A Spoonful of Sugar

How to explain the health care crisis

Why 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.

This makes Sick an honest read. It’s hard not to come away appalled by the American health care system, but it’s also hard not to come away thinking that, one way or another, it does mostly work. Sort of. For the most part, it’s not that people die or literally fail to get lifesaving treatment—though that happens more often than it should—but that chronic conditions (like diabetes or hypertension) are frequently undertreated, while people treated for serious conditions too often end up alive but in penury. And all this despite the fact that American health care is far more expensive than any other health care on the planet. There must be a better way.

It’s at this point that we’re brought face-to-face with the drawbacks of narrative journalism. As good as Sick is—and it’s very good—one can’t help but notice that after more than two hundred pages of diagnosing the ills of the U.S. health care system, Cohn devotes little space at the end of his book to suggesting solutions. And while authors may have a legitimate beef with reviewers who spend time essentially complaining that the author didn’t write the book they wanted written, in this case the criticism is hard to escape. It’s glaringly anticlimactic to get to the end of Sick and discover little more than a few paragraphs suggesting that, yes, universal health care would be a good idea, and perhaps it could take the form of Medicare for everyone. Or maybe we should emulate the French system. Or something.

What to do? This dilemma is displayed in high relief by comparing Sick to The Health Care Mess: How We Got Into It and What It Will Take To Get Out, by Julius Richmond and Rashi Fein, originally published in 2005 but recently released in paperback. Both books cover much of the same ground (though Richmond and Fein spend a lot of time on issues of medical education, a subject not likely to interest many laymen), but if Sick is like a high school class in the history of American health care, The Health Care Mess is more like a college course. (The graduate seminar version would be one of those indigestible Brookings tomes.) Richmond and Fein spend a fair amount of time explaining how the incentives of the American health care system work mostly in the direction of making care more expensive, and the result is that by the time they start talking about solutions in their final chapter we’re better prepared to understand both the substantive tradeoffs between different plans as well as the political lay of the land for getting any of them implemented.

Unfortunately, not many people will get to that final chapter. In taking the usual policymaker’s approach to book writing, Richmond and Fein have produced a treatise that few ordinary citizens—even smart, engaged citizens—will ever pick up. Where Sick reads like a novel, The Health Care Mess reads like a white paper.

The answer, then, isn’t to abandon the narrative form that Cohn uses to such advantage. Rather, it’s to extend it so that it get us thinking about solutions as much as it does about problems—and the obvious place to do this is outside the United States, since that’s where alternatives to the U.S. system exist. In fact, the format of Sick almost begs for narratives about overseas health care systems. The book is basically a tour around America, with each of its eight chapters named after the place in which its story unfolds. So why not include chapters on Manchester, Malmö, and Marseilles, each of them highlighting in narrative form both the good and bad points of the British, Swedish, and French systems? At the very least, France deserves special treatment since, as Cohn correctly points out, its health care system is frequently held up as a model. How does the French system, in which waiting lines are nearly nonexistent and everyone is covered, manage to make smart and reasonable choices about cost, achieving enviable results while spending more than the chronically underfunded British system but less than the chronically inefficient American system?

Moreover, since political attacks on national health care proposals often depend on disparaging comparisons to the state-run systems of other countries (the familiar “hip replacements in Canada” trope), overseas is also the best place to see if those attacks are fair. Are waiting lines for hip replacements in Canada really out of control? Do Swedes really have to wait an average of nearly half a year for heart surgery? Do cancer patients really do poorly in Germany? Whether it’s policy or politics you’re interested in (or both), the best place to find the answers is outside the United States.

That all matters more than usual because a decade after the failure of Bill Clinton’s health care reform proposals, it’s looking more and more like national health care is going to be back on the political—and therefore the journalistic—agenda over the next few years. CEOs are increasingly antsy about rising insurance premiums, the ranks of the uninsured continue to grow, medical costs are plainly out of control, and more and more people are starting to realize that tying health care to employment makes little sense in an era where the average worker changes jobs every seven years.

In an increasingly globalized world, the war on terror has sobered us to the dangers of crippling the foreign reporting and institutional memory of all but a handful of national newspapers. Health care may be about to remind us of this in an entirely new context. Anyone for reopening that Stockholm bureau?

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Kevin Drum writes the Political Animal blog for The Washington Monthly.