How Do We Cure a Sick Health Care System?

Johnathan Cohn, author of SICK, discusses why the U.S. is the only developed country that does not guarantee access to medical care as a right of citizenship.

September 4, 2007
 |  Every day, millions of hard-working people struggle to find affordable medical treatment for themselves and their families — unable to pay for prescription drugs and regular check-ups, let alone for hospital visits. Some of these people end up losing money. Others end up losing their health or even their lives.

The United States is the only country in the developed world that does not guarantee access to medical care as a right of citizenship. As outrageous as that fact is, why is it so? What does it mean in the lives of individual Americans and their families? And what can we do about it?

Like Michael Moore’s critically and commercially successful documentary, SiCKO, Jonathan Cohn’s new book, SICK probes the larger problems by focusing on the stories of individuals — most of them working members of the middle class — who are cruelly let down by our failing system.

Jonathan Cohn is a senior editor at The New Republic, where he has been since 1997. Prior to that, Jonathan worked for six years at The American Prospect, where he remains a contributing editor. A senior fellow at Demos, Cohn has also written for many other publications, and is the author of SICK: The Untold Story Of America’s Health Care Crisis — And The People Who Pay The Price.

Terrence McNally: How did you grow to focus as much as you do on health care?

Jonathan Cohn: It happened a little bit by accident. In the 1990s, I was working at The New Republic both as an editor and a writer, and picked up some stories about health care here and there along the way. This was in the years not that long after the fight over the Clinton health care plan. People in Washington really didn’t want to talk very much about health care, and the country wasn’t in the mood for another big health care debate. As I started learning about the issue, it quickly became apparent that all the problems that had led to that earlier debate hadn’t gone away. In fact, they were getting steadily worse. As I read more about the history of health care in this country, I learned that we keep coming back to this debate every 10 to 20 years.

In Washington we talk about numbers, and we have lots of jargon to refer to this policy and that policy — “the crowd-out effect” and “reimbursement levels.” That’s all well and good, but for too long not enough people have cared enough about health care politics to actually make a change. I set out to write a book that could build a bridge between the world of policy and the world of everyday lives.

TM: You said there haven’t been enough people caring enough to fix health care. To me, that’s similar to the War on Drugs. I believe many people agree that drug prohibition doesn’t work, but changing it isn’t one of their top priorities. On the other side, however, there’s a moneyed interest group — the correctional unions and the corrections industry — for whom the status quo is issue number one. In health care, you have a diffuse bunch of people who know something’s wrong versus a single minded and well-financed group for whom preserving the status quo is their number one priority — so far, in both cases, that’s a losing battle.

JC: I’m hardly an expert on the drug war, so it would be wrong of me to really weigh in on that. But I think your description of the way the fight over health care has played out in this country is very true.

If you look over the history going back to the 1920s, which is really when our insurance system comes into existence, the roster of people opposed to change has evolved slightly. In general, some constellation of the insurance industry, drug industry, hospitals and doctors move in and out of the list, depending on what period you’re talking about and what particular issue.

People who are making a lot of money off the way we provide health care now don’t want to change the system, and the number of Americans who find this situation a personal threat to their livelihoods and to their lives has not been large enough to overcome that.

TM: Not large enough or powerful enough.

JC: Exactly. I’m one of those people who would love there to be a world where somehow we could limit the power of corporations and special interest groups. I’m all in favor of things like campaign finance reform. But, I don’t think we’re likely to achieve that in the next two to three years, so it’s incumbent upon us to fortify the support.

You know, polls generally find people in favor of universal health care. It’s a very nice sounding idea. Everybody likes to think that health care is a right. But when the fights start, people get cold feet. They say maybe it’ll mean I have to pay higher taxes or whatever, and they back off. Work has to be done on the organizing front.

TM: The nurses union in California put forth a public financing initiative, which many believe was intended as a precursor to single payer health care — and they failed. Are we unlikely to see single payer health care unless we can mobilize the power of numbers to defeat the power of dollars.

JC: I believe in public financing of campaigns, but I don’t think at the end of the day you’ll ever really tip the balance in favor of the people. Business groups with money are going to find a way to influence politics. I think that’s a reality, there’s nothing we can do about it.

I spend a lot of time looking at history. What happened in 1993 and 1994? What happened in the 1940s when Harry Truman tried it? What happened in the 1960s when Lyndon Johnson succeeded, when the Democrats in Congress created Medicare and Medicaid?

Compare today and ’94 for example. Two differences stand out that I think might be really important in the next few months. The business community has traditionally been lukewarm at best, but pockets of the business community are now not only coming out in favor of universal health care, they actually seem committed to putting some muscle into making it happen.

I think this is not because they’re particularly benevolent or because they’ve become quasi-socialists overnight. They see this as a bottom line issue. They’re sick of paying for these benefits. I think they’ve come to the conclusion that they’re better off if somebody takes this off their hands.

The other positive difference is that groups like the nurses in California, like SEIU, the Service Employees Union, are really putting a lot of time and energy into organizing around this.

It’s very easy to focus on all the people in ’94 who were against reform — pharmaceutical companies, the health insurance associations, the people who gave us “Harry and Louise” — but the big problem back then was the lack of push on the other side. During the 1990s, when Clinton was rolling out his health care plans, he was also pushing NAFTA. The unions were so busy fighting him on NAFTA that they didn’t have the stomach or the resources to really support him on universal health care.

TM: So they were at best lukewarm allies.

JC: Yes, exactly. Going forward, I hope that whoever is going to push this in the next few years would think more strategically about how to build support — because that’s what it’s going to take.

TM: With regard to the business community, one of the statistics that we hear a lot is that every automobile that comes off an assembly line in our beleaguered American auto manufacturers includes $1500 or more for health care. Their Japanese, Korean and German rivals don’t bear that cost because those countries have universal health care. For the first time ever, in July foreign cars outsold domestic cars in America.

JC: I live in Michigan so this is a local story for me. People throw around these numbers pretty easily, so whether it’s $1500 or what have you, it’s unquestionably true that the older industrial companies committed themselves to providing a certain level of benefits that their competitors abroad do not have to provide.

In California, the grocery strike from a couple of years ago was all about health benefits. The grocers feared that Wal-Mart was coming in and was not obligated to pay its non-unionized employees health benefits. I think most people concluded that the grocers basically won that strike. The existing union workers at grocery stores got to keep their benefits, but new workers don’t and over time, they’ll all see the benefits go down.

TM: Yes, they ended up with a two-tier system of those who were grandfathered and those who were not.

JC: Which was a pretty big concession from the union. The irony is, one of the grocers, Steve Bird, the CEO of Safeway, is probably the most recognizable face who’s come out very enthusiastically for universal health care. Now it’s easy to sort of roll your eyes and say “Oh, he’s just looking for PR,” but I can tell you, I’ve written about this guy, he’s put a lot of energy into it.

His ideas of universal health care are a little different than mine — in terms of what kind of benefits should be provided and who exactly should administer them. But a few months ago when Senator Ron Wyden, a Democrat from Oregon and a very committed advocate of what I would call good universal health care, got up to introduce his plan, Steve Bird was standing right next to him, saying this is basically a good idea and we need to go forward with it.

TM: Your book covers the history well. Let’s talk for a moment about why health care in the United States is linked to employment.

I’ve read it goes back to World War II, when there were wage and price controls and a labor shortage. Not allowed to compete on wages, one of the competitive perks a company could offer was health insurance. Then, though Truman, Nixon, Johnson, all wanted to go toward universal health care, we ended up with a gerry-rigged system. While America’s manufacturing base and its unions were strong and workers were less mobile, it seemed to work, but it doesn’t make much sense anymore.

JC: There are lots of historical circumstances along the way that encouraged and propelled it down this path. There was a very logical reason why at the end of the day we came to the corporations. The reality is that to make health insurance work you need a group of people.

TM: You need a large pool.

JC: At any one time you have a bunch of people who are healthy, and you have a few people who are unhealthy and have very large medical bills. Money from people who are healthy covers the expenses of those who are sick. That’s the whole point of insurance.

You need a sort of randomly selected group of people, that’s the only way insurance can work. This is one of the reasons that every other developed country has eventually said “Look, the most logical way to do this is to take the largest pool, get the whole country contributing, so we’re all in this together.

When we started this conversation about health insurance in the 20s and the 30s, there were people talking about having national health insurance as part of the New Deal along with the Social Security Act. At that time the AMA was very opposed, and so we didn’t get national health insurance. But they had to come up with some other way to do it. If you’re looking for large groups of people in society, where are you going to find them? The workplace.

TM: Why do you believe people are made so easily afraid of single payer universal health care? Let me suggest that it’s because of the way it’s been defined and defamed. People talk about being for or against “government health care,” when, in fact, we’re really talking about “government health insurance.”

JC: That’s absolutely right. Universal health care, single payer health care, is a term that a lot of people consider radioactive. But no one’s talking about taking all the doctors and hospitals in the country and turning them into government employees like you find at the Post Office. The irony, however, is that some of the best health care in America — if you believe the experts — is actually the VA, an example of doctors paid by the government.

But let’s leave that out, because we’re a long way from creating that for the rest of the country. Single payer health insurance basically means that the government provides health insurance to everybody. These are still private doctors and private hospitals. You can even have universal health care that is not single payer. I mean if you’re really wedded to this idea that you can’t have the government be the insurer, you could do it through private insurance. I think at the end of the day it’s less efficient, but it can be done that way too.

If the idea of government run health insurance sounds really scary to you, then ask yourself what is the most popular health insurance program in the United States today, the one that everybody treasures, that if you take polls and ask people, are you happy with your health insurance, you get the highest positive response? It’s Medicare. And who runs Medicare? The federal government.

TM: Exactly. Why the disconnect?

JC: I can tell you, in my own interviews people say, “Don’t let the government get its hands on my Medicare.” Now that’s a disconnect.

I think there’s two things going on: In America — and this goes back to the founding of the country, back to why we’re different than Europe, back to the 17th century — we’re more independent-minded and more suspicious of the State.

That’s one part of it, but another is that we’ve spent the last 20 to 30 years in a fairly conservative era, hearing over and over again that the government screws things up, the government can’t do anything right, the private sector is better, business is better. This has been drummed into our heads.

TM: … When you link that to the confusion between insurance and care …

JC: It’s a very combustible mix.

You can argue about other parts of the economy, but on health care I think the evidence is unambiguous. The government does it better. That’s true here, and it’s true abroad.

There’s obviously a demonization of national health insurance abroad — which takes by the way 30,000 different forms. Every country does it in a different way that meets its own cultural preferences. But look at Germany, France, Switzerland and Japan — four countries who do health insurance in radically different ways. All of them manage to provide their citizens with good care, and cutting edge — when they need it. Nobody seems to do preventive care that well, but there they’re as good as we are.

All these countries have convenience, they have choice of doctor, they cover everybody and they spend less than we do. To hear conservative predictions, you would think that to have universal health care means you’re going to have to wait five months to get treatment for your heart attack, you could never choose your own doctor, and you’d be paying all of your money in taxes.

TM: What’s the overhead in private health insurance in this country that goes to insurance, marketing, administration etc.? … Something like 21, 22 percent?

JC: It depends on the insurer. The best, the most efficient are down to 10, 12, 15 percent, but in general you’re talking 15, 20, 25, 30 percent.

TM: And Medicare?

JC: Two to three percent.

TM: How much of our GDP do we pay on health care compared to Canada? The last time I looked it was over 15 percent here and around 10 percent there.

JC: Yes, I think we’re at three or four percent GDP more than Canada.

TM: That means we’ve got a fudge factor equal to four percent of our GDP. Our GDP is enormous. You can ask how long do they wait or how much do they ration? But then you have to look at the fact that we would have four percent of our GDP to pick up the slack. Do you agree?

JC: Absolutely, no question.

TM: Finally, I believe you can’t counter a good story — even a false one — with facts. As persuasive as those numbers we just laid out might be, you have to do it with stories. Though your book fills in the policy questions and the history — like Michael Moore’s movie, SiCKO — it focuses on personal stories, especially of working and middle-class folks who probably believed they were going to be okay.

JC: At the end of the day, people are going to ask, “How would universal health care affect me?” You can throw all the statistics in the world out there, but I think stories are finally going to get people’s attention — which is why I wrote the book the way I did. They’ll remember a story.

I hope that they read my book or see Michael Moore’s movie, and say, “Oh, that could be me … But for a little bit of luck here or there, I could have gone through that … And this is not fair. It shouldn’t have happened to that person, and I don’t want it happening to me. This is wrong. We need to change it.”

Personal narrative has the power to make seemingly abstract numbers and figures suddenly seem personal. I think that’s really the whole ball game.

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