Ever wonder why American health care and medications cost so much? Do you have any idea what the recently enacted Patient Protection and Affordable Care Act really does? How about whether it’s best to have a long or short hospital stay?

Washington University medical students Elisabeth Askin and Nathan Moore, like legions of medical students before them, discovered that answers to these and other questions aren’t easy to find -- despite the fact that 10 percent of the American workforce is in health care. The information is scattered among tomes and journals, many of which seem designed to proselytize rather than enlighten.

“In so many writings, the author has an agenda,” Askin said. “Sometimes there’s so much research you don’t know what’s what; you can’t see the forest for the trees. I found it really frustrating.”

So did Moore. Together, they decided to do something to help themselves, their fellow medical students and, ultimately, the people for whom they will provide care.

Last summer, they set about writing "The Health-Care Handbook: A Clear and Concise Guide to the United States Health-Care System."

“No one has time to read a whole book (on every topic) and they shouldn’t have to,” Askin said.  “We distilled the information.”

The book comes in under 200 pages, but Askin and Moore made every page count.

“H.L. Mencken said that ‘for every complex problem there is an answer that is clear, simple and wrong,’” Moore quoted, “but every page in our book is a whole book somewhere.” 

Lest things appear too simple, throughout the highly sourced book a caveat is repeated: “Everything is always more complicated than you think.” 

Then they work diligently to make it appear less so.

Tour de force

Future doctors are steeped in science and medicine but receive little formal training in the structure in which they will practice. They learn little about how insurance, government, economics, politics, technology, health literacy – the single best predictor of health status – and numerous other factors affect how they provide medical care. 

“Issues we face are not clearly understood by a lot of people – how health care is organized and financed,” said Dr. William A. Peck, director of Washington University’s Center for Health Policy.  “Elisabeth and Nathan felt there was a need for a foundational book about health care and the health-reform act.”

When the pair approached Peck for advice, he warned of possible impediments.

“I wanted them to know that it could interfere with their medical studies,” Peck said. “I anticipated it would take them longer than a year and I was concerned that neither of them had a lot of experience writing.

“At our first meeting, they handed me a partial outline and it took them less than a year to go from outline to book. It is a tour de force.” 

Each of the book’s five chapters ends with a glossary, a suggested reading list and numerous references. With its dense data simplified in splashes of colored graphs and conversational text sprinkled with occasional bits of humor (e.g., ‘maybe you’ve heard, but Americans aren’t the healthiest people around’), the book is now expected to reach a much wider audience than originally anticipated.  

“This is a book the entire country needs to read,” said Dr. Ed Weisbart, chair of Physicians for a National Health Program-St. Louis. “Certainly, every med student and everyone else in health care would get a better understanding of how health care is organized in America.

“They bent over backward to be nonjudgmental and just present the facts; a balanced and evenhanded description of things,” said Weisbart, the former chief medical officer for Express Scripts.

“It astonishes me that two people in the middle of med school could find the time and energy to produce this.”

Parallel destinies

None was more surprised than the two young authors.

They met at Washington University and “bonded over how much they miss breakfast tacos.” The bond would soon be strengthened by constant work to produce a book.

“We didn’t know what the hell we were doing,” said Moore of their decision to collaborate on a book. “But if something really matters to you, you will find a way to do it.”

Nathan Herling Moore, 26, is a third-year Wash U. medical student from Oklahoma City, Okla.; Elisabeth Boehme Askin, 26, is in her second year of medical school at Wash U. An only child, she was born in Dallas, but moved with her mother to Waco, Tex. when she was nine, a month before the 1993 government standoff with the Branch Dividian religious cult that ended in a deadly fire.   

“My mother thought she’d made a mistake,” Askin laughed. 

The two followed similar paths to medical school. After high school, both graduated Phi Beta Kappa with liberal arts degrees from the University of Texas at Austin. Moore majored in biology; Askin majored in history. Neither entered medical school immediately after receiving a bachelor’s degree. 

During a four-year break, Askin worked as an editorial intern at Texas Monthly magazine and in customer service for a financial services agency, both in Austin. She enrolled in the pre-health post-baccalaureate program at San Francisco State University in 2008 to complete prerequisites for medical school. 

After completing his degree at Austin in 2007, Moore tried his hand as a chemistry teacher, waiter, bartender, camp counselor and toy salesman. He settled on med school in 2009 and entered Washington University. Askin began the program a year later.

Dynamic duo

“I got interested in health policy and public health and found it difficult to get a clear picture of what health care in America is,” Askin said. “Nathan brought up doing a book and in two or three weeks, we had an outline.

“The trick to doing something is just to do it,” Askin added. “If someone had told me I was going to be in med school and write a book, it would have seemed insurmountable.” 

Moore shakes his head in agreement, as both do when the other is talking, then he admits that Askin wrote the entire first draft, jumpstarting the project by writing about 120 pages in three months. 

“It was one of the most impressive things I’ve ever seen,” Moore said.  “Elisabeth is a phenomenal writer.”

Askin concedes that her writing has improved since a college honors thesis novella.   

“I’m from a family of readers and I always enjoyed writing, but I found I’m not cut out to write fiction,” she laughed.

The book, however, has made her aware of something even more important. When a professor kiddingly evaluated the book an “A+”, Moore said she realized she had grown up.

“I was pleased by what the professor said, but I had moved past that mindset,” she said. “I want this (book) to be helpful; we both do. Our job is not done until it has made an impact.”

Both did the tedious research for the book and Moore kept everything on track. 

“Nathan is so on top of it,” Askin said. “He’s organized and knows what we need to do next; I’d be a mess without him.” 

Together, they covered a lot of ground, tackling every conceivable issue, including controversial ones – covered in a ‘pros’ and ‘cons’ format – like the length of hospital stays, the role of politics and lobbyists, how to reduce costs, and the Affordable Care Act. But they began from an obvious starting point.

“To change the system and improve it, we must first agree on what the problems are; that’s where our book comes in,” Moore said.  “We made it as fact-based and neutral as possible so people can see how all these things work together.”

Currently, Moore said, some 32 health professions do not train together, although their efforts often overlap or intersect. Their goal is for every medical professional to have a base of knowledge of how to relate to each other to promote better care. 

“A lot of health care involves politics that divides people – our book will help people focus on the issues.”

While health care has significantly improved in the past 50 years, they say, the biggest problem is cost.

“We are going through a difficult time and have to think how to improve things in a very different way,” Askin said.  “We are at a turning point. Ten to 20 years down the line, things are going to be better because so many smart people are working to make them better.”

Peck includes Askin and Moore in that number.

“I never underestimate the quality of our medical students and students like Nathan and Elisabeth are the reason why,” Peck said.

Hot off the press

Askin is married to David Askin, a human resources manager in Washington University’s Department of Surgery. She spends her leisure time painting.

Moore co-founded Washington University’s Health Economics and Policy Interest Group; he is vice chair of the American College of Physicians National Council of Student Members, and he teaches college prep courses for the Princeton Review. He relaxes by availing himself of St. Louis’ many live music events. 

They are awaiting the printing and web-posting of their book without a hint of trepidation.

Several undergraduate, graduate and residency programs in the St. Louis area have already printed draft copies for their students, and medical schools in four other states have expressed an interest in adding the book to their curricula.

“The book fills a gap,” said Dr. David Windus, professor of medicine and associate dean for Medical Student Education at Wash U. “It’s something that did not exist and we are proud of what they have done.”

“The support we got from Wash U students, professors, practicing physicians and the administration was amazing,” Moore said.

The book acknowledges other supporters, including, classmates, friends and family. It is available on Amazon both as an e-book and as a glossy paperback.

"The Health-Care Handbook" could not be timelier given the uncertain future of health care in America, Peck notes in his foreword to the book.