Review —
A Spoonful of Sugar
How to explain the health care crisis
By Kevin DrumWhy are so many of the most pressing subjects in national politics also the most tedious? Social Security reform is certainly right up there. H. L. Mencken himself would have a hard time making an interesting story out of payroll tax caps and trust-fund solvency projections. What else? Poverty programs for Africa. Comprehensive energy independence plans. The looming current-account deficit with China.
And, of course, health care policy in all its detailed glory. Capitation rates. Health savings accounts. Single payer versus multipayer plans. Cost containment. Privacy issues. The uninsured. FDA testing reform. COBRA and HIPAA. The ghost of Hillarycare.
If you’re starting to nod off already, you’re not alone. Even more than in most policy areas, health care is one where the details matter a lot, but those details are almost mind-numbingly boring. This makes it a tough nut to crack for most journalists.
Jonathan Cohn, a senior editor at The New Republic, was obviously well aware of this problem when he decided to write Sick, an exploration of the history and operation of the U.S. health care system. How do you make the story of the origins of Blue Cross come alive? How do you decipher the intricacies of SCHIP and Medicaid? How do you describe the difference between experience rating and community rating without lapsing into incomprehensible wonk-speak? Or explain our continued attachment to linking health care to employment? Cohn’s solution is simple: he decided to treat his subject as an exercise in narrative journalism.
This is hardly a surprising decision since narrative has become a staple of contemporary reporting. What makes it unusual here is its scope. Rather than using the narrative formula to highlight a specific health care problem—as, for example, The New York Times did in early 2006 in its monster four-part, twenty-thousand-word series about the diabetes epidemic—Cohn uses a series of bite-sized narratives as a clever framing device to draw readers into what would otherwise be a dreary description of seventy years of health care policy.
This approach has its drawbacks (more on this later), but on its own terms it succeeds brilliantly. Take the story of Lester Sampson, a longtime worker at J.P. Morrell, a meat-processing operation in Sioux Falls, South Dakota. Sampson began working for Morrell during World War II, left for a few years after being drafted, and then returned after the war, eventually working on the plant floor for thirty years. During that time he chose to accept a reduced pension plan in return for a promise of continued medical coverage after he left Morrell.
So when he retired in 1985 and took a job with the local school system, Sampson declined its medical insurance because Morrell already covered him. Why bother with two plans, after all? The answer came a few years later when Morrell, under increasing financial pressure, unilaterally ended its retiree medical plan. The school system’s medical plan was open only to new hires, and although Medicare had begun covering Sampson when he turned sixty-five, its protection is spotty and full coverage required the purchase of a Medigap policy at a cost of about $400 a month—a big chunk of money for a blue-collar retiree. For a while, Sampson and his wife Audrey reduced their costs by taking annual trips south where they bought prescription drugs across the border in Nogales, Mexico, but after a few years, those trips stopped. The extra $400 a month kept eating away at their savings, eventually forcing them to sell their retirement home and move into an apartment in Sioux Falls.
In 2003, Congress passed a prescription drug bill that should have helped the Sampsons out. Unfortunately, the choice of plans was bewildering, and Audrey Sampson spent months trying to find a plan that would cover an expensive medication she took for a rare lung disorder. She never did.
It’s almost impossible not to come away from this story asking all the right questions. How could Morrell just unilaterally end its retiree medical plan? Why do employers allow employees to sign up for medical coverage only when they’re first hired? Why are prescription drugs cheaper in Mexico than here? And why was the 2003 prescription drug program so insanely complex?
Well, a spoonful of sugar makes the medicine go down, and by the time you get to the answers, which are woven in throughout the chapter, you’re actually interested in reading about them. And by presenting the explanatory policy and history segments in small chunks (usually not much more than four or five pages at a time), Cohn makes them easily digestible. At about the time a reader might be tempted to start skimming ahead, the wonkishness stops and the storytelling picks up again.
It helps that Cohn is a terrific storyteller, as well as one who doesn’t insist on twisting his tales into polemics. The story of the Sampsons is typical. Their lives were never threatened. By hook or by crook they always managed to get the treatment they needed. They had to sell their retirement home, but they were never reduced to poverty by medical bills. What’s more, Cohn even makes clear that Morrell’s decision, as brutal as it was, was driven by competitive forces in the meat-processing industry that were mostly beyond the company’s control. Morrell was caught in the middle of the same screwy, jury-rigged health care system that all the rest of us are caught in, too.
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Bob LeDrew - Flacklife![[TypeKey Profile Page]](http://www.cjr.org/nav-commenters.gif)
Thu 2 Aug 2007 11:57 AMI find the rhetoric some use to disparage the Canadian health-care system laughable. I am a 40-year-old man who has had bladder cancer; my father has had multiple cancer diagnoses as well as an abdominal aortic aneurysm, emphysema, and circulation problems in his legs; my mother has respiratory difficulties and has a fractured vertebra from a fall; and I have had friends who have had kidney transplants and who have fought cancer, in one case for 10 years.
Neither I nor any of these people suffered an unacceptable wait. Treatment has been effective and prompt.
I hear the propaganda -- 'socialized medicine', bare-bones care, nightmare -- and I'd laugh if it weren't so pathetic.
I'm not a health-care expert; but right wing policy shops in the United States (and Canada) must not be looking at the same health-care system that I'm part of.
NoMoreBlatherDotCom![[TypeKey Profile Page]](http://www.cjr.org/nav-commenters.gif)
Thu 2 Aug 2007 10:59 PMCanada and the other countries mentioned in the review are different from the U.S. in that none of them neighbor a Third World country. In fact, there are 500 million people to the south of the U.S., almost all of whom are very poor. Combined with a power-mad Democratic party that fully supports massive illegal immigration and you've got a recipe for disaster.
And, Dem bloggers and others who try to sell UHC consistently fail to discuss that side of this issue or handwave it away. Do either of the books discuss that side of the issue? Oddly enough, that's not in the review, but then again I wouldn't expect it to be since Drum is not only one of those handwavers, but comments trying to discuss illegal immigration's impact on UHC were deleted from his site.
Perhaps the CJR could provide us with a review of these books from someone who's more skeptical about UHC or at least someone who's not afraid to discuss everything involved in its implementation.
Danb![[TypeKey Profile Page]](http://www.cjr.org/nav-commenters.gif)
Sat 4 Aug 2007 09:00 AMFew health care reform proposals give much more than a nod, if that, to preventive medicine and --heaven forbid-- public health. There is still a public health system, but it receives only 2 cents of every dollar spent on health.
In this vein, we as a nation are fairly overweight, dependent upon the auto, etc. and we over consume many things.
Couple this to the emerging energy crisis --hospitals are enormous energy sinks-- and you've got a truly unsustainable system. It is most likely to crack, however portions of it may react to reflect the reality of a post peak oil world --and include global warming as a second driving force.
The future of health care is in taking preventive care seriously and universal care (all current red herrings and canards for preserving the status quo will lose credibility) for all.
Wonks almost never place health care in an ecological context, the one that really matters.
SalHepatica![[TypeKey Profile Page]](http://www.cjr.org/nav-commenters.gif)
Sun 5 Aug 2007 01:34 PMNoMoreBlather fails to live up to his screen name when he cites illegal immigration as a significant argument against universal health care. The other countries that do not "border a Third World country" nevertheless have a lot of poor and disenfranchised immigrants in their population. These people managed to arrive in places like Canada, Britain, Germany and France despite their inability to "walk across the border." There are these things called boats, trains and airplanes that make it possible. You think it's really all that difficult for poor Africans to catch a boat to France or cross the Strait of Gibraltar into Spain? Migration from the Middle East into Western Europe is mostly a land trip. Ever occur to you that universal health care might offer another opportunity to double and triple check immigrants' legal status?
As for blaming the Democratic party for illegal immigration, it was the Bush administration that sharply cut workplace green-card enforcement when it came to town. Prosecutions went from the thousands in 1998 to something like the low hundreds in 2002. The Bush administration has only recently rushed to replace funding to border patrols that it sharply cut in its first term.