The Best American Magazine Writing 2014

by The American Society of Magazine Editors

  In the men’s room, I threw my undershorts into a waste bin and washed my pants in the sink, trying to keep the wet spot small. I was in my stocking feet, putting my pants back on, when a guard entered abruptly and stood alert and suspicious in the doorway. He informed me that the library was closing. I’ll be only another moment, I assured him.

  A few minutes later, shielding the wet seat of my pants with my briefcase, I met a friend for dinner nearby. When the maître d’ asked whether we preferred eating outdoors or in, I suggested we sit outside. I didn’t tell my friend where I’d been that day.

  Over the years, I’d spoken to very few people about Shier—my brother, serious girlfriends, my wife, a few close friends. I didn’t feel any need to be heard, and the chance of being misunderstood, of being taken for no more than the innocent victim, long ago, of a criminal’s heinous acts seemed great. Pity, I thought, would take things in the wrong direction for me. What I wanted to know now was: What happened to me?

  • • •

  In the months following my visit to the building on Riverside, I placed an occasional call to state and county agencies in California, trying to track down some of the details that might have framed my story. Doing this, I came to suspect that I was missing the memory of certain events. I could recall many scenes from my childhood in the Valley, even remember some vividly, but I also became aware of gaps in that period of time from which nothing surfaced.

  In the fall of 1996, I visited a therapist for the first time. I’d briefly seen a psychiatrist when I was in college, but we were not able to get anywhere. Years later, I understood it was because I hadn’t been capable at the time of doing the required work. My expectation was that she would somehow simply fix me, get me over the anxiety, over the humiliation.

  I chose therapy because my own efforts to clarify my past seemed dramatically unproductive, and because I was now, once again, of a mind that something was wrong with me. I had begun to recognize patterns in my behavior. If I sensed, for example, that I was being manipulated by someone, or disrespected, I quickly became furious out of all proportion. And I’d freeze sometimes when faced with a serious threat instead of calmly moving toward some sort of resolution. I suspected that these habits—no great insight—were rooted in my childhood experience.

  Also, a persistent, anxiety-induced muscular tension across my shoulders had by now become so severe that I’d ruptured a cervical disc. When a regimen of steroids brought only limited relief, my doctor recommended surgery. After a second doctor said I had no option but surgery, I reluctantly agreed—until the surgical procedure was drawn up for me on a piece of paper: I’d be placed facedown and unconscious on an operating table, and a one-inch vertical slit would be opened in the nape of my neck. I said no, absolutely not. I’d live with the pain.

  From the beginning, the therapist encouraged me to move at my own pace through the memories I was able to retrieve, and to resist the urge to fit any of these events into a pattern. I remember him saying in one of our first sessions, with regard to my apparent inability to protect myself in complex emotional situations such as my stepfather’s betrayal, that I did “not even understand the concept of self-protection.” I resented the statement. It made me feel stupid—but it also seemed like a start.

  We worked together for four years. I described for him the particulars of the abuse: the sandpaper burn of Shier’s evening stubble on my skin; his antic chihuahua, which defecated on the floor of the apartment and raced around on the bed when we were in it; Shier’s tongue jammed into my mouth. I described the time he forced me to perform fellatio in my home while my mother and brother were away. Shier lay back on Mother’s sleeping couch, self-absorbed, palming my head like a melon, supremely at ease. I told the therapist about my inability to break off the relationship with Shier and about my mother’s apparent intention to look the other way.

  At the start of therapy, I speculated that the real horror of those years would prove to be the actual acts of abuse—my choking on his semen, the towel forced over my face to silence me, the rectal bleeding. After a while, I began to see that the horror was more elusive, that it included more than just betrayals and denials and being yanked around in Shier’s bed like a rag doll. The enduring horror was that I had learned to accommodate brutalization. This part of the experience remained with me long after I walked out of Shier’s apartment for the last time.

  Caught up in someone else’s psychosis, overmatched at every turn, I had concentrated on only one thing: survival. To survive I needed to placate. My response to emotional confrontation in the years following that time, I came to see, was almost always to acquiesce or to overreact angrily, with no option in between. Therapy led me to comprehend that I had not, as I wanted to believe, been able to tough out the trauma. I had succumbed, and others besides me had experienced the consequences of my attempt to endure. I had ahead of me now a chance to do better, to be a person less given to anger.

  I visited the therapist twice a week to start with, occasionally for double sessions; then it was once a week or less frequently until we decided we’d come to a resting place. In our final sessions, I fitted the pieces of my story together differently, creating “another narrative,” as therapists are wont to say, of the early years in California, a broader context for the physical and emotional damage. After that, long-term sexual abuse no longer organized the meaning of my life as it had during the years I believed that I’d simply walked away from it.

  One night in 1998, driving from the town where I had been seeing the therapist forty miles upriver to my home, I suddenly felt flooded with relief. The sensation was so strong I pulled over and got out of the truck. I walked to the edge of what I knew to be an unfenced, cultivated field. At first I thought I was experiencing physical relief, the breakdown of the last bit of tension in my upper back, which, after many weeks of physical therapy, no longer required surgery. But it was something else. A stony, over-bearing presence I’d been fearful of nearly all my life wasn’t there anymore. I stood in the dark by the side of the road for a long while, savoring the reprieve, the sudden disappearance of this tyranny. I recalled a dream I’d had midway through my therapy. I burst through a heavy cellar door and surprised an ogre devouring the entrails of a gutted infant, alive but impassive in the grip of his hand. The ogre was enraged at being discovered. What seemed significant was that I had broken down the door. It didn’t matter whether it was the door into something or the door out.

  Therapy’s success for me was not so much my coming to understand that I had learned as a child to tolerate acts of abuse. It was discovering a greater capacity within myself to empathize with another person’s nightmare. Most of the unresolved fear and anger I once held on to has now metamorphosed into compassion, an understanding of the predicaments nearly everyone encounters, at some level, at some time, in their lives.

  • • •

  A commonplace about trauma, one buried deep in the psyches of American men, is that it is noble to heal alone. What I’ve learned in recent years, however, is that this choice sometimes becomes a path to further isolation and trouble, especially for the family and friends of the one who has been wounded. I took exactly this path, intending to bother no one with my determined effort to recalibrate my life. It took a long while for me to understand that a crucial component of recovery from trauma is learning to comprehend and accept the embrace of someone who has no specific knowledge of what happened to you, who is disinterested.

  We need others to bring us back into the comity of human life. This appears to have been the final lesson for me—to appreciate someone’s embrace not as forgiveness or as an amicable judgment but as an acknowledgment that, from time to time, private life becomes brutally hard for every one of us, and that without one another, without some sort of community, the nightmare is prone to lurk, waiting for an opening.

  I’m not interested any longer in tracking down the details of Harry Shier’s death, or in wondering how, if it is still there
, I might reenter his apartment above the building on Riverside Drive to gaze out at the sky through the corner window. I’m on the alert, now, though, for an often innocuous moment, the one in which an adult man begins to show an unusual interest in the welfare of someone’s young son—especially if it’s my grandson. He still, at the age of nine, reaches out for my hand when we start to cross a dangerous street.

  Time

  WINNER—PUBLIC INTEREST

  There was little surprise this year when Time won the National Magazine Award for Public Interest for Steven Brill’s “Bitter Pill,” a 24,000-word piece that clearly explains the inordinately complicated business that is American health care. The reporting is thorough, even obsessive; the analysis, both dispassionate and damning; the sympathy for health-care consumers suffering financial distress, strongly felt yet never disabling. Brill was the founder of American Lawyer—which won four National Magazine Awards while he was editor in chief—and later CourtTV and Journalism Online, a company that helps publications charge for content. Time won the National Magazine Awards for Public Interest in 1999 and 2001, when Walter Isaacson was editor, and Magazine of the Year in 2012, while Rick Stengel was in charge.

  Steven Brill

  Bitter Pill: Why Medical Bills Are Killing Us

  1. Routine Care, Unforgettable Bills

  When Sean Recchi, a forty-two-year-old from Lancaster, Ohio, was told last March that he had non-Hodgkin’s lymphoma, his wife Stephanie knew she had to get him to MD Anderson Cancer Center in Houston. Stephanie’s father had been treated there ten years earlier, and she and her family credited the doctors and nurses at MD Anderson with extending his life by at least eight years.

  Because Stephanie and her husband had recently started their own small technology business, they were unable to buy comprehensive health insurance. For $469 a month, or about 20 percent of their income, they had been able to get only a policy that covered just $2,000 per day of any hospital costs. “We don’t take that kind of discount insurance,” said the woman at MD Anderson when Stephanie called to make an appointment for Sean.

  Stephanie was then told by a billing clerk that the estimated cost of Sean’s visit—just to be examined for six days so a treatment plan could be devised—would be $48,900, due in advance. Stephanie got her mother to write her a check. “You do anything you can in a situation like that,” she says. The Recchis flew to Houston, leaving Stephanie’s mother to care for their two teenage children.

  About a week later, Stephanie had to ask her mother for $35,000 more so Sean could begin the treatment the doctors had decided was urgent. His condition had worsened rapidly since he had arrived in Houston. He was “sweating and shaking with chills and pains,” Stephanie recalls. “He had a large mass in his chest that was … growing. He was panicked.”

  Nonetheless, Sean was held for about ninety minutes in a reception area, she says, because the hospital could not confirm that the check had cleared. Sean was allowed to see the doctor only after he advanced MD Anderson $7,500 from his credit card. The hospital says there was nothing unusual about how Sean was kept waiting. According to MD Anderson communications manager Julie Penne, “Asking for advance payment for services is a common, if unfortunate, situation that confronts hospitals all over the United States.”

  The total cost, in advance, for Sean to get his treatment plan and initial doses of chemotherapy was $83,900.

  Why?

  The first of the 344 lines printed out across eight pages of his hospital bill—filled with indecipherable numerical codes and acronyms—seemed innocuous. But it set the tone for all that followed. It read, “1 ACETAMINOPHE TABS 325 MG.” The charge was only $1.50, but it was for a generic version of a Tylenol pill. You can buy a hundred of them on Amazon for $1.49 even without a hospital’s purchasing power.

  Dozens of midpriced items were embedded with similarly aggressive markups, like $283.00 for a “CHEST, PA AND LAT 71020.” That’s a simple chest X-ray, for which MD Anderson is routinely paid $20.44 when it treats a patient on Medicare, the government health-care program for the elderly.

  Every time a nurse drew blood, a “ROUTINE VENIPUNCTURE” charge of $36.00 appeared, accompanied by charges of $23 to $78 for each of a dozen or more lab analyses performed on the blood sample. In all, the charges for blood and other lab tests done on Recchi amounted to more than $15,000. Had Recchi been old enough for Medicare, MD Anderson would have been paid a few hundred dollars for all those tests. By law, Medicare’s payments approximate a hospital’s cost of providing a service, including overhead, equipment, and salaries.

  On the second page of the bill, the markups got bolder. Recchi was charged $13,702 for “1 RITUXIMAB INJ 660 MG.” That’s an injection of 660 mg of a cancer wonder drug called Rituxan. The average price paid by all hospitals for this dose is about $4,000, but MD Anderson probably gets a volume discount that would make its cost $3,000 to $3,500. That means the nonprofit cancer center’s paid-in-advance markup on Recchi’s lifesaving shot would be about 400 percent.

  When I asked MD Anderson to comment on the charges on Recchi’s bill, the cancer center released a written statement that said in part, “The issues related to health care finance are complex for patients, health care providers, payers and government entities alike. … MD Anderson’s clinical billing and collection practices are similar to those of other major hospitals and academic medical centers.”

  The hospital’s hard-nosed approach pays off. Although it is officially a nonprofit unit of the University of Texas, MD Anderson has revenue that exceeds the cost of the world-class care it provides by so much that its operating profit for the fiscal year 2010, the most recent annual report it filed with the U.S. Department of Health and Human Services, was $531 million. That’s a profit margin of 26 percent on revenue of $2.05 billion, an astounding result for such a service-intensive enterprise.1

  The president of MD Anderson is paid like someone running a prosperous business. Ronald DePinho’s total compensation last year was $1,845,000. That does not count outside earnings derived from a much publicized waiver he received from the university that, according to the Houston Chronicle, allows him to maintain unspecified “financial ties with his three principal pharmaceutical companies.”

  DePinho’s salary is nearly two and a half times the $750,000 paid to Francisco Cigarroa, the chancellor of entire University of Texas system, of which MD Anderson is a part. This pay structure is emblematic of American medical economics and is reflected on campuses across the United States, where the president of a hospital or hospital system associated with a university—whether it’s Texas, Stanford, Duke, or Yale—is invariably paid much more than the person in charge of the university.

  I got the idea for this article when I was visiting Rice University last year. As I was leaving the campus, which is just outside the central business district of Houston, I noticed a group of glass skyscrapers about a mile away lighting up the evening sky. The scene looked like Dubai. I was looking at the Texas Medical Center, a nearly 1,300-acre, 280-building complex of hospitals and related medical facilities, of which MD Anderson is the lead brand name. Medicine had obviously become a huge business. In fact, of Houston’s top ten employers, five are hospitals, including MD Anderson with 19,000 employees; three, led by ExxonMobil with 14,000 employees, are energy companies. How did that happen, I wondered. Where’s all that money coming from? And where is it going? I have spent the past seven months trying to find out by analyzing a variety of bills from hospitals like MD Anderson, doctors, drug companies, and every other player in the American health-care ecosystem.

  When you look behind the bills that Sean Recchi and other patients receive, you see nothing rational—no rhyme or reason—about the costs they faced in a marketplace they enter through no choice of their own. The only constant is the sticker shock for the patients who are asked to pay.

  Yet those who work in the health-care industry and those who argue over health-care policy seem inured to the shock. When
we debate health-care policy, we seem to jump right to the issue of who should pay the bills, blowing past what should be the first question: Why exactly are the bills so high?

  What are the reasons, good or bad, that cancer means a half-million- or million-dollar tab? Why should a trip to the emergency room for chest pains that turn out to be indigestion bring a bill that can exceed the cost of a semester of college? What makes a single dose of even the most wonderful wonder drug cost thousands of dollars? Why does simple lab work done during a few days in a hospital cost more than a car? And what is so different about the medical ecosystem that causes technology advances to drive bills up instead of down?

  Recchi’s bill and six others examined line by line for this article offer a close-up window into what happens when powerless buyers—whether they are people like Recchi or big health-insurance companies—meet sellers in what is the ultimate seller’s market.

  The result is a uniquely American gold rush for those who provide everything from wonder drugs to canes to high-tech implants to CT scans to hospital bill-coding and collection services. In hundreds of small and midsize cities across the country—from Stamford, Conn., to Marlton, N.J., to Oklahoma City—the American health-care market has transformed tax-exempt “nonprofit” hospitals into the towns’ most profitable businesses and largest employers, often presided over by the regions’ most richly compensated executives. And in our largest cities, the system offers lavish paychecks even to midlevel hospital managers, like the fourteen administrators at New York City’s Memorial Sloan-Kettering Cancer Center who are paid over $500,000 a year, including six who make over $1 million.