The Big Business of Health Care

DATE October 6, 2004 ACCOUNT NUMBER N/A
TIME 12:00 Noon-1:00 PM AUDIENCE N/A
NETWORK NPR
PROGRAM Fresh Air

Interview: Donald Barlett and James Steele discuss their new book,
"Critical Condition"
TERRY GROSS, host:

This is FRESH AIR. I'm Terry Gross.

My guests are Pulitzer Prize-winning journalists Donald Barlett and James
Steele. Their new book examines what's gone wrong with America's health-care
industry. It's called "Critical Condition: How Health Care in America Became
Big Business & Bad Medicine." They write, `American health care has become a
lottery. If you work for a large company that provides generous benefits, you
win. If you work for a small company or as an independent contractor, you
lose. These are the lucky ones, the ones who have health insurance. Beyond
them are 44 million others. Their number's growing who do not.'

Barlett and Steele have worked together for three decades, first at the
Philadelphia Inquirer and since 1997 as editors at large for Time magazine.
They've won two Pulitzer Prizes and two National Magazine Awards. Their book
"America: What Went Wrong?" was on the best-seller list for eight months.

I think there's a general perception that people are paying more for health
insurance, paying more for their drugs and that, in some ways, they're getting
less; that there's more restrictions being placed on what their insurance will
reimburse them for. Is that an accurate perception?

Mr. DONALD BARLETT (Co-author, "Critical Condition"): Well, there's no
question about that. When you look at what we spend, I mean, the numbers are
so large they don't mean anything to people, $1.7 trillion. But what should
mean something to people is we spend twice as much on health care per capita
than, say, Greece, France, Italy, Spain, Japan. And the people in those
countries and a lot of other countries live a lot longer than we do. So
there's something clearly amiss here.

GROSS: Well, when people complain about the rising costs of health insurance
and of drugs and everything, the answer we usually get is, `Well, there are so
many new procedures...'

Mr. JAMES STEELE (Co-author, "Critical Condition"): Right.

GROSS: `...and so many new drugs that we didn't have before, and the research
is expensive. Those high-tech imaging diagnostic tools we use are very
expensive,' and those costs are passed on to us and that's why we're paying
more. Is that an accurate analysis of why we're paying more, James Steele?

Mr. STEELE: That's the most common description you hear, you're absolutely
right, Terry. I mean, you hear that everywhere, you read it everywhere. We
put a much higher priority on procedures rather than care. I mean, that's one
of the big problems in this country. And as a result of that, we're very much
into the latest bit of technology, we're very much into the latest pill that
comes down the track, we're very much into the latest medical process by which
we think we'll solve a situation. But we don't deal with basic care in this
country, which is the reason why, we think, in part, our life expectancy here
is lower than almost every other developed country. So that doesn't do it.

The other thing which we think is at the root of it--and this is what we found
so fascinating--that much of the turmoil in health care, much of the problems,
so much of what we see out there is a direct result of the decision the
country made over the--basically about three decades ago to go for
market-based, for-profit health care. I mean, the whole purpose of this
supposedly was to bring business methods, efficiencies to health care. And
the reason we embraced this back in the early '80s was that, at the time,
health-care costs were rising very rapidly. And they were, at the time,
roughly 11 percent of our Gross Domestic Product. Now here we are 25 years
later plus, and they're at 15.3 and still going up.

So the whole experiment has not worked, but, at the same time, billions of
dollars have flowed out of the system that have nothing whatsoever to do with
health care and done nothing whatsoever to really, substantially improve
patient care. But they've been a wonderful boon for Wall Street, a wonderful
thing for investors who got in on the ground floor of many of those companies.

Mr. BARLETT: By focusing on a market-based system, what we've done is reward
procedures. We don't reward good care. We pay someone for doing procedures.
And that's really the worst kind of health-care system imaginable.

GROSS: Well, what do you mean by that, that we reward the doctor for
performing procedures?

Mr. BARLETT: Well, it's like you indicated: the latest test, the latest
diagnostic test. The more tests you do, the more surgeries you perform...

GROSS: How does that reward doctors?

Mr. BARLETT: Well, they're getting paid for the procedure. And one of the
real sad aspects of what's happened to the health-care system in this country
is the demise of the family practitioner, the general practitioner. And I
know a lot of people think, `Well, I'm not going to feel sorry for doctors and
their salaries.' But the fact of the matter is family practitioners get paid
embarrassingly little in this country. It's the doctor who does the procedure
who is doing reasonably well, and the more high-tech surgery, the better off.

But what this has done is create--it's not a health-care system. It's
basically a medical industrial complex in which the money is flowing to an
industry, not an entity that's actually caring for people. The other aspect
of it that we talk about is that we spend nothing on preventative care, and
that's really where, ultimately, the real benefits are going to come for
society as a whole, not in treating people.

GROSS: If you're just joining us, my guests are Donald Barlett and James
Steele, two investigative reporters. And their new book is on the health-care
industry and what's wrong with it. It's called "Critical Condition."

So much of your book is about the turning of the health-care industry into a
for-profit industry, you know, including hospitals, of course. And you trace
the kind of for-profit emphasis of, say, hospitalization to the early 1980s
and the Reagan administration. What was the turning point there, in the era
of the so-called Reagan revolution, in changing the health-care system?

Mr. STEELE: Well, the irony at the turning point then was not unlike some of
the problems we have now, which was that costs were going up, people were
trying to look around for a way to restrain those costs, and everybody said,
`government can't do this. Private industry can do it. It has the
efficiency. We need business methods to bring some sanity out of this, and
that's why we need to go with the for-profit model.' At the time there'd been
any number of experiments in HMOs. It hard to think--HMOs now are like a bad
word in most of America. But, ironically, in the beginning, they were seen as
a very positive force, as a way to provide a lot of this overall care without
being outrageously expensive. But by the early '80s, many of these had been
converted from not-for-profit to for-profit models, which had made many of the
original founders and stockholders a lot of money. So the idea was business
methods.

And what we found was when we looked at this whole issue--and in the
beginning, that made so much sense to people. But if you look at it over
time, health care isn't like any other business. And I think that's the thing
that everybody underestimated at the time and didn't see properly. It's not
like selling automobiles or televisions or apparel, where you want a
competitive situation, where you can go into a store and see, `What's the
cheapest thing here?' You can't really do that with health care. It's not
the same kind of an animal.

Also, in most business, you want to sell more of the product. You want to
sell more cars, you want to sell more clothing, you want to sell more TVs. Do
we want to sell more health care? Probably not. We need to manage it better,
and that's what we haven't done.

GROSS: So what exactly did the Reagan administration do in the early 1980s
that changed health care?

Mr. STEELE: They basically privatized the HMOs. They put the message
out--they made various arrangements with brokerage houses to promote the
process. They sent the message out that for-profit, privately run hospitals
would be certainly encouraged; that government would play less of a role in
the lives of health care. That was the message out there.

GROSS: So what kind of federal funding had existed that was cut back?

Mr. BARLETT: Well, that's what people tend to forget because so many years
have passed. The HMOs initially were funded by the federal government, and it
was a very small amount of money. And they actually started out, you know,
doing reasonably well. But once they converted the HMO to a for-profit
business, then the marketplace took over.

And we're not anti-market. I mean, the market works wonderfully. As Jim
indicated, if you're selling cars or cereal or cosmetics or whatever, that
works fine. But in health care, you don't want to be selling more of a
product. You want to either manage it, or you want to sell less. The ideal
health-care system would one in which, you know, very few people need any
drugs of any kind and people are living long without surgical procedures.
That would be the ideal. And the way you achieve that, in part, at least is
through preventative care, not through treatment. But the for-profit
system--obviously, that runs counter to what underpins the profit system.

GROSS: You've looked at--well, are there other big government changes,
federal policy and funding changes, after the Reagan administration that set
us on the course that we're on now?

Mr. STEELE: The basic thing that happened, really, in the early '80s was it
was not so much a funding thing per se, so much as it was cutting off funds to
the existing federally sponsored--or encouraged, we should say--agencies.
There were other things all throughout the '80s and '90s. I mean, some of the
big ones are antitrust rulings that certainly encouraged the consolidation of
the private hospitals into HCA. The Hospital Corporation of America predated
the '80s, but in the '80s on they had a tremendous incentive to get bigger and
bigger and bigger, which they've since done. The same thing with Tenet, the
second-largest hospital chain.

And what happened with this--it wasn't so much a direct policy after that
occurred, but the message was there: `Look, Washington wants private
industry, you know, the market to determine things in hospitals. We want to
be more efficient, we want to run better.' And, of course, anybody who's ever
been in a hospital or looked at a hospital or even taken a cursory look at
health care knows what a chaotic field it is. I mean, even in the best of
circumstances, there's just so many different aspects to it. So that hit home
even with people who otherwise would have been sympathetic. So all of those
things happened, including some--I know antitrust rulings I believe in the
early '90s encouraged that process, but it was more just that general...

GROSS: These are antitrust rulings that made it less likely that you would be
punished for violating antitrust laws.

Mr. STEELE: Right, they encouraged...

GROSS: So it loosened the regulations?

Mr. STEELE: It loosened things, and it encouraged the formation of bigger
companies in that sense. But the most important thing was just an overall
encouragement of the market. And what happened in health care was very
similar to a lot of things in the economy at the time. We were told that
businesses run better if they pay more attention to how they'd done the last
week or month or whatever. I mean, the bottom-line orientation of business
from the '80s on--the business school model was very powerful. So a lot of
that is just part of what happened in health care, but the difference is
health care just wasn't like these other industries. And that's why it just
has failed so miserably.

GROSS: Now you point out that the efficiency model that some hospitals
borrowed from industries hasn't really worked in the hospital setting. Can
you give us an example or two of something that was borrowed from the
efficiency model of industry, applied to the hospital and it's not working?

Mr. STEELE: I know exactly what you're talking about. This was one of those
eye-openers that we came across when this whole efficiency, market-based
medicine began to take over. A number or consulting companies studied the
auto industry, or they took certain processes that had been developed in the
auto industry--first-in-time inventory, total quality management, a whole
range of these things--and began to apply them to hospitals. One of the
things that clearly didn't work was the concept of just-in-time inventory.
This was a concept that was embraced by manufacturing, particularly auto
plants. The idea was you didn't have excess bolts and fenders and things of
that sort sitting around in a warehouse. You tried to keep a continuous
stream of things going into the production of your cars. And this was adopted
by other industries as well. The model...

GROSS: So you don't order it until you really need it.

Mr. STEELE: You don't order it till you really need it. And the idea was,
`Yeah, we'll do the same thing in hospitals. We won't spend X amount of money
on things that we don't need yet.' And it's great with cars, of course,
because if you do run a little short, while it may affect your production,
it's certainly not a life-threatening issue. But in a hospital, if you're
suddenly running out of sutures or a medical pump or some other device that
you need in a very critical situation, the lack of the proper inventory is an
extremely serious matter.

GROSS: And you've seen that happen?

Mr. STEELE: And we've talked to nurses who have been in operating rooms where
suddenly there weren't the proper materials or things were missing; that they
actually had to have a patient wired up to equipment for a period of time
until the missing part was then brought in to let the surgeon to continue the
procedure.

GROSS: My guests are Pulitzer Prize-winning journalists Donald Barlett and
James Steele. Their new book about the health-care industry is called
"Critical Condition." We'll talk more after a break. This is FRESH AIR.

(Soundbite of music)

GROSS: My guests are Donald Barlett and James Steele. This investigative
team has won two Pulitzer Prizes. Their new book is called "Critical
Condition: How Health Care in America Became Big Business & Bad Medicine."

There seem to be so many contradictory forces at work right now 'cause, you
know, on the one hand, you're saying doctors are rewarded for performing
certain high-tech procedures. And, on the other hand, doctors are being
warned not to perform a lot of high-tech procedures unless it's absolutely
necessary, because the price of the procedure is so high. So do those two
things balance each other out or what?

Mr. STEELE: Your point is absolutely right in terms of these contradictory
forces. I mean, one of the most bizarre things we ran across is that the one
health plan that would pay for Viagra, on one hand, but would not pay for a
woman's birth control pills. So it's like, `What is going on here?' I mean,
there should be some kind of consistency here, but you see that throughout
health care.

One of the things that just amazed us about the research in this was there are
things in medicine we had no idea in health care. And one of them is anytime
you go see a doctor and you come out with a billing sheet, there will be these
little five-digit codes about whatever they did: general office visit,
immunization, whatever it is. This has become this battleground in health
care between insurers and many doctors around the country because many doctors
will see additional things when they're in there, and they'll check off
several of these. And they feel they should be paid for them because they
spent more time with the patient, and they brought their expertise and
knowledge to bear, which seems fair as it can be to us. But when it goes to
the insurers, very often the three or four things they check which would lead
to more payment are boiled into one category. It's a complicated term in the
industry called downcoding.

But this goes on all over the country. And there are now computer programs
that the insurers use to compress the billing of doctors. And it's been a
tremendous source of loss of revenue to many doctors who are not salaried but
who depend on their fees, depend on their reimbursements. And it's just
typical of one of these things that's going on behind the scenes that the
average patient has no knowledge of but which is impacting on their health and
certainly impacting on the way their doctors view their profession.

GROSS: So the bureaucracy is basically deciding what the doctor gets paid for
when he makes a diagnosis.

Mr. BARLETT: Sure. And it's also impacting the way you're treated.

Mr. STEELE: Right.

Mr. BARLETT: If you're going in for a--and the doctor is looking down at that
sheet with all those codes on it, and he sees that he can do two or three at
once, he's not going to do it in many cases because he's only going to get
paid for one. But if he brings you back three times, he will get paid for the
three separate procedures. This is nonsensical. This is not good business.
It's just bad medicine, bad economics.

GROSS: Now you point out in your book that there's a whole new profession
that has grown around the new health-care system, and it's the medical
bureaucracy. How much of our health-care dollars is actually going to fund
this huge bureaucracy?

Mr. STEELE: Some studies have put it at nearly 1 out of $3 to the
administrative costs to just run the system. And, again, this is one of the
ironies of our embrace of this market-based, free-market medicine from the
'80s because supposedly all of this was to make everything more efficient.
But what's happened with this is with the emphasis on competition, multiple
insurers, multiple providers, there are literally thousands of plans out there
that provide various things. I mean, the average doctor's office anymore,
they have to have a staff of people processing these things because it can
mean money out of their pocket unless they're properly overseeing that whole
process.

So the bureaucracy is everything from the doctor's office to the insurer on up
the line. I mean, how many of us have spent time calling call centers for
various things that--a simple referral, to find out, has it been faxed to the
doctor. That's all part of a process which is essentially aimed, like, in
many cases, to discourage care. But the fact of the matter is it leads to
this huge administrative overlay because they're not defined billings and what
we pay for things.

GROSS: Now some people who are particularly skeptical or cynical believe that
sometimes they are intentionally overbilled or that doctors are intentionally
underpaid, underreimbursed in the hopes that--you know, that the company is
hoping that you're not going to take the time to call and argue with this and
that if you don't take the time, they're going to gain that extra money 'cause
they overbilled you. How cynical are these people who think that?

Mr. BARLETT: I don't think they're cynical at all. There's no question this
is going on. The reason is you can't have this happening over and over and
over again as it does unless it is deliberate.

GROSS: Give me an example of the problem.

Mr. BARLETT: Well, they'll deny a payment for a procedure that is clearly
covered under a policy in the hope that the person will then submit a check
and pay for it. A smart consumer will challenge it. And here's the problem
with this: Nobody has time to do this. If you're working a full-time job,
you do not have time to spend on the telephone. And this is really
significant time. Those of us who are lucky enough to have a stay-at-home
wife who will man the phone and stay on that phone and say, `I want to talk to
your supervisor,' and then `I want to talk to your supervisor,' will, in the
end, ultimately win because they're right. But most people don't have the
time. They can't spend that kind of time getting what should be an honest
answer.

GROSS: Donald Barlett and James Steele will be back in the second half of the
show. Their new book about the health care industry is called "Critical
Condition." I'm Terry Gross, and this is FRESH AIR.

(Soundbite of music)

(Announcements)

(Soundbite of music)

GROSS: Coming up, Barlett and Steele offer a proposal for improving the
health-care system. And we remember comic and actor Rodney Dangerfield. He
died yesterday at the age of 82.

(Soundbite of music)

GROSS: This is FRESH AIR. I'm Terry Gross back with the Pulitzer
Prize-winning investigative team of Donald Barlett and James Steele. Their
new book is about the health-care industry. It's called "Critical Condition:
How Health Care in America Became Big Business & Bad Medicine."

Have you seen a system that you think works that we should be learning from?

Mr. STEELE: We studied just briefly some of the foreign systems and the
Canadian system. And I think the first thing we should say is that there
isn't any health-care system anywhere in the world that's, to our way of
thinking, a model. Every one of them has certain kinds of flaws. But the
thing that stands out with most of--systems elsewhere and the Canadian,
certainly the French, the German system, the Italian system is that everybody
is covered. So if something happens to you, you're not having to face a
possibility that you might lose your house, lose your savings, in some other
way face financial ruin, which can happen in this country if you do not have
insurance. That's the main thing those other systems have done, which we have
not done and which we've refused to do.

Everybody pounds the Canadian system in this--not everybody, but a lot of
people are always pointing to the long waits up there, as though there aren't
waits in this country anymore, which there are, not everywhere but in many
jurisdictions. But they've provided a floor of coverage, which goes a long
way toward taking care of most Canadians in terms of their basic health needs.
And it's not a surprise to us that Canadians live longer than we do.

Mr. BARLETT: There was a recent study just on that point Jim's talking about
that attribute 18,000 deaths in one recent year to people who really needed
medical attention but wouldn't seek it because they didn't have the money.
And there's a--you know, one of the glib responses you often hear is, `Nobody
needs to go without health care in this country. Anybody that walks into an
emergency room, anyone anywhere, will be treated.' There's a certain amount
of truth in that. But what it ignores is, you know, there's a fairly nice
segment of the population that sincerely believes, you know, that they need to
pay their own way and, as a consequence, won't get help.

GROSS: But, you know, a lot of people say, `Do you really want your health
care in the arms of the government?'

Mr. BARLETT: We thought about this a lot, a lot, OK? What are you going to
do? There is just too much animosity toward government to come up with a
government system and not without some reason. So what is the answer then?
And we thought maybe the solution would be something like the Federal Reserve
system, in which you have a quasi-independent board, organization, that
controls all health care but is not dependent on Congress, the White
House--you know, you have--there's staggered terms--and totally independent.
It can--free to make decisions without having to worry about what Congress is
going to say about funding.

It has a lot of merit, we think, for not just paying the bills or collecting
the money or making sure everybody's covered but doing the kinds of medical
research now that are not done in this country: looking at preventive
medicine. You mentioned, you know, the test business. Tests are conducted
here willy-nilly without anybody--no independent authority looking at the
tests and saying, `Are these worth the money? Are we getting our money's
worth from these tests? Are we getting any really good medical results from
these tests?' This is especially true with drugs. And an independent
organization like this could do the studies that nobody can do today without a
vested interest. And the vested interest part of this is really critical
because whether it's research into diseases, treatment of diseases or drugs or
whatever, there are so many vested interests now that there is really no pure
research out there anymore.

GROSS: I mean, for example, a lot of the research is funded by the
pharmaceutical companies.

Mr. BARLETT: Exactly.

Mr. STEELE: Right. And one of the things that--you know, we don't have any
illusions about people--a lot of people will certainly attack the book because
it's saying, `All you want is another big government agency,' which is not
what this is calling for in any way. But what's interesting is that even
attitudes within the profession clearly are starting to change on this. And
one of the most revealing studies that we came across and which we deal with
in the book was there's an institution in Washington called the Center for
Studying Health System Change, and they've been around a long time. And they
poll and they interview people, and they see where folks are at on various
issues. And every two years they go out and they survey doctors, nurses,
insurers and other professionals in selected big cities across the country.

Their study in 2004 turned out to be a real eye-opener to them because, for
the first time, they had people talking about people who, previous to that,
had just had their basic faith in the private system saying, `This is not
working. This whole thing is a mess.' And one of them said, in
particular--one surprised benefit consultant reported in the study--`There's
now a lack of resistance to government involvement. People are starting to
see that the government is going to have to be involved here.' It may not
necessarily mean running everything but at least establish some standards, at
least providing some overall guidelines because it's not functioning the way
everybody thought it would 25 years ago when we embraced this wholeheartedly.

GROSS: My guests are Pulitzer Prize-winning journalists Donald Barlett and
James Steele. Their new book about the health-care industry is called
"Critical Condition." We'll talk more after a break. This is FRESH AIR.

(Soundbite of music)

GROSS: If you're just joining us, my guests are Donald Barlett and James
Steele. And their new book is an assessment of the health-care industry.
It's called "Critical Condition."

Now let me ask you a question about Vioxx, which is now going to be taken off
the market because the latest study found that it seems to cause, in a small
but significant percentage of people who take it, heart attack. And I'm
wondering, what's the moral of that story for you?

Mr. BARLETT: In some ways the Vioxx story really symbolizes everything that's
wrong in the prescription drug field. This was a drug for arthritis,
basically. They wanted to expand it into another area, which is very common,
called off-label prescriptions. Off-label prescriptions are a huge field
because then the pharmaceutical company doesn't have to go through the process
of running tests to get FDA approval. They just encourage doctors to use it,
whatever that drug may be. But in this case...

GROSS: And an off-label is--it's not what the drug was officially created
for.

Mr. BARLETT: Exactly.

GROSS: But it can treat this other condition.

Mr. BARLETT: Right.

Mr. STEELE: Right.

Mr. BARLETT: Right. There's some reason to believe that people benefit from
its use for another condition. But in Merck's case, they wanted FDA approval
for this, and that's how this test--their drug trial came about. And Vioxx
flunked because it was a much longer-term trial than they had originally for
the approval of the arthritis treatment. But here you have a case of a drug
which has been sold the most way drugs are today, on television, with
celebrity spokespeople. In Vioxx case, it's Dorothy Hamill, the skater, who
was also identified as one of the most trusted sports figures. This is the
way we sell health care today, on market medicine, encouraging people to take
products that they may or may not need. Doctors are always available to write
the prescriptions. And doctors complain, as a result of the advertising, that
they feel under pressure to write prescriptions they would not normally write.
The patient comes in with a specific request.

And so, in some ways, Vioxx represents everything that's wrong out. We're
marketing drugs. We're not marketing treatment for a condition. We're
creating a market-driven demand for a product. And there's none more--you
know, probably the best example are the erectile dysfunction drugs out there.
Was there a demand for three different drugs to treat what, prior to their
appearance on the market, was called impotence? But now you've got to have a
new name, you have to have a new--one that's going to fly in advertising
circles. You have the hyped market of tens of millions of men who need this.
Not likely.

So what is the real market? Well, we found in talking to people, one of the
markets is guys in their 20s who want to drink heavily and have sex. That's
not what health care's about. That's not what it should be about. It's one
reason we have high costs. Money's being spent on research that we don't
really need. And it's one of the reasons we look at, you know, this kind of
proposal we've made for this overall system to just do pure research, what's
going to help the largest number of people.

GROSS: Couple questions about malpractice insurance. I know of at least a
couple of doctors who've either given up their practice or had to move either
to a new city or, you know, or a new kind of practice because their
malpractice insurance was so high. And it's not because they had any
problems. It's just 'cause rates for their particular specialty in their
particular geographical location were sky high. And some people say, yes,
that's a problem because the trial lawyers are greedy, and they're asking for,
you know, incredibly high, you know, payments when they win lawsuits. Other
people have their own explanations for why rates are so high. Based on the
evidence that you've gotten, why is malpractice so high right now?

Mr. BARLETT: It's a little bit of both on those--Pennsylvania's a really good
example of this because it's, depending on who you talk to, either first or
second in the country in terms of malpractice litigation. But the other half
of that equation that no one talks about is this: Pennsylvania also has the
largest number of bad doctors who are not disciplined by the state. And so
you have more people out there practicing medicine who shouldn't be in
Pennsylvania than in most other states.

GROSS: Why aren't they disciplined?

Mr. BARLETT: Well, for whatever reason, the state just doesn't look into bad
doctors in Pennsylvania. It just does not happen. There's a massive database
down in Washington that tracks every malpractice, every complaint, every
infraction reported by a hospital about a doctor. This was just supposed to
be another one of those great consumer items, except the name of the doctor is
kept secret. But you can look at that and see how many are from Pennsylvania,
and Pennsylvania's near the top. And this is one explanation for high
malpractice here. There are more bad doctors. And then you do have frivolous
lawsuits. There's no question that that goes on. But the idea that you can
put a cap on there, which a lot of people favor, of $250,000, what do you say
to the woman we write about in the book who had both breasts lopped off?
$250,000, that's it?

GROSS: She didn't have cancer, it turned out.

Mr. BARLETT: No.

Mr. STEELE: Right.

GROSS: Right.

Mr. BARLETT: Absolutely not.

GROSS: So that was a mistake.

Mr. BARLETT: It was a mistake.

GROSS: The double mastectomy was a complete mistake.

Mr. BARLETT: Complete mistake. Is that $250,000? If it was my wife, it
wouldn't be.

Mr. STEELE: Malpractice also varies fairly significantly from state to state.
There are many, many states where it's not the issue that it is in states like
Pennsylvania and New Jersey. I think New York state is actually the state
with the largest awards in this area, if I'm not mistaken, but--so it varies
from state to state. And even states that have placed a cap on things, it
hasn't shown any particularly marked increase in the quality of the health
care. I mean, California's had a cap for a long time, and the system in
California, if anything, is in worse shape than almost any other state...

GROSS: Right.

Mr. STEELE: ...just in terms of basic inability to deliver health care,
constant turmoil, salaries going down, doctors chronically upset and with good
reason. So it's one piece of that whole equation. And if you're in a state
where it's been a big issue or you know a doctor, it's a tremendous issue.
But overall it--we have to deal also with the issue of catastrophic coverage.
I mean, that's what's part of it, too. I mean, a lot of the litigation is
because an accident has happened in one way or another, and there's no way to
take care of that person other than the insurance route. I mean, that is
another thing that could also be dealt with and the kind of thing we propose
at the end, you know, with true catastrophic coverage.

GROSS: I mean, so it would be covered--so if an error was made, your health
costs would be covered by your medical insurance...

Mr. BARLETT: Right.

GROSS: ...and not by the lawsuit.

Mr. STEELE: Not by the lawsuit, exactly.

GROSS: Is that what you're saying? Yeah.

Mr. BARLETT: It would take it off the table.

Mr. STEELE: Right.

GROSS: Right. Well, I want to thank you both very much.

Mr. STEELE: Nice to be with you, Terry.

Mr. BARLETT: Thank you, Terry.

GROSS: Donald Barlett and James Steele are editors at large for Time
magazine. Their new book is called "Critical Condition."

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Profile: Remembering Rodney Dangerfield
TERRY GROSS, host:

And now we're going to remember Rodney Dangerfield. The comic and actor died
yesterday at the age of 82. Dangerfield created his persona around his
signature line.

Mr. RODNEY DANGERFIELD: One of my problems--you know, I don't get no respect,
no respect at all.

(Soundbite of laughter)

Mr. DANGERFIELD: Every time I get in an elevator, the operator says the same
thing to me: `Basement.'

(Soundbite of laughter)

Mr. DANGERFIELD: I get no respect. The other day I was standing in front of
a big apartment house. The doorman asked me to get him a cab.

(Soundbite of laughter)

Mr. DANGERFIELD: Same thing with my friends. No respect. My friends tell me
when I call on the phone I should use a certain signal. I have to let it
ring twice, hang up and don't call back.

GROSS: Although Dangerfield never stopped complaining on stage that he got no
respect, he was actually revered by many younger comics, not only for his
stand-up comedy but for his performances in such movies as "Caddyshack," "Back
to School" and "Natural Born Killers." Jim Carrey wrote the introduction for
Dangerfield's book, "It's Not Easy Bein' Me," which was published a few months
ago. I spoke with Dangerfield in July, and his voice sounded weak, which
wasn't surprising considering the health problems he'd faced in the past four
years, including heart-bypass surgery, a heart attack and surgery to bypass
clogged arteries in his brain. Nevertheless, Dangerfield told me he hoped to
perform again. Here's an excerpt of our interview.

(Soundbite of July interview)

GROSS: Rodney Dangerfield, welcome to FRESH AIR. Now I gotta ask you, you
know, your comedy is built around your most famous line, `I don't get no
respect.' And you've said that "The Godfather" inspired you to come up with
it. How did it come to you? Did you think of it the first time you saw "The
Godfather" movie? Like, how did it actually...

Mr. DANGERFIELD: Maybe not the first time...

GROSS: Yeah.

Mr. DANGERFIELD: ...but I heard the word `respect.' When "The Godfather"
came out, all you hear was, `She's with me. Show her respect.' `I want
respect. I'm with him.' `OK. Don't know respect? Respect--you're out of
your mind, you know? Respect.' So I wrote a joke about respect and see what
the reaction would be. It's the first joke I wrote. I was working in a place
called Upstairs at the Duplex in Greenwich Village. And I told the joke, and
I says--the first time I said ...(unintelligible) `I don't get no respect.' I
said, `When I was a kid, they played hide-and-seek. They wouldn't even look
for me, you know?' And that was the first joke I wrote, and that was the--and
the audience came over to me afterwards and said, `Hey, me, too, Rodney, no
respect.' `Me, too, Rodney, no respect.' And all of a sudden I found an
image, you know? And it's been good for me (laughs).

GROSS: Now you started doing the `respect' stuff when you came back to show
business...

Mr. DANGERFIELD: Right.

GROSS: ...at around the age of 40. You had left show business for around 12
years. You had a family; you needed to make money to support your family...

Mr. DANGERFIELD: Right.

GROSS: ...and you went into the aluminum siding business for a while.

Mr. DANGERFIELD: Right.

GROSS: What was your act like the first time around?

Mr. DANGERFIELD: When I quit show business--you have any idea how well I was
doing at the time I quit? I was the only one who knew I quit. But...

(Soundbite of laughter)

GROSS: So what were the first jokes you remember telling on stage?

Mr. DANGERFIELD: When I was 17 years old, I was booked by an agent named Jack
Miller(ph), who packed about 10 people in his car in New York, and we all
drove out to Newark. And the first joke I told out there, and it still got a
laugh for me, you know. I said, `Look at the audience tonight. The women
look like a beautiful bed of roses. Of course, there's a weed here and there,
you know.' So that was the joke I told, and I was 17.

GROSS: Now when you started performing, you didn't use the name Rodney
Dangerfield. That was a name...

Mr. DANGERFIELD: My legal name is Jack Roy, R-O-Y. And I started performing,
and that was the name I used the first time in my career. When I came back
the second time, then I became Rodney Dangerfield. And with a name like that,
if you don't hit, you're an idiot, you know.

GROSS: Now you were born with the last name of Roy, but Roy was actually your
father's stage name.

Mr. DANGERFIELD: That's right.

GROSS: His birth name was Cohen.

Mr. DANGERFIELD: His first name was Phil, Philip. Philip Cohen is his legal
name, but he became Roy and Arthur. Arthur was my uncle, and they did a
vaudeville act, you know--comedy vaudeville act. And that was...

GROSS: What was the act like?

Mr. DANGERFIELD: They would break plates. They would throw plates into the
theater like a boomerang, and it would swing over the people's heads and come
back to the stage. That was quite a feat to do it, but they did that mostly
in their act; that was part of it, you know. And other than that, there were
some little juggling and humor, whatever went on there, you know.

GROSS: Now I know you weren't close to your father, and he really didn't even
live with the family when you were growing up. But I'm wondering if you went
to see him much, if you saw his act much.

Mr. DANGERFIELD: I never saw his act; I was too young. But I used to go to
see him twice a year. He lived in New York, a half-hour from Kew Gardens
where we lived. And I'd take a subway in, 10 years old, 12 years old,
whatever it was, and I'd meet him for an hour, then he'd walk me back to the
subway and I'd go home. My father saw me two hours a year; that's what it
amounted to.

GROSS: So did it make you want to be in show business?

Mr. DANGERFIELD: Who knows? I don't know. You know, show me some love, show
me some--I mean, hear the laughs, the applause. I'll take love any way I can
get it, you know. And I guess--Who knows?--to get love, you know, in show
business; to try and make some money, but there's no money in it when you
start. So it's just because you like to do it, I guess.

GROSS: We're listening to an interview with Rodney Dangerfield. He died
yesterday at the age of 82. We'll hear more after a break. This is FRESH
AIR.

(Soundbite of music)

GROSS: Let's get back to the interview with Rodney Dangerfield that we
recorded over the summer. He died yesterday at the age of 82.

(Soundbite of July interview)

GROSS: It seems like you had a really rough childhood. You never got to see
your father, but two hours a year you got to see him. You didn't really like
your mother; she sounds like she was a really difficult woman.

Mr. DANGERFIELD: Yeah.

GROSS: Was there anything that was fun or funny in your childhood? Were
there...

Mr. DANGERFIELD: Nothing funny at all.

GROSS: Seriously? So you think you had an unhappy childhood all the time?

Mr. DANGERFIELD: Extremely. I never went to a ball game; no one took me
anywhere. Being brought up with no father and a mother who was extremely
selfish, right?--she never made me breakfast her entire life; always got up at
11:00. But before I'd go to school, I'd mind the newsstand for an hour and a
half, and I always had the same breakfast: Orangeade, doughnut and coffee.
That was a home-cooked meal for me (laughs).

GROSS: When you decided to get back into show business, one of the ways you
did it was by opening up your own club.

Mr. DANGERFIELD: Well, I'll tell you, the club was opened way after I was in
show business. I was already doing OK when I opened the club, you know. And
I opened the club for--well, one big reason was I had two small kids at home,
you know, at four and eight, and I couldn't leave town and leave them alone.
I had a domestic situation that was difficult, you know. So I decided to open
a nightclub, so that I could be in New York and work in New York only and my
kids won't be alone, you know.

GROSS: Now you helped a lot of comics get started at your club.

Mr. DANGERFIELD: Yeah. Yeah.

GROSS: You want to name some of them?

Mr. DANGERFIELD: Yeah. Well, Jim Carrey. I met Jim, though--he worked at a
club, too, but I met him--I was working in Toronto, and they told me to catch
this fellow; they think he's pretty good. And I caught him, and he was doing
impressions. And he was great, great. So I asked him to work with me. And
the first job we went to was Caesars Palace in Las Vegas, which was a big deal
to him, he told me. You know what I mean? And after that he opened for me
for two years on the road. So I was directly responsible helping him get in
the States and everything else.

Sam Kinison is one of my proteges--or was. He's a genius, Sam Kinison was,
you know. He was too much--and I thought he was great. And I put him on my
show; twice he was on. And Jerry...

GROSS: Seinfeld?

Mr. DANGERFIELD: Yeah, Jerry Seinfeld. He was on the show, too, and a lot
of others: Bob Saget, Louie Anderson, Rita Rudner.

GROSS: Can you talk a little bit about how you put together your act? Do
jokes just come to you whole, or do you have to, like, work at them and refine
them?

Mr. DANGERFIELD: Well, sometimes you hit one right off the bat, suddenly,
boom, right? And sometimes you can try, but you've got to sit and write one,
like I wrote a joke, you know, the other day. It was in the book, I think,
you know. I'm getting old. I had an accident. I was arrested for hit and
walk.

GROSS: Did your mother ever see you perform? Did she live to see you become
very successful?

Mr. DANGERFIELD: I don't know. No, no. No. My father did. In fact, I flew
him up here from Florida to come to the club and spend a night or two in the
apartment with me. So he flew up there. He saw whatever success I had at the
time.

GROSS: Did your relationship change when he saw how successful you were?

Mr. DANGERFIELD: No, I don't think that had nothing to do with it. Our
relationship changed because I became older, and I forgave him for everything.
He cried to me, and he said, `Will you forgive me?' He meant for never seeing
me, never--know what I mean?

GROSS: Mm-hmm.

Mr. DANGERFIELD: Two hours a year, I told you. And knowing my mother, he
couldn't have been happy with her, you know. I like my father better as a
person, you know?

GROSS: Now you write in your book that your father's funeral was one of the
loneliest moments of your life...

Mr. DANGERFIELD: Yeah, right, right.

GROSS: ...and that you were the only one there.

Mr. DANGERFIELD: I was there alone, you know.

GROSS: Yeah, you were the only one at the funeral.

Mr. DANGERFIELD: I was there alone. And as they were lowering his body into
the ground, one of the workers comes over to me and says, `Hey, Rodney, can I
have your autograph?' What timing, you know (laughs)?

GROSS: Now having built so much of your career on this `don't get no respect'
image, do you realize how appreciated you are now in comedy? Do you have a
sense of that?

Mr. DANGERFIELD: Yeah. In my own head, though, you see, I can never be a big
shot. And I just--like, if I check in a hotel and the bellhop grabs my bag, I
feel like I should be taking the bag, you know? But I appreciate the fact
that I'm popular with people. It's a very nice feeling rather than to be
unpopular. So I'm happy about the way things went.

GROSS: Rodney Dangerfield recorded in July. He died yesterday at the age of
82 of complications after heart-valve replacement surgery.

(Credits)

GROSS: I'm Terry Gross.
Transcripts are created on a rush deadline, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of Fresh Air interviews and reviews are the audio recordings of each segment.