by Steven Brill
In using the Obamacare saga to tell the broader story of American healthcare politics and economics, I benefited from the work of reporters who had been on that beat long before I parachuted in. The New York Times, The Wall Street Journal, The Washington Post, Politico, and ProPublica were especially helpful. Indeed, Charles Ornstein’s reporting at ProPublica guided me on several issues and assured me that I wasn’t off base on others. I’m sure his work has done the same for many other journalists.
Several industry publications, such as Modern Healthcare, were also helpful. As soon as it was launched and The Washington Post’s Sarah Kliff started writing there, Vox became another great source of guidance.
A half dozen books about the history and politics of American healthcare provided the basics of the education I needed and, as cited in the Source Notes that follow, the basis for some of what I reported.
The book of books for anyone interested in the subject is Princeton professor Paul Starr’s Pulitzer Prize–winning The Social Transformation of American Medicine (Basic Books, 1982). Professor Starr followed that sweeping history of American healthcare with a book that was even more useful for my recounting of the recent years of the American healthcare battle: Remedy and Reaction: The Peculiar American Struggle Over Healthcare Reform (Yale University Press, 2011). It was my guide to the struggle of twentieth-century American presidents to reform the system, and to the obstacles and accidents of history that befell them along the way.
Inside National Health Reform (University of California Press, 2011), written by a true insider—former Ted Kennedy healthcare aide John McDonough—provided a road map of the ins and outs of the Obamacare legislative process, allowing me to start from a base of knowing the chronology, the players, and many of the issues. My interviewing was much smarter because of McDonough.
David Blumenthal and James Morone’s The Heart of Power (University of California Press, 2010) provided a similar history of past political battles, as did Power, Politics, and Universal Health Care, by Stuart Altman and David Shactman (Prometheus Books, 2011).
Landmark, a book published by The Washington Post’s reporting staff, who exhaustively covered the passage of Obamacare as it happened, also provided important grounding as I began my reporting.
I also want to thank Professor Uwe Reinhardt, the renowned Princeton healthcare economist, whose writings and conversations provided great insight.
Although I conducted all of the interviews and did most of the research, two of my former Yale students, Elaina Plott and Tessa Berenson, helped gather materials related to some of the Yale–New Haven Hospital court cases and the 1943 War Labor Board decision on health insurance benefits. Additionally, the Time research staff, particularly Andrea Sachs, helped nail down some of the factual material in the portions first published in Time.
At Random House, Executive Editor Will Murphy provided great guidance, mixing encouragement with sharp line editing and questioning, as well as a perfect pitch for talking me out of including material that complicated the narrative while encouraging me to add information that explained it more clearly. Will did a terrific job with a difficult subject and author.
Publisher Susan Kamil and Deputy Publisher Tom Perry were enthused about this project from the start and oversaw the work that their colleagues at Random House did in making everything come together. In that regard, Benjamin Dreyer, Evan Camfield, and Richard Elman were attentive to every detail required to transform my typing into a finished book worthy of Random House’s standards. Editorial assistant Mika Kasuga tirelessly coordinated all aspects of my work with this editing and publishing team, after which London King, Leigh Marchant, and their respective publicity and marketing teams kept coming up with creative ways to give this book the largest audience possible. Finally, I want to extend a special appreciation to copy editor Michelle Daniel, who did much more than the usual polishing, including catching a bunch of careless errors and making several suggestions to improve the reader experience.
I owe great thanks to David Kuhn. I always knew he was a good friend and great editor, because we had worked together on one of my magazine ventures. Now I know he’s a great agent. He is still willing to edit manuscripts, and he retains his knack for making writers keep the narrative moving. But now he also helps mightily to turn all that into a winning publishing plan.
Three longtime journalist-friends—Jill Abramson, Jim Warren, and Bob Woodward—were dragooned into reading drafts and providing detailed advice and criticism. So, too, was another former Yale student, Louise Story, who is now a star New York Times reporter.
I am also grateful to physicians Peter Bach and Jennifer Brokaw, as well as to two physicians who asked not to be named. All helped me through the world of medicine and medical terminology.
And, of course, I owe a huge debt to the sources listed on the pages that follow, who gave me so much time and tolerated even the most rookie (and, on occasion, hostile) questions. I am equally grateful to the many more sources who are not listed because they asked not to be, or because their input, while helpful to my overall education, was not directly a source for an event in the narrative.
I interviewed 243 people—many of them multiple times—over twenty-seven months in the reporting that made its way into America’s Bitter Pill. That means I took up a lot of people’s time, for which I thank them. I asked even more of several of those sources—the families who opened their medical records to me—and I owe them a special debt.
Finally, there’s my family. Yes, I’m grateful for how Emily, Sophie, and Sam and their mother, Cynthia, tolerated me when I was absorbed in researching, organizing, and writing all of this. But that was easy compared to how I pestered them to read various parts of even the earliest drafts.
Beyond that, I can never forget the support of a different kind that they provided during the days described in the first chapter, staying with me at all hours in the hospital and helping me recover at home (once I convinced them that my surgery was not an over-the-top act of undercover journalism). For all of that—and for Cynthia’s loving and wise partnership in this as in everything else—I am forever thankful.
APPENDIX
Q&A WITH PRESIDENT OBAMA
Author’s Note
As the text and Source Notes indicate, most officials of the Obama administration cooperated in the reporting of this book.
President Obama agreed to answer questions put to him in writing because, assistant press secretary Eric Schultz explained, “He wants to his voice to be in this book, but wants to offer more thoughtful answers than a brief in-person interview” would provide. I would have preferred an in-person interview, as should my readers, because written answers run the risk of being filtered by the president’s communications apparatus, and because, as demonstrated below, many of the president’s answers deserved the kind of follow-up that only a conversation can facilitate. However, I was assured that the president had read all of my questions and personally signed off on the answers.
Below is the full text of the questions submitted to the president, and his answers, we well as those questions that he specifically declined to answer.
Dear Mr. President:
I have been informed that you have agreed to answer, in writing, a limited number of questions for the book that I am writing about the saga of healthcare reform. The questions will be based on the letter I wrote to you on May 19 outlining my areas of inquiry.
I much appreciate your willingness to engage in this discussion.
As discussed with your press office, I will quote your answers in the book as having been prepared and authorized by you personally.
I am limiting the questions below to a subset of what I outlined in the May 19 letter, although if you want to comment on other issues I raised in the letter, that would, of course, be that much better.
Here are the questions:
QUESTION 1
With regard to point #1 in the letter (healthcare policy in the context of Professo
r Guido Calabresi’s Tragic Choices), how much did you worry about “owning” all of American healthcare as you pushed ahead? Do you think Americans who believe themselves to be on the short end of decisions about the allocation of scarce healthcare resources will ever accept those decisions? (Narrow networks that are provided in lower-cost insurance plans would be a good current example.) Do you think democracies—and ours in particular, in today’s Washington—can handle these “tragic choices” well without resorting to expert, independent panels akin to the base-closing panels?
THE PRESIDENT’S ANSWER
Declined to answer.
QUESTION 2
Is it fair to say that the more you dug into the issue of healthcare during the 2008 campaign—and the more you met people like Mrs. Amy Chicos (in Iowa) on the campaign trail, who were besieged by medical bills—the more you became determined to take this on? Relatedly, I know that many on your staff urged at the start of the Administration that you put healthcare aside in favor of worrying about the stimulus package and the economic recovery. Why didn’t you?
THE PRESIDENT’S ANSWER
Well, we didn’t have the luxury of working on just one big issue—the times demanded more. Within a month of my inauguration, we passed the Recovery Act. By virtually every independent economist’s estimation, that set of policies helped stave off another Great Depression. And combined with a lot of other actions we’ve taken since then, helped put us on the longest stretch of uninterrupted private sector job creation in our history. We had to take action and we did.
But America can do more than one thing at a time. And I believed that reforming our health care system wasn’t a side project, but a vital part of rebuilding our economy. My top priority has always been to restore the notion that America is a place where if you work hard, you can get ahead. And even before the crisis, few things were doing more to expose working families to economic insecurity than a broken health care system. It was clear that we couldn’t address the problem of the middle class falling behind in the long term, without taking on health care in the short term. And we had a once in a generation chance to do it.
Everywhere I went on that first campaign, I heard directly from Americans about what a broken health care system meant to them—the bankruptcies, putting off care until it was too late, not being able to get coverage because of a pre-existing condition. I didn’t just learn about this through the stories of others, I had my own, watching my mom struggle with health insurers to get the care she needed when she was sick. The more people I met, the more it seemed that those kinds of experiences were happening to far too many people. And when the going got tough, thinking of those Americans and what they were going through is what kept me going.
QUESTION 3
With regard to #7 in the letter (the anecdote about what others thought was your flat performance at the your first candidates’ forum, focusing on healthcare, in Las Vegas in 2007), how would you characterize your performance? Someone on your staff said you said it was “not my best night.” True? Also, do you recall Hillary Clinton’s performance? (I know this was a long time ago and seems unimportant in the scheme of things, but I consider your evolution from this point an interesting aspect of the narrative. Any memory you have of it would be helpful.)
THE PRESIDENT’S ANSWER
Declined to answer.
QUESTION 4
Do you recall a memo that Peter Orszag wrote to you just after the law was passed urging you to put in charge someone with experience launching and running ventures as complicated as HealthCare.gov? What were your reasons for not doing so? If you do not recall the memo, do you recall Peter and Larry Summers advising you to do this? Would you tell a president succeeding you that he or she should heed advice like that when it comes to challenges of this nature?
THE PRESIDENT’S ANSWER
At this point, I am not so interested in Monday Morning quarterbacking the past. We failed at its launch. We learned from that and worked hard to pull ourselves out of the hole we put ourselves in before the end of open enrollment. I can tell you this. We learned a lot of lessons. And we’ve taken steps to apply those lessons across the government.
[Health and Human Services] Secretary [Sylvia] Burwell has hit the ground running at HHS. She has made significant changes to ensure accountability and transparency as we head into the second open enrollment period. There is a new Marketplace CEO and CTO position, for example.
We’ve also created a digital service corps to rapidly and effectively prevent, diagnose, and fix technology problems across the federal government. A lot of the HealthCare.gov challenges came from government trying to adapt to technology that is constantly changing and evolving. The digital service corps will create the culture required to help government change along with it. That’s going to make a difference in the long run.
Ultimately, technology has the opportunity to dramatically improve the way people can interact with their government, to make it easier to get answers and services. What you saw towards the end of the last open enrollment, when the Marketplaces were working, was that for the first time, people could compare plans, side by side, and see exactly what they were going to pay for coverage that met their families’ needs. That is revolutionary in the individual market, where before the ACA, you often had to pass a medical screening just to find out what a plan cost.
But on the lessons I have taken from the HealthCare.gov experience, it is fair to say we are embedding those lessons in much bigger work my administration does today. If you believe in making government work for people, you have to operationalize that—and we have work to do in these final years and plenty of room to improve.
QUESTION 5
What do you think the odds are that Todd Park and the alumni of the tech surge team that you have now brought into the Administration can truly change how the government manages technology and technology procurement? How will they be empowered to make changes if (or inevitably, when) they run into red tape and resistance within agencies? Put differently, how can the procurement establishment be prevented from rejecting a guy like the tee-shirted Mikey Dickerson?
THE PRESIDENT’S ANSWER
Well, it wouldn’t be the first time we beat the odds. That is in some way the history of the American experience—us beating the odds through sheer will and dedication to improve things for people. Mikey Dickerson now works at the White House (frequently without a jacket or tie). And he is leading an effort to simplify and improve digital services to help make sure America’s government can be innovative, flexible, and help bring in the talent we need, empowering the great people who already work across the government to take on some of our biggest challenges. I have sent a very clear mandate throughout this administration that it is time to shake things up, change the pace of business. And I hope and expect that future presidents will maintain that attitude.
QUESTION 6
Denis McDonough told me that you always ended the pre-launch meetings with the admonition that none of the plans to attract enrollment would matter unless the technology worked. What would you tell a future President about how perhaps that admonition was not enough?
THE PRESIDENT’S ANSWER
The first week I was on the job, I sought out advice from my first Defense Secretary, Bob Gates, who had been around longer than I had. He said, “One thing you should know, Mr. President, is that at any given moment, on any given day, somebody in the federal government is screwing up.” Which is true, because there are two million employees, and they do remarkable work every day. But, even if you’re firing at a 99.9% success rate that still leaves a lot of opportunity for things not to go as planned.
So you’ve got to have a culture in place where people aren’t afraid to admit there’s a problem. And you’ve got to have a team in place that’s coordinated and flexible enough to tackle the problems that arise. If you don’t have either of these, small problems become big problems quickly.
QUESTION 7
With regard
to #4 in the letter (the political climate), how would you explain the difference in what has happened with Obamacare following its passage compared to the mostly-bipartisan acceptance of Social Security and Medicare once the political fights over passing that legislation were over? (I refer to, and document in the book, the willingness of most on both sides of the aisle in those prior instances to focus on the best ways to implement and improve those laws.)
THE PRESIDENT’S ANSWER
Keep in mind, not only did the ACA become law, it was upheld by the Supreme Court in 2012, and, in the same year, voters rejected the candidate who promised to repeal it. Despite all that, you’ve seen a sustained effort to sabotage the law at every turn—from fifty-something repeal votes to efforts aimed at defunding its implementation, to lawsuits. This from a party that’s typically opposed to frivolous lawsuits.
In contrast, consider what happened when the prescription drug program Medicare Part D was enacted. It had some early challenges. There were technical implementation problems impacting millions of people. Democrats weren’t happy with many aspects of the law. It even added hundreds of billions of dollars to the deficit, unlike the ACA, which will help lower the deficit. But once it was the law, everyone pitched in to try and make it work. Democrats weren’t about to punish millions of seniors just to make a point or settle a score, they held town halls to get seniors signed up. And a decade later, the program is wildly popular.