleader for Obamas foreign policy. On Time .com, commenter MatthewKilburn supported incremental steps toward engagement but wrote that the manner in which the Presidentand apparently, Rand Paulis so willing to wash away any restriction on that country, and in doing so enrich the current authorities while emptying our current tool kit of any future available carrots, is foolish. RicardoRivera disagreed: We must move away from outdated policy that harms the Cuban people more than it will harm those in charge of Cuban politics.

THE TEDDY AWARDS Joe Kleins annual shout-outs for the politicians who showed the most courage

included President Obama for his moderate, sane and humane policies (despite some considerable missteps). Critics pounced. What an ugly 8 years this will have been! wrote D. Wymard of Fort Lauderdale, Fla.

In his own words (needless unforced errors, negligent foreign policy) Klein castigates Obama, and yet turns around and awards the Teddy. Rather hypocritical!

ConversationB

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Briefing

I am very proud of all the employees ... who stood up against some of the extortionist efforts of the criminals.

KAZUO HIRAI, Sony CEO, speaking for the rst time about the devastating hack of Sony Pictures Entertainment that prompted the studio to pull, but then eventually release, The Interview following threats of 9/11-style attacks on theaters that screened the movie

We have just been hit

at the heart of our liberty.

They were disrespectful

to the families who

lost their loved ones.

BILL DE BLASIO,

New York City mayor, on the police ofcers

who turned their backs on him during funerals

for slain colleagues. De Blasio has feuded with cops who say he

failed to support them during protests against

the use of force

SERENA WILLIAMS,

tennis player, on the cup of miracle

coffee she requested after losing, 6-0, the rst set of a match

at the Hopman Cup in Australia.

Williams went on to win the next two sets

and the match

ANNE HIDALGO, mayor of Paris, after gunmen killed at least 12 people at the ofces of the satirical newspaper Charlie

Hebdo, in a terrorist attack on Jan. 7 that shook France

20The number of new

Cardinals chosen by Pope Francis, none from the U.S., as he diversies

Catholic Church leadership

46 millionThe number of people Starbucks says received gift cards for the

coffee chain during the holidays, about 1 in 7 Americans

HE SOMETIMES

CALLS ME BRO.

DAVID CAMERON, British Prime Minister, describing his close

relationship with U.S. President Barack Obama

The number of miles (3,900 km) traveled

by a lost Seattle puppy named Penny,

who ended up in Pennsylvania before her microchip was

scanned and her owners located

2,400

I just asked them to get me

a shot of espresso.

BrisketPrices for the

barbecue meat have surged amid rising

demand and a cattle shortage

McNuggetsSales in Japan were halted after vinyl was found in one

of the McDonalds chicken bites

GOOD WEEK

BAD WEEK

THE WEEKTERROR CAME

TO PARIS

Sources: New York Times (2); Daily Mail; ESPN; Reuters; Wall Street Journal; AP

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time January 19, 2015

LightBoxBrieng

FOR PICTURES OF THE WEEK, GO TO lightbox.time.com

Photograph by Peter MacdiarmidGetty Images

A Tactical TiltThe cargo ship Hoegh Osaka, which was

carrying 1,400 cars, was deliberately grounded on a submerged sandbank near the Isle of Wight in England on Jan. 3 in

order to keep it from capsizing. All 25 crew members were rescued overnight.

Brieng

the french, who have seen two devastating world wars and a revolution on their soil, are known for keeping cool heads in the face of tragedy and violence. Yet little could have prepared them for the gruesome events of Jan. 7. It seemed a gray, rainy Wednes-day like any other, until two gunmen wearing black ski masks stormed into the ofces of the satirical weekly newspaper Charlie Hebdojust before midday, in Paris congested 11th district, and let loose a fusillade of bullets. Outside on the street they shot dead a police ofcer and ed in a black car driven by a third mana horrifying sequence of events lmed by a witness and seen around the world.

The men killed 12 people in the attack, among them three of Frances best-known cartoonists, the papers top editor and two police ofcers. Rushing to the scene, Presi-dent Franois Hollande stood ashen-faced on the chilly sidewalk, some 3 miles (about 5 km) from his grand Elyse Palace, and appealed for the French to show we are a unit-ed country. This was an act of exceptional barbarity, he said, and declared the attack a terrorist operation.

The massacreFrances worst terrorist attack in memorywas something

else too: it was an act foretold.For months, French of-

cials have expressed concerns that the country was becom-ing increasingly vulnerable to a terrorist attack. Last month their nervousness appeared well justied, when two sepa-rate drivers rammed their cars into Christmas crowds in the provincial cities of Nantes and Dijon, injuring dozens of people, while a third attacker wielded a knife, shouting, Al-lahu akbar, or God is great.

Those car rammings now seem amateurish and opportunisticmore the work of lone-wolf terrorists acting without support. In contrast,

An Attack Foretold French RFLDOVZHUHconcerned even EHIRUHWZRJXQPHQVWRUPHGD3DULVQHZVSDSHUBY VIVIENNE WALT/PARIS

the men who mounted the Jan. 7 massacre worked like a well-drilled cell primed to in-ict maximum damage.

Their target was clear: Hard-line Islamists have threatened Charlie Hebdo for years for publishing countless caustic

commentaries and cartoons directed at extremist Muslims (as well as ultra-religious Jews and conservative Catholics). In 2011 Muslims rebombed Charlie Hebdos previous of-ce building in Paris amid widespread protests after the paper published an issue pur-portedly edited by the Prophet Muhammad, with a cartoon lampooning him. French people quickly assumed that the assault had been an act of retaliation against the papers antireligious stance.

The attacks ruthless ef-ciency shocked Parisians as much as the result. Arriving at the very moment Charlie

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Hebdos journalists were in their weekly editorial meet-ingthe only time the entire staff gathers in the build-ingthe two assailants sprang from their vehicle carrying automatic ries and wasted no time killing as many people as they could. They were well equipped, they had military weapons, they had probably bulletproof vests, French ter-rorism consultant Jean-Charles Brisard told the BBC after watching video footage from a closed-circuit security camera outside the building. These in-dividuals were well trained.

The attackers are precisely the sort of terrorists the French

government has most feared. With more than 5 million Muslims, France has the largest Islamic population in all of Europe. Many French Muslims emigrated from French-speaking North Africa or were raised as children of immigrants from those coun-tries. Their communities have been hard hit by years of reces-sion as France struggles with record-high unemployment now nearing 11%.

Some young French Mus-lims, disillusioned by the economic hardship and what they see as a French popula-tion increasingly hostile to outsiders, have looked abroad for direction and meaning, to the jihadist groups ghting in Syria and Iraq. French police believe about 1,200 French citizens have joined Islamist groups in Syria and Iraq since 2011by far the most ghters to have joined the jihadists from any Western country. French ofcials now fear that those ltering home might re-turn with professional military skills and a desireor even instructionsto harm France.

In response to the attack, Hollande quickly ordered Frances security threat raised to its highest level in years, while Interior Minister Ber-nard Cazeneuve vowed to hunt down the attackers so they can be punished with the se-verity that their barbarous acts are worthy of.

Those words sound reassuringfor now. And as darkness fell on Jan. 7 Parisians came together in mass gatherings to show their sympathy for the dead and to insist on their right to express themselves free of the threat of violence. But citizens and security ofcials alike know that unity will not necessarily deter future attacks.

Figures Who Were Literally Irreplaceable HUHVQRRQHLQ)UDQFHZKRFDQoOOWKHLUUROHBY CLAIRE BERLINSKI

Im a journalist but was only by chance in the vicinity of the massacre at the French satirical newspaper Charlie Hebdo. I was en route to visit a friend. This took me past the papers ofce and thus put me at the heart of the bloodiest attack France has seen in the past 50 years.

On my approach, it was immediately obvious that there had been a massive terrorist attack. Such attacks have a characteristic signature. Swarms of ambulances. Police vehicles and mobile labs. Grim-faced cops. Crime-scene tape stretching for blocks. A very particular expression on the faces of dazed and bewildered onlookers.

I asked the rst cop I saw what had happened. She was in no mood to explain: Youll see it on the news.

How bad is it?Grave. Not quite

translatable, but as bad as it gets will do.

France is in shock. The attack killed 12 people and injured several others critically, as of press time. The number of fatalities may rise. Masked gunmen attacked the papers ofce. But their object was not merely to terrorize. This is obvious, and let no one tell you otherwise. This was an attack on France. It was an outright declaration of war.

It was an attack on press freedom in particularon journalists, writers, cartoonists and intellectuals who were as well known here as Jon Stewart and Stephen Colbert are to Americans. They were known above all for their willingness to say whatever they damn well pleasedno matter whom they offended or how many death threats resulted. While their publication was best known for its parodies of Muslim

extremists, they were more than happy to say whatever they pleased about Jews and Catholics tooand never were that respectful, either. But only radical Islamists thought the proper rejoinder was simply to kill them all.

In December 2011, the magazines ofce was rebombed following an issue it claimed was guest edited by the Prophet Muhammad. Shortly before the latest attack, it tweeted a mildly amusing cartoon of the leader of the Islamic State of Iraq and Greater Syria.

The cartoonists who diedCharb, Cabu, Tignous, Wolinskiwere household names. Bernard Maris, known as Uncle Bernie, was an economist to whom the French have listened every Friday morning on the radio since the 1990s.

Le Monde, Radio France and France Tlvisions have lent their staff to keep Charlie Hebdo going, but France is not a big enough country to replace such gures readily. They were literally irreplaceable. This is true of every human being, of course, but they in particular lled a role no one else in France can ll.

In 2012, in an interview with Le Monde, Stphane Charbonnier, Charlie Hebdos director, was asked if he was tempted to tone down the publications inclination toward the inammatory.

It may sound pompous, he replied, but Id rather die standing than live on my knees.

It hardly sounds pompous at all. Especially given that this is precisely what he did.

Berlinski, an Americanjournalist and biographer, livesin Paris

17

1. THE BROKEN POLITICS OF EUROPEEuropean economics arent as bad as they were at the height of the euro-zone crisis in 2012, but the poli-tics of Europe are now far worse. Within key countries like Britain and Germany, anti-E.U. political parties continue to gain popularity, undermining the ability of governments to deliver on painful but needed reforms. Friction will grow among European states as periph-eral governments come to increasingly resent the inu-ence of a strong Germany un-checked by a weak France or an absent Britain. Finally, an angry Russia and the aggres-sive Islamic State of Iraq and Greater Syria (ISIS) will add to Europes security worries.

2. RUSSIASanctions and lower oil prices have weakened Russia enough to infuriate President

Vladimir Putinbut not enough to restrain him. Moscow will continue to put pressure on Ukraine, and as a result, U.S. and European sanctions will tighten. As Russias economy sags, Putins approval ratings at home will increasingly depend on his willingness to confront the West. Western compa-nies and investors are likely targetson the ground and in cyberspace.

3. THE EFFECTS OF CHINAS SLOWDOWNChinas economic growth will slow in 2015, but its all part of Xis plan. His histori-cally ambitious economic-reform efforts depend on transitioning his country to a consumer-driven eco-nomic model that will result in levels of growth that are lower but ultimately more sustainable. The continuing slowdown should have little impact inside China. But

Sea of Troubles H1HZ

5. ISIS, BEYOND IRAQ AND SYRIAISIS faces military setbacks in Iraq and Syria, but its ideological reach will spread throughout the Middle East and North Africa. It will grow organically by setting up new units in Yemen, Jordan and Saudi Arabia, and it will inspire other jihadist orga-nizations to join its ranksAnsar Beit al-Maqdis in Egypt and Islamists in Libya have already pledged allegiance to ISIS. As the militant groups inuence grows, the risk to Sunni states like Saudi Ara-bia, the United Arab Emirates and Egypt will rise.

6. WEAK INCUMBENTSFeeble political leaders, many of whom barely won re-election last year, will become a major theme in 2015. Brazils Dilma Rous-seff, Colombias Juan Manuel Santos, South Africas Jacob

Zuma, Nigerias Goodluck Jonathan and Turkeys Recep Tayyip Erdogan will each face determined opposition and formidable obstacles as they struggle to enact their political agendas.

7. THE RISE OF STRATEGIC SECTORSGlobal businesses in 2015 will increasingly depend on risk-averse governments that are more focused on political stability than eco-nomic growth, supporting companies that operate in harmony with their political goalsand punishing those that dont. Well see this trend in emerging markets, where the state already plays a more signicant role in the economy, as well as in rogue states searching for weapons to ght more power-ful governments. But well also see it in the U.S., where national-security priorities have inated the military-industrial complex, which now encompasses technol-ogy, telecommunications and nancial companies.

8. SAUDI ARABIA VS. IRANThe rivalry between Shiite Iran and Sunni Saudi Arabia is the engine of conict in the Middle East. Washington and other outside powers are increasingly reluctant to intervene in the region, while both countries struggle with complex domestic politics and rising anxiety about the ongoing negotiations over Irans nuclear program.

Brieng | World

Expect Tehran and Riyadh to use proxies to fuel trouble in more Middle Eastern coun-tries than ever in 2015.

9. TAIWAN/CHINARelations between China and Taiwan will deteriorate sharp-ly in 2015 following the oppo-sition Democratic Progressive Partys landslide victory over the ruling Nationalist Party in Taiwanese local elections this past November. If China decides that its strategy of economic engagement with Taiwan has failed, it might well backtrack on existing trade and investment deals and signicantly harden its rhetoric. The move would surely provoke public hostil-ity in Taiwan and inject even more anti-mainland senti-ment into the islands politics. Any U.S. comment on rela-tions between China and Tai-wan would quickly increase tensions between Beijing and Washington.

10. TURKEYLower oil prices helped, but President Erdogan used election victories in 2014 to try to sideline his political enemiesof whom there are manywhile remaking the countrys political system to tighten his personal hold on power. But hes unlikely to win the authority he wants this year, creating more disputes with his Prime Minister, weakening policy coherence and worsening political unpredictability. Given the instability near Turkeys borders, where the war against ISIS rages, thats bad news for everyone. Refu-gees from Syria and Iraq are bringing more radicalism into the country and adding to economic hardship.

Fallen star Turkeys Erdogan is one of a number of incum-bent leaders who will face strong rivals at home in 2015

Past approval rating

DilmaRousseff,

post-2010peak

RecepTayyip

Erdogan,2011

ShinzoAbe,2013

BarackObama,

post-2012peak79%

71% 67%57%

Brazil Turkey Japan U.S.

Current approval rating

56%51%

44% 43%

Rousseff,2014

Erdogan,2014

Abe,2014

Obama,2014

Brazil Turkey Japan U.S.


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GAY MARRIAGE In the latest sign of the nations growing acceptance of same-sex marriages, Florida became the 36th state to allow them on Jan. 6. The newly lifted statewide ban was enacted just six years ago with 62% of the vote.

CORRUPTION Former Virginia governor Bob McDonnell was sentenced Jan. 6

to two years in prison after being convicted on federal corruption charges. The onetime GOP rising star had been considered a potential presidential candidate. His wife Maureen, who was also found guilty of corruption, will be sentenced on Feb. 20.

DRUGS

300%The approximate increase in seizures of metham-phetamine at the California-Mexico border from 2009 to 2014. Authorities say the rise is the result of tighter U.S. laws that have restricted domestic access to meths key ingredients, leading more people to manufacture the drug south of the border.

HISTORY The contents of a package that Samuel Adams and Paul Revere buried in a cornerstone of the Massachusetts State House in 1795 were revealed by the Boston Museum of Fine Arts on Jan. 6. Thought to make up what could be one of the oldest time capsules in the U.S., the box included ve newspapers, 24 copper and silver coins, a seal of the Commonwealth and a silver plate possibly made by Revere. The most recent coins are from 1855, when the items were rst discovered, placed in a brass box and reburied.

The Rundown


Nation

From top: Prince Andrew, Alan Dershowitz and

Jeffrey Epstein

Settling Old ScoresA new lawsuit could revive a KLJKSURoOHVH[case BY MICHAEL SCHERER

the 13-page legal filinglanded at a Florida court-house on Dec. 30 with a bang. As part of a lawsuit ac-cusing the Justice Depart-ment of botching a major sex-crime prosecution, attor-neys Bradley Edwards and Paul Cassell, a former feder-al judge, laid out the shock-ing claims of their latest client, Jane Doe #3, who has been named elsewhere as Virginia Roberts. She said she had been kept as a teen-age sex slave by the wealthy American nancier Jeffrey Epstein. Cassells suit has the potential to both re-open the long-closed case and force the Justice Depart-ment to change the way it deals with crime victims during plea negotiations.

In the recent ling, Rob-erts said Epstein arranged for her to have sex with his friend Prince Andrew, the Queen of Englands second son, and trafcked her to nu-merous prominent American politicians, a well-known Prime Minister and others, including noted Harvard professor Alan Dershowitz, one of Epsteins attorneys. Buckingham Palace strongly denied the allegations, which had rst been hinted at in a civil lawsuit in 2009 and later in press reports that included a photograph of Prince An-drew with his arm around a teenage Roberts. Dershowitz

declared the accusations false and libelous and vowed to seek the disbarment of Cas-sell and Edwards. Cassell and Edwards, in turn, have sued Dershowitz for defamation. A representative for Epstein dismissed the accusations as old and discredited.

The truth of the claims has never been litigated before a court. That fact still motivates Cassell, a victim-rights advocate and law professor. Beginning in 2005, police and the FBI uncovered evidence that Ep-stein recruited an expansive network of underage girls, allegedly including Roberts, for paid sex. Prosecutors al-

lowed Epstein to plead guilty in 2008 to two state felonies, including soliciting a minor for prostitution. He was required to register as a sex offender and sentenced to 18 months in prison, of which he served 13. As part of the deal, prosecutors agreed to try to keep the settlement details off the public record.

Several of the victims, including those like Roberts who later settled civil law-suits against Epstein, were bothered by the leniency of the deal. This stinks to high heaven, says Cassell. Two victims sued the Justice De-partment for violating the 2004 Crime Victims Rights Act, which was meant to en-sure that victims are given a voice in criminal proceed-ings. In the Dec. 30 ling, Roberts and another victim asked to join the case.

If Cassell is successful, the lawsuit could eventu-ally overturn the initial settlement and change the way the Justice Department handles pretrial negotia-tions. Its a big case, says Meg Garvin, director of the National Crime Victim Law Institute.

In lings, the Justice De-partment has argued that Epsteins alleged victims had no right to consultation, since the case was settled before criminal charges were brought. After the law-suit began, Attorney Gen-eral Eric Holder issued new guidelines, directing pros-ecutors to make reasonable efforts to make such con-sultations anyway.

Cassell considers that a small victory but says he hopes his case will send the message that federal pros-ecutors cant keep victims in the dark.

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Most Cancer Is Out of Our Control Random DNA changes are usually to blameBY ALICE PARK

we think we know what causes cancer: smoking, the suns UV rays, tumor-causing genes we inherit from Mom and Dad. But these factors alone cant explain why cancer in its many forms is poised to edge out heart disease as Americas No. 1 killer within the next few years. That rise has sparked a spate of research into how much of cancer is within our control and how much of it is simply a roll of the genetic dice.

Now, in an eye-opening study published in Science, researchers report that the majority of cancer types are the result of pure chance, the product of random genetic mutations that occur when stem cellswhich keep the body

GLIOBLASTOMA The cells that cause this

cancer divide often, making many errors

OVARIAN GERM CELL A hard-to-treat cancer, its mostly the result of stem-cell DNA-copying errors

BASAL-CELL CARCINOMA

The most common skin cancer is triggered

by exposure to UV rays

LIVERRisk of this cancer

increases with age and heavy alcohol use

LUNGSmoking, and the

carcinogens in tobacco smoke, are the main drivers of lung cancer

MELANOMABecause skin cells divide so frequently, this cancer is among

the deadliest

PANCREATICThis cancer is strongly

affected by random mutations as opposed to

lifestyle factors

OSTEOSARCOMABone cells are actively

dividing, leading to many chances for tumor-

causing mistakes

Health

LIFESTYLE OR BAD LUCK? IT DEPENDS

ON THE CANCER

chugging along, replacing older cells as they die offmake mistakes copying the cells DNA.

Cristian Tomasetti and Dr. Bert Vogelstein at the Sidney Kimmel Com-prehensive Cancer Center of Johns Hopkins University School of Medicine found that the more stem cells there are in certain kinds of tissues and the more often they divide, the more likely that tissue is to develop cancer over a per-sons lifetime. About 65% of cancers are the result of these DNA mistakes made by stem cells.

Only a small proportion of a tissues cells are stem cells, which are essentially templates for making more tissue. The catch is that this kind of DNA copying is also the process behind cancer, which is triggered by cells that pick up muta-tions in their genes when they divide.

The element of chance does not, however, mean you should stop wear-ing sunscreen or take up smoking. My biggest fear is that people will do nothing. The opposite is true, says Tomasetti, who stresses that while we may not be able to prevent all tumors, we can focus on early detection and tak-ing advantage of lifesaving treatments like chemotherapy and radiation, among other things. We need to do everything we did before, but we want to do it even more than before.

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time January 19, 2015Source: Science

fortunedatastore.comTo nd out more, go to Copyright 2014 Time Inc. FORTUNE and the FORTUNE Database names are trademarks of Time Inc. All rights reserved.

The Fortune Databases give you everything you need: key nancial and company contact information in an easy-to-use spreadsheet...the ability to download, sort and mine the data...a roundup of the largest and most important companies to research, prospect and target.

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100 Best Companies to Work ForFortune Global 500

Mario Cuomos life storythe proud son of immigrants who raised him to believe in faith, family and work and to use his own gifts to enter public service and reach the pinnacle of New York politicswill always be inspiring.

But it is especially important to us today because he believed that every American, native-born or immigrant, should have the same chance hed had, and that that could only happen in a strong community with a com-passionate, effective government.

He deplored winner-take-all econom-ics and winner-take-all politics. He be-lieved to the end that our country could give anyone the chance to rise without pushing others out or down, and that at its best, the essential role of government is to give everyone a fair chance to rise.

He never believed government could replace strong families and individual initiative. The beautiful family he and Matilda created and the lives their

children have lived are more than enough proof of that.

He simply believed that without a hand up government, too many people would be left behind and our country would be diminished. Once an avid and able baseball player, Mario said in an interview for Ken Burns Baseball series, You nd your own good in the good of the whole. You nd your own indi-vidual fulllment in the success of the community.

Everything Mario Cuomo did was part of his passionate determination to strengthen the bonds of community, from his early efforts to address AIDS, to his support for mentoring and health care programs for children who needed them, to his initiatives to create more economic opportunities in upstate New York. For him the struggle to solve par-ticular problems was not interest-group politics but community building, mak-ing the weak links stronger.

He believed that he could do his part to build the more perfect union of our founders dreams. He did it with a politics like Lincolnswhom he so admired and wrote aboutbased on the better angels of our nature. He had a ne mind, competitive drive and unsurpassed elo-quence. While he loved to debate, often ercely, with reporters and opponents, he wanted his adversaries to have a fair chance to make their case.

That was never more clear than in 1993, when his thorny critic, the New York Post, hit hard times. As the Postgraciously said on Jan. 1, Mario Cuomo stepped in and heroically performed a one-man rescue mission . . . because he was convinced it was in New Yorks best interests, not necessarily his own.

As all the political world knows, I owe a great debt to Mario Cuomofor declining to run for President in 1992, then electrify-ing our convention with his nomination speech for me. I later wanted to nominate him for the Supreme Court, but he de-clined. I think he loved his life in New York and was content to be our foremost citizen advocate for governments essen-tial role in building a strong American community, living and growing together.

In all the years since, Mario Cuomo never stopped believing that, in our hearts, Americans dont want to be di-vided, driven by resentment and insecu-rity. He saw problems and setbacks as a part of the human condition, mountains to be climbed and opportunities to be seizedtogether.

Mario Cuomos America of com-munity, compassion and responsibility will live as long as there are people who believe in it as strongly as he did, who dene our success by the chances we give to others who have dreams and the deter-mination to chase them.

In his keynote address to the 1984 Democratic Convention, Mario said, We still believe in this nations future . . . Its a story . . . I didnt read in a book, or learn in a classroom. I saw it and lived it . . . Please, make this nation remember how futures are built.

That memory is Mario Cuomos lasting gift to us.

Clinton is the 42nd President of the United States

Mario Cuomo, who died Jan. 1 at 82, at a New York hotel in 1986

DIED

Mario Cuomo New York governor, presidential hopeful, liberal lionBy Bill Clinton

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the internet was designed in a way that would allow it to withstand missile attacks. That was cool, but it resulted in an unintended side effect: it made it more vulnerable to cyber-

attacks. So now it may be time for a little renovation.The roots of the Internets design come from

the network built by the Pentagons Advanced Re-search Projects Agency to enable research centers to share computer resources. The ARPANET, as it was called, was packet- switched and looked like a shnet. Messages were broken into small chunks, known as packets, that could scurry along differ-ent paths through the network and be reassembled when they got to their destination. There were no centralized hubs to control the switching and rout-ing. Instead, each and every node had the power to route packets. If a node were destroyed, then trafc would be routed along other paths.

T hese ideas were conceived in the early 1960s by a researcher at the Rand Corp. named Paul Baran, whose motive was to create a net-work that could survive a nuclear attack. But the en-gineers who actually devised the trafc rules for the ARPANET, many of whom were graduate students avoiding the draft during the Vietnam War, were not focused on the military uses of the Net. Nuclear survivability was not one of their goals.

Antiauthoritarian to the core, they took a very collaborative approach to determining how the packets would be addressed, routed and switched. Their coordinator was a UCLA student named Steve Crocker. He had a feel for how to harmonize a group without centralizing authority, a style that was mir-rored in the distributed network architecture they were inventing. To emphasize the collaborative na-ture of their endeavor, Crocker hit upon the idea of calling their proposals Requests for Comments (RFCs), so everyone would feel as if they were equal nodes. It was a way to distribute control. The Inter-net is still being designed this way; by the end of 2014, there were 7,435 approved RFCs.

So was the Internet intentionally designed to sur-vive a nuclear attack? When Time wrote this in the 1990s, one of the original designers, Bob Taylor, sent a letter objecting. Times editors were a bit arrogant back then (I know, because I was one) and refused to print it because they said they had a better source. That source was Stephen Lukasik, who was deputy

director and then director of ARPA from 1967 to 1974. The designers may not have known it, Lukasik said, but the way he got funding for the ARPANET was by emphasizing its military utility. Packet switching would be more survivable, more robust under damage to a network, he said.

Perspective depends on vantage point. As Luka-sik explained to Crocker, I was on top and you were on the bottom, so you really had no idea of what was going on. To which Crocker replied, with a dab of humor masking a dollop of wisdom, I was on the bottom and you were on the top, so you had no idea of what was going on.

Either way, the Nets architecture makes it dif-cult to control or even trace the packets that dart through its nodes. A decade of escalating hacks raises the question of whether its now desirable to create mechanisms that would permit users to choose to be part of a parallel Internet that offers less anonymity and greater verication of user iden-tity and message origin.

T he vener able requests -for- comments process is already plugging away at this. RFCs 5585 and 6376, for example, spell out what is known as DomainKeys Identied Mail, a service that, along with other authentication technologies, aims to validate the origin of data and verify the senders digital signature. Many of these techniques are already in use, and they could become a founda-tion for a more robust system of tracking and au-thenticating Internet trafc.

Such a parallel Internet would not be foolproof. Nor would it be completely benecial. Part of what makes the Internet so empowering is that it per-mits anonymity, so it would be important to keep the current system for those who dont want the option of being authenticated.

Nevertheless, building a better system for verify-ing communications is both doable and, for most users, desirable. It would not thwart all hackers, perhaps not even the ones who crippled Sony. But it could tip the balance in the daily struggle against the hordes of spammers, phishers and ordinary hackers who spread malware, scarf up credit-card data and at-tempt to lure people into sending their bank- account information to obscure addresses in Nigeria.

Isaacson, a former managing editor of Time, is the author of The Innovators

HACK ATTACKS

Time to Build a More Secure InternetYes, anonymity is empowering. But escalating hacks and scams show that we need a safer alternative

40 MILLIONNumber of

Americans who have had personal

information stolen by cybercriminals

$100 BILLIONLoss to the

U.S. economy in 2013 as a result

of cybercrime

Walter IsaacsonCOMMENTARY


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What I LeaMy $190,00

NATION

Photo-illustration by Ann Elliott Cutting

arned From 00 SurgeryBy Steven Brill

Its a condition I had never heard of until a week before, when a routine checkup by my extraordinarily careful doc-tor found it.

And thats when everything changed.Until then, my family and I had enjoyed great health. I

hadnt missed a day of work for illness in years. Instead, my view of the world of health care was pretty much centered on a special cover story I had written for Time a year be-fore about the astronomical cost of care in the U.S. and the dysfunctions and abuses in our system that generated and protected those high prices.

For me, an MRI had been a symbol of proigate American health carea high-tech prot machine that had become a bonanza for manufacturers such as General Electric and Sie-mens and for the hospitals and doctors who billed patients billions of dollars for MRIs they might not have needed.

But now the MRI was the miraculous lifesaver that had found and taken a crystal-clear picture of the bomb hiding in my chest. Now a surgeon was going to use that MRI blue-print to save my life.

A week before, because of the reporting I had done for the Time article, I had been like Dustin Hoffmans savant character in Rain Manable and eager to recite all varieties of statistics on how screwed up and avaricious the American health care system was.

We spend $17 billion a year on articial knees and hips, which is 55% more than Hollywood takes in at the box ofce.

Americas total health care bill for 2014 was $3 trillion. Thats more than the next 10 biggest spenders combined: Japan, Germany, France, China, the U.K., Italy, Canada, Bra-zil, Spain and Australia. All that extra money produces no better, and in many cases worse, results.

There are 31.5 MRI machines per 1 million people in the U.S. but just 5.9 per 1 million in the U.K.

Another favorite: We spend $85.9 billion trying to treat back pain, which is as much as we spend on all of the coun-trys state, city, county and town police forces. And experts say that as much as half of that is unnecessary.

Weve created a system in which 1.5 million people work in the health-insurance industry while barely half as many doctors provide the actual care.

And all those high-tech advancespacemakers, MRIs, 3-D mammogramshave produced an ironically upside-down health care marketplace. It is the only indus-try in which technological advances have increased costs instead of lowering them.

When it comes to medical care, cutting-edge products are irresistible and are usedand pricedaccordingly. I could recite from memory how the incomes of industry

i usually keep myself out of the stories i write, but the only way to tell this one is to start with the dream I had on the night of April 3, 2014.

Actually, I should start with the three hours before the dream, when I tried to fall asleep but couldnt because of what I thought was my exploding heart.

Thump. Thump. Thump. If I lay on my stomach, my heart seemed to push down through the mattress. If I turned over, it seemed to want to burst out of my chest.

When I pushed the button for the nurse, she told me there was nothing wrong. She even showed me how to read the screen of the machine monitoring my heart so I could see for myself that all was normal. But she said she under-stood. A lot of patients in my situation imagined something was going haywire with their heart when it wasnt. Every-thing was ne, she promised, before giving me a sedative.

All might have looked normal on that monitor, but there was nothing ne about my heart. It had a time bomb ap-pended to it. It could explode at any momentthat night or three years laterand kill me almost instantly. No heart attack. No stroke. Id just be gone, having bled to death.

Thats what had brought me to the fourth-oor cardiac-surgery unit at New YorkPresbyterian Hospital. The next morning I had open-heart surgery to x something called an aortic aneurysm.

INATION | HEALTH CARE

Editors note: In 2013, Steven Brill wrote Times trailblazing special report on medical bills. His subsequent book, Americas Bitter Pilla sweeping inside account of how Obamacare happened and what it does, and does not do, to curb the abuses Brill chronicled in Timewas published Jan. 5. This article is adapted from that book.

Adapted from Americas Bitter Pill by Steven Brill. 2015 by Brill Journalism Enterprise LLC. Reprinted by arrangement with Random House, a division of Random House LLC. All rights reserved. Photograph by Peter Larson for TIME

Delos Toby Cosgrove The Cleveland Clinic CEO was a celebrated heart surgeon before becoming one of the savviest hospital executives in the world

The Cleveland Clinic Model

The vast network of hospitals, clinics and doctors practices in Ohio draws patients

from all over the world

Its about the people who determine what comes out of Washingtonfrom industry lobbyists to union activists, from Senators tweaking a few paragraphs to save billions for a home-state industry to Tea Party organizers ghting to upend the Washington status quo, from turf-obsessed pro-curement bureaucrats who crashed the governments most ambitious Internet project ever to the seless high-tech whiz kids who rescued it, and from White House staffers ght-ing over which faction among them would shape and then implement the law while their President oated above the fray to a governors staff in Kentucky determined to launch the signature program of a President reviled in their state.

But late in working on the book from which this article is adapted, on the night of that dream and in the scary days that followed, I learned that when it comes to health care, all that political intrigue and special-interest jockeying play out on a stage enveloped in something else: emotion, par-ticularly fear.

Fear of illness. Or pain. Or death. And wanting to do some-thing, anything, to avoid that for yourself or a loved one.

When thrown into the mix, fear became the element that brought a chronically dysfunctional Washington to its knees. Politicians know that they mess with peoples health care at their peril.

Its the fear I felt on that gurney, not only in my dream but during the morning after the dream, when I really was on the gurney on the way into the operating room.

Its the fear that continued to consume me when I was recovering from my operation. The recovery was routine. Routinely horrible.

After all, my chest had just been split open with what, according to the website of Stryker, the Michigan-based company that makes it, was a Large Bone, Battery Powered, Heavy Duty Sternum Saw, which has increased cutting speed for a more aggressive cut. And then my heart had been stopped and machines turned on to keep my lungs and brain going.

Its about the fear of a simple cough. The worst, though routine, thing that can happen in the days following surgery like mine, I found out, was to cough. Coughing was torture because of how it assaulted my chest wounds.

I developed a cough that was so painful, I blacked out. Not for a long time; there was a two-two count on Derek Jeter just before one of the episodes, and when I came to, Jeter was about to take ball four. However, because I could feel it coming but could do nothing about it, it was terrifying to me and to my wife and kids, who watched me seize up and pass out more than once.

In that moment of terror, I was anything but the well-informed, tough customer with lots of options that a robust free market counts on. I was a puddle.

There were occasions during those eight days in the hos-pital when the non-drug-addled part of my brain wondered, when nurses came in for a blood test twice a day, whether one test was enough and what the chargemaster cost for both was going to look like.

But most of the time the other part of my brain took over, the part that remembered my terror during those blackouts and the overriding fear, reprised in dreams that persisted for weeks, that lingered in someone whose chest had been

executives continued to skyrocket even during the re-cession and how much more the president of the Yale New Haven Health System made than the president of Yale University.

I even knew the outsize salary of the guy who ran the supposedly nonprot hospital where I was struggling to fall asleep: $3.58 million.

Which brings me to the dream I had when I nally got to sleep.

As I am wheeled toward the operating room, a man in a nely tailored suit stands in front of the gurney, puts his hand up and orders the nurses to stop. Its the hospitals CEO, the $3.58 million-a-year Steven Corwin. He, too, had read the much publicized Time article, only he hadnt liked it nearly as much as Jon Stewart, who had had me on his Daily Showto talk about it.

We know who you are, the New YorkPresbyterian CEO says. And we are worried about whether this is some kind of undercover stunt. Why dont you go to another hospital? I dont try to argue with him about gluttonous prots or salaries or the possibility that he was overusing his MRI or CT-scan equipment. Instead, I swear to him that my surgery is for real and that I would never say anything bad about his hospital.

In real life, I could have given hospital bosses like him the sweats, making them answer questions about the dys-functional health care system they prospered from. Their salaries. The operating prots enjoyed by their nonprot, non-tax-paying institutions. And most of all, the outrageous charges$77 for a box of gauze pads or hundreds of dollars for a routine blood testthat could be found on something they called the chargemaster, a massive menu of list prices they used to soak patients who did not have Medicare or pri-vate insurance. How could they explain those prices, I loved to ask, let alone explain charging them only to the poor and others without insurance, who could least afford to pay?

But now, in my dream, I am the one sweating. I beg Cor-win to let me into his operating room so I can get one of his chargemasters. If one of the nurses peering over me as he stopped us at the door had suggested it, Id have bought a years supply of those $77 gauze pads.

1. Why U.S. Health Care Is So Hard to Fix health care is americas largest industry by far, employing a sixth of the countrys workforce. And it is aver-age Americans largest single expense, whether paid out of their pockets or through taxes and insurance premiums.

So the story of how our country spent years trying to overhaul this vast portion of the economyand still left the U.S. with a broken-down jalopy of a health care systemis an irresistible tale.

The story of how what has come to be called Obamacare happenedand what it will and will not dois about poli-tics and ideology. In a country that treasures the market-place, how much do we want to tame those market forces when trying to cure the sick? And in the cradle of democ-racy, or swampland, known as Washington, how much tam-ing can we do when the health care industry spends four times as much on lobbying as the No. 2 Beltway spender, the much feared military-industrial complex?

38

NATION | HEALTH CARE

yond his brothers tragic visits to two hospital emergency rooms, Ted Kennedys rsthand experience with health care began with a sisters severe mental disabilities, was extended by a three-month stay in a western Massachusetts hospi-tal following a near fatal 1964 plane crash and continued through his sons long battle with cancer.

Everyone involved in the writing of the Affordable Care Act similarly saw and understood health care as an issue that was more personal and more emotionally charged than any other. Accordingly, they struggled with one core question: How do you pay for giving millions of new customers the means to participate in a marketplace with inated pricescustomers with a damn-the-torpedoes attitude about those prices when theyre looking up from the gurney? Is that possible? Must the marketplace be tamed or tossed aside? Or must costs be pushed aside, to be dealt with another day?

Even the seemingly coldest sh among politiciansthe cerebral, no drama Barack Obamadrew on his encoun-ters with people who desperately needed health care to frame, and ultimately fuel, his push for a plan.

Everywhere I went on that rst campaign, I heard di-rectly from Americans about what a broken health care system meant to themthe bankruptcies, putting off care until it was too late, not being able to get coverage because of a pre-existing condition, Obama would later tell me.

should we be embarrassed and maybe even enraged that, as my book chronicles, the only way Obama ended up being able to reform health care was by making backroom deals with the industry interests who wanted to make sure that reform didnt interfere with their proteering?

Of course. Well be paying the bill for that forever.But should we blame Obama for making those deals?I dont think so. Obamacare gave millions of Americans access to afford-

able health care, or at least protection against being unable to pay for a catastrophic illness or being bankrupted by the bills. Now everyone has access to insurance and subsidies to help pay for it. That is a milestone toward erasing a na-tional disgrace. But the new law hasnt come close to mak-ing health-insurance premiums and out-of-pocket costs low enough so that health care is truly affordable to everyone, let alone affordable to the degree that it is in every other developed nation. Worse, it did little beyond some pilot proj-ects and new regulations to make health care affordable for the country. Instead, it provided massive government subsidies so that more people could buy health care at the same inated prices that so threaten the U.S. Treasury and our global competitiveness.

The Obama Administration trumpeted Obamacare as a modern innovation that would force another hidebound industry to be more competitive. expedia for health insurance was a winning political bumper sticker in an age when even Democrats were wary of being accused of anything that could be labeled as income redistribution. But the real bumper sticker might have read money for the poor and middle class so they can get insurance to buy the same product everyone else does at the same price that makes everyone in the health care industry so rich .

sawed open and whose heart had been stopped. As far as I was concerned, they could have tested my blood 10 times a day if they thought that was best. They could have paid as much as they wanted to that nurses aide with the scale or to the woman who awlessly, without even a sting, took my blood. The doctor who had given me an angiogram the afternoon before the surgery and then came in the following week to check on me became just a nice guy who cared, not someone who might be trying to add on an extra consult bill.

In the days that I was on my back, to have asked that nurse how much this or that test was going to cost, let alone to have grilled my surgeona guy I had researched and found was the master of aortic aneurysmsabout what he was going to charge, seemed beside the point. It was like ask-ing Mrs. Lincoln what she had thought of the play.

When youre staring up at someone from the gurney, you have no inclination to be a savvy consumer. You have no power. Only hope. And relief and appreciation when things turn out right. And you certainly dont want politi-cians messing around with some cost-cutting schemes that might interfere with that result.

That is what makes health care and dealing with health care costs so different, so hard. The Obamacare story is so full of twists and turnsso dramaticbecause the poli-tics are so treacherous. People care about their health a lot more than they care about health care policies or econom-ics. Thats what I learned the night I was terried by my own heartbeat and in the days after when I would have paid anything for a cough suppressant to avoid those blackouts.

Its not that this makes prices and policies allowingindeed, encouragingrunaway costs unimportant. Hardly. My time on the gurney notwithstanding, I believe every-thing I have written and will continue to write about the toxicity of our proteer-dominated health care system.

But now I also understand, rsthand, the meaning of what the caregivers who work in that system do every day. They achieve amazing things, and when its your life or your childs life or your mothers life on the receiving end of those amazing things, there is no such thing as a runaway cost. Youll pay anything, and if you dont have the money, youll borrow at any mortgage rate or from any payday lender to come up with the cash.

Most of the politicians, lobbyists, congressional staffers and others who collectively wrote the story of Obamacare had some kind of experience like that, either directly or vi-cariously through a friend or loved one. Who hasnt?

The staffer who was more personally responsible than anyone else for the drafting of what became Obamacare had a mother who, in the year before the staffer wrote that draft, had to take an $8.50-an-hour job as a night-shift gate agent at the Las Vegas airport. She worked every night, not because she needed the $8.50her semiretired husband was himself a doctorbut because a pre-existing condition precluded her from buying health insurance on the individual market. That meant she needed a job, any job, with a large employer. Her daughters draft of the new law prohibited insurers from stopping people with pre-existing conditions from buying insurance on the individual market.

And then there was Senator Edward Kennedy, for 50 years the champion of extending health care to all Americans. Be- Th

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2. How To Fix It: Let the Foxes Run the Henhouseis there something we can now do to fix that? how can we go beyond Obamacare?

Thats the puzzle I was struggling with before my operation, so when I was able to move around afterward, I went back to New YorkPresbyterian to talk to its top executives. We discussed the aggressive chargemaster bills I had gotten following my surgerytotaling more than $190,000and the fact that the hospitals brand name was so strong, it had to offer only a 12% discount off those exorbitant prices ($451 for each of the eight times a portable X-ray machine took a picture of my battered chest) to my insurer, UnitedHealthcare. I then discovered that for mas-sive hospital systems like New YorkPresbyteriana prod-uct of the merger of New York Citys two most prestigious hospitalsthis kind of leverage over even the largest in-surers, like United, was not unusual.

But we also talked about how the kind of care I received wasnt an accident. For example, only a third of CEO Cor-wins annual bonus (which accounts for about half his an-nual pay) is based on the hospitals nancial results. The rest is based on an elaborate patient-satisfaction survey and an even more elaborate set of metrics related to patient care.

It was then that my idea for how to x Obamacare and American health care gelled: Let these guys loose. Give the most ambitious, expansion-minded foxes responsible for the chargemaster but also responsible for providing stellar care of the kind Corwin gave me even more free rein to run the henhousebut with conditions that would cut costs and, in fact, kill the chargemaster.

Several months before, I had begun toying with the same thought after encountering other leaders of high-quality hospital systems who were fast expanding their footprints and in the process gaining leverage over insurers.

At one event, I had been intrigued by Delos Toby Cos-grove, CEO of the Cleveland Clinic, a vast network of hospi-tals, clinics and doctors practices that dominated northeast Ohio and had such a good reputation that patients traveled there from all over the world.

Cosgrove, a celebrated heart surgeon, had built the Cleve-land Clinics heart program into one of the worlds best. He was also regarded as one of the savviest hospital executives in the world, widely admired for the way he ran what he had propelled into a $6 billion, 75-facility enterprise.

I had watched Cosgrove blanch while participating in a program about health care reform when another panelist implied that he dominated his market. Not possible, he said. If we expand too much, the FTC will be all over us.

Should the Federal Trade Commission really want to stop a guy like Cosgrove from dominating health care in Cleve-land? I wondered.

But then I remembered Jeffrey Romoff, CEO of the Uni-versity of Pittsburgh Medical Center (UPMC), who had long been enmeshed in litigation over whether he had conspired to control his market. By buying up doctors practices, clin-ics and other hospitals, Romoff truly did dominate health care in and around Pittsburgh. Furthermore, he once told me that he saw any attempts to hold him back as impediments he needed to overcome.

By now, UPMC had settled litigation with, and was about to complete a divorce from, Highmark Insurancethe Blue Cross Blue Shield company it had been accused of conspiring with to control the provider and insurance markets, respec-tively, in western Pennsylvania.

Through 2014, UPMC was lling the Pittsburgh area air-waves and every billboard not already taken by Highmark with touts for its own insurance company as the one that patients could use to get full access to its facilitiesbecause, beginning in 2015, UPMC would no longer recognize High-mark insurance.

At the same time, Romoff was fighting a lawsuit from the city of Pittsburgh that might have embarrassed other hospital executives. The city charged that UPMCs prices and prots were so high and its salaries, including Romoffswhich by then was more than $5 millionwere so exorbitant that it did not deserve nonprot tax-exempt status and should therefore be subject to the citys payroll tax. That would mean a lot to Pittsburgh, because UPMC was the biggest nongovernment employer in Pennsylvania.

UPMCs rst defense was that it didnt have any employ-ees; only its subsidiaries did. By the summer of 2014, a state judge would agree. He dismissed the case, though the city would be allowed to le the same action against the vari-ous subsidiary hospitals. Nonetheless, the suit highlighted UPMCs status as perhaps the worlds most tough-minded, prot-oriented nonprot.

So to put it charitably, Romoff, who is not a doctor, didnt seem to be the kind of hospital leader that Corwin or Cos-grove was.

Yet it was when I went to see Romoff (once I was able to travel) that the idea I had begun playing with after those talks with Corwin and other hospital leaders became fully formed.

Sitting in front of a window in his suite atop the U.S. Steel Tower, overlooking his citys football and baseball sta-diums, Romoff laid out a vision for health care that put it all together for me.

We spent much of the time talking about his UPMC insurance company and its competition with Highmark.

By then, Highmarks insurance market share in the Pittsburgh region had shrunk from 65% to 45%. Romoff calculated that with all the business he was taking away with his own insurance company, plus the inroads made by other insurers with whom he had signed network deals, Highmarks share would be 25% by the end of 2014 and still sinking. He expected that his insurance company would end up the leader in the marketand he was going to do everything he could to get to 100%.

Would he be worried about being so successful that he would drive out all the other insurance companies? I asked. Of the things that keep me up at night, that is not one of them, Romoff answered with a smile.

He was unabashedly trying to become the dominant insurer. And he was already by far the dominant provider through his 20 hospitals and hundreds of clinics, labs and doctors practices.

In other words, like the Geisinger Health System in Pennsylvania, only on a much larger scale and with little

Photograph by Peter Larson for TIME


The UPMC System

Romoffs UPMC is now touting its own insurance company, creating a system of

health care without a middleman

Jeffrey Romoff The University of Pittsburgh Medical Center CEO bought practices, clinics and other hospitals to dominate health care in Pittsburgh

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company players. There could be no monopolies, only oligopo-lies, as antitrust lawyers would call them. The larger markets, such as New York City, Los Angeles and Chicago, might have to have four, ve or even more players to make the competi-tion real and to make sure that, with accompanying regula-tory requirements, their footprints were big enough and their marketing plans robust enough to serve patients throughout their regions, not just in the wealthier areas.

That would mean the hospital and all the doctors it con-trolled would be subject to pricing and service-delivery standards that liberal reformers have sought since the mid20th century. Health care in the U.S. would nally be treat-ed as a public good, not a free-market product. However, the change would have come jujitsu-style, not by a government takeover. It would have come because the private players had driven it to that state.

These fully integrated brands could pursue recent inno-vations that offer less expensive, more consumer-friendly health care, such as storefront urgent-care centers that are smart alternatives to expensive, time-wasting hospital emer-gency rooms. These urgent-care centers are now being opened piecemeal by for-prot and often lightly regulated compa-nies. Why not put them under the banner and branded ac-countability of the big hospital systems? In fact, Cosgroves Cleveland Clinic has already opened a dozen urgent-care and express-care (for more routine needs) centers. Id rather pay him to care for me than pay a walk-in center owned by a private-equity fund.

The second regulation would cap the operating prots of what would be these now-allowed dominant market players, or oligopolies, at, say, 8% a year, compared with the current average of about 12%. That would force prices down. Better yet, an excess-prots pool would be created. Those making higher prots would have to contribute the difference to struggling hospitals in small markets.

A third regulationwhich, again, the hospital systems would have to agree to in return for their being allowed to achieve oligopoly or even monopoly statuswould prevent hospital nance people from playing games with that prot limit by raising salaries and bonuses for themselves and their colleagues (thereby raising costs and lowering prots). There would be a cap on the total salary and bonus paid to any hospital employee who did not practice medicine full time of 60 times the amount paid to the lowest salaried full-time doctor, typically a rst-year resident. (Under that formula, Corwins and Cosgroves salaries would stay about the same but Romoff in Pittsburgh would take a big cut.)

A fourth regulation would require a streamlined appeals process, staffed by advocates and ombudsmen, for patients who believed they were denied adequate care or for doctors who claimed they were being unduly pressured to skimp on care.

A fth regulation would require that any government-sanctioned, oligopoly-designated integrated system have as its actual chief executive (not just in title) a licensed physi-cian who had practiced medicine for a minimum number of years. Sorry, Mr. Romoff. The culture of these organizations needs to be ensured, even if that means choosing leaders based on something in addition to their business acumen and stated good intentions.

competition in the market, Romoff could sell me health insurance, which would cover me when I used Romoffs hospitals, clinics, doctors and labs.

3. Cutting Out the Middlemanthere would be no middleman. no third-party insur-ance company.

To me this was a hugely appealing idea, despite UPMCs record of high prices and its take-no-prisoners approach to competition. Why? Because it was the structure that made sense, not the particulars of Romoff and UPMC.

The insurance company would have not only every in-centive to control the doctors and hospitals costs but also the means to do so. It would be under the same roof, con-trolled by Romoff. Conversely, the hospitals and doctors would have no incentive to inate costs or overtreat, because their ultimate boss, Romoff, would get the bill when those extra costs hit his insurance company.

As Romoff put it, All the incentives are aligned the right way. Its the beauty of being the payer and provider at the same time. The alignments of interest are just so pure.

When the incentives are not aligned, he added, supply-ing a quote that could easily be read the wrong way, its why seniors dying of cancer get chemo when they should just get hospice care.

Maybe, but how could we know that those cancer patientswho would have no place to go in and around Pittsburgh except to UPMC if Romoff had anything to say about itwouldnt be denied chemotherapy that they actu-ally needed if Romoff-employed doctors were the ones hold-ing the prescription pads?

Wasnt Romoffs interest the one that was the most pure-ly aligned of all?

Thats where doctor-leaders like Corwin and Cosgrove come inalong with strong oversight and regulation.

Hospitals are already consolidating. It is happening all over the country, including in Corwins New York City and Cosgroves Cleveland.

Lets let them continue. More important, as they con-tinue, lets encourage them to become their own insurance companies, la Romoff, so they can cut out the middleman and align those incentives.

Lets harness their ambition to expand, rather than try to gure how and when to contain their ambition.

Why shouldnt I be able to buy Cosgroves Cleveland Clinic health insurance? What a great brand! I would know that I could use all his facilities and doctors, and he would know that his incentivewhich, he says, has always been the samewas to provide good care, not expensive care full of unnecessary and overpriced CT scans and blood tests. And I would know that doctors whom I could hold account-able would determine the nature of that care, not insurance companies.

But lets ensure that accountability by insisting on tight regulation, mostly through the smarter use of federal anti-trust law and state regulatory authority, in return for giving doctor-leaders the freedom to expand and also the freedom to become their patients insurance companies.

The rst regulation would require that any market have at least two of these big, fully integrated providerinsurance C

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4. Hundreds of Billions in Savingsi bet that with this plan, we could cut 20% off the two-thirds of our health care bill not paid by Medicare or Medicaid. Heres a sketch of how the math could work:

First, administrative costs for insuranceincluding vet-ting claims, paying bills, paying managers and executives and distributing prots to shareholdersaccount for 15% to 20% of private health care costs. Couldnt half or more be saved by cutting out middleman insurance companies? Corwin or Cosgrove would still have to employ managers, actuaries, accountants and salespeople on the insurance side of their integrated operations, but surely not to the extent that an insurance company responsible for paying bills from multiple third-party hospitals and other providers would. Nor would they have to deliver prots to shareholders.

Lets say we could save 10% by eliminating middlemen.Second, on the provider side of the equation, the main

culprit in driving costs upthe incentive for overtreating and overtesting that comes with billing for each patient encounter and procedure instead of billing for overall treatmentwould be eliminated. And the general incen-tive to maximize revenue would be tamped down by the new regulation capping operating prot at 8%.

That could likely save another 10%.The total, then, could be 20% of nongovernment health

care costs, or $400 billion a year, and maybe $100 billion more saved by allowing Medicare and Medicaid to pay those integrated providers this way.

That would go a long way toward bringing American health care costs as a percent of our gross domestic product closer to those of the countries we compete with.

One of Corwins competitors, the giant North ShoreLIJ Health System, is now selling its own insurance. Corwin told me that although he is more comfortable being on the provider side of the street, he would consider doing the same if he thought his hospital system were big enough to provide that full spectrum of quality care and if he needed to do it in order to be competitive.

The rst thing we can agree on about the health care system in the United States, the Cleveland Clinics Cosgrove said, is that it is not a system at all. Its just a collection of disparate providers. So, yes, we are consolidating, he contin-ued, noting that although the number of hospital beds in the U.S. had declined in recent years from 1 million to 800,000, there is still only 65% occupancy.

Doctors, said Cosgrove, have consolidated their practices, often under the umbrella of hospital systems like his, be-cause medical knowledge doubles every two years. So you continually need to specialize still more to keep up. And the more you consolidate, the more you can specialize. The more you specialize and do a lot of just one or two things, the better you are at them and the more cost-effective you are. Thats why they call it practicing medicine.

Would integrating insurance into that system be the next logical step beyond consolidation? That seems right, Cosgrove said. In fact, he added, we recently applied for an insurance license.

The momentum for the consolidation I have in mind is clearly there. We just need to seize it rather than resist it, and then control it and push it in the right direction.

Sixth, any sanctioned integrated oligopoly provider would be required to insure a certain percentage of Medicaid patients at a stipulated discount.

Wait a minute, I can hear my readers thinking. These guys generate thousands of those obscene chargemaster bills a year. Now youre going to put them in charge?

Which brings me to my nal regulation: These regu-lated oligopolies would be required to charge uninsured patients no more than what they would charge competing insurance companies whose insurance they accepted, or else a price based on their regulated prot margin if they didnt accept other insurance. In other words, no more chargemaster.

All of this may seem complicated, but the rules required to set up this structure would be a drop in the bucket com-pared with the thousands of pages of laws and millions of pages of rules and regulations that are now on the books. And it is certainly more realistic than pining for a public single-payer system that is never going to happen.

Combining the work that the Corwins and Cosgroves of the world do with Romoffs plan boils down to this: Allow doctor-leaders to create great brands that both insure con-sumers for their medical costs and provide medical care.

Let them act on their ambitions. Let them compete with other legitimate players in their markets, or even with one another if they want to expand.

That kind of competition is already happening. But as things stand now, an employer who wants to get health care for his workers, or an individual who is shopping on the Obamacare exchanges, has to gure out which insurance company has which hospitals and doctors in its network and what discounts it has negotiated. This change would create a new, clearer competitive process.

Instead of hoping for the best with UnitedHealthcare, I could just go on the exchange and pay Corwin to use all of his New YorkPresbyterian doctors and facilities to keep me healthy. Period. Full stop. There would be total clarity about which facilities and doctors are in my network.

Or my employer could pay him after negotiating the price.

It would be insurance the way its supposed to workthe risk associated with the cost of my heart surgery would be spread across a pool of premiums that Corwin collected from tens or hu

time magazine - january 19, 2015

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