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February 18, 2013 11:53 AM Getting the Knowledge on Health Reform from the New Republic’s Jonathan Cohn

By Harold Pollack

During the health reform fight, a handful of people emerged with distinctive voices, who had a huge impact. The best of them combined the policy expertise, empathy, and graceful writing to command public attention as we finally extended health insurance coverage to millions of people.

Jonathan Cohn, senior editor of the New Republic was certainly one of those people. His award-winning 2007 book Sick chronicled the plight of uninsured and underinsured Americans. The New Yorker’s Atul Gawande called Sick “stunningly important … In one damning true story after another, Jonathan Cohn lays bare the tragedy of our health care system.”

Jonathan also originated and ran an influential blog called “The Treatment,” covering the daily fight over health reform. I was a special correspondent for “The Treatment” during 2009 and 2010. Having Jonathan as my editor there was a just a very special opportunity for me in my midlife-crisis journalism career.

Jonathan and I sat down for a two-part video conversation at healthinsurance.org regarding how health reform is going, the President’s inaugural address, and other matters. Please check it out.

Some of the video is included above. An edited transcript follows, below the fold, for those who prefer.

cohn_pollack_WH Jonathan Cohn: [0:03] All right. I’m Jonathan Cohn. I’m a Senior Editor at the New Republic. I have been writing about domestic politics and policy for…we won’t say how long it is, but I have been writing about healthcare for…I’m going to say more than a decade. [0:21] I started in the late ’90s, in the great aftermath of the Clinton healthcare plan, when nobody wanted to talk about healthcare.

[0:32] I eventually spent a lot of time talking to people who found themselves in the position of not being able to pay their medical bills. .. They didn’t have insurance. They had insurance that didn’t cover what they needed. That sort of introduced me to the world of healthcare policy?” which I’ve been covering ever since.

[0:50] Since 2007… I’ve been covering the debate over healthcare reform, the struggle to pass healthcare reform, the defense of healthcare reform, and now be the implementation of healthcare reform.

Harold: [1:10] You and I went to the White House together, and were jammed in the back of the East Room, watching the President sign that. At the time, it seemed like the culmination ‑‑ at least psychically ‑‑ it seemed like, “Wow, we finally accomplished it,” but what it really was was getting to Square One, or actually Square Minus One. How do you think it’s going?

Jonathan: [1:36] My starting point is that we look back where we were. As recently as three months ago, we didn’t know whether healthcare reform, the Affordable Care Act, Obamacare, would still be on the books. [1:50] As you said, after President Obama signed the law, it had to survive its Supreme Court challenge, it had to survive the 2012 election. The fact that it’s still on the books, as far as I’m concerned, is great. That’s a number one headline, “The law is still there!”

[2:09] Now we get to implementation. It’s going to be complicated and it’s going to be messy. This is, first of all we’re dealing with a crazy healthcare system…

Harold: [2:21] It’s going to be a wild ride because there’s risks to all sides in this…. There are all these purple state Republican governors who are under incredible pressure to take the money and Medicaid. If they don’t, they’re really going to have to explain to doctors and hospitals and nursing homes and patients why they’re leaving huge amounts of money on the table and leaving people unserved. [2:44] At the same time, Democrats picking up the health insurance exchanges are running the risk that it’s just going to be an incredible mess and that they’re going to be held accountable for all the glitches of this unbelievably complicated venture….

Jonathan: [3:01] The law still exists and now we have to implement the law. Let’s face it, this was always going to be difficult. It was always going to be difficult because the healthcare system is very complicated and because we have chosen to address that with an equally complicated law.

That’s a function of politics ‑‑ when I say politics it’s not just a function of the fact that we have lots of special interests. [3:28] But it’s also a split in the function of public opinion. When you look at the Affordable Care Act, you think, “Oh my god, who created this crazy, complicated…” Even people like you and me have to read it over again and ask experts what it means, why is that?

[3:44] Well, partly it’s because to get something through Congress you have to get enough votes. To get the votes, you have to make sure that every interest group, that is‑that hospitals were OK with it, the drug makers, people who wanted to give coverage to people. You just go down the line. And you have the unions, the employers, the insurers, everybody.

But it’s also the fact that people have very conflicting opinions about what they want. The starting point for any realistic political conversation about healthcare reform was always the fact that people who have private insurance right now through their employers, most of them, they want to keep that insurance.

[4:29] So if the conversation starts off with, “We’re going to get rid of the current system to give you something else,” it doesn’t matter how good that new system is. You and I can sit and talk ourselves blue in the face about what a great‑how a single‑payer system, something like Medicare, something like they have in a lot of foreign countries—how great that would be. I believe that, by the way. And then you probably do too. It doesn’t matter, that was not going to go anywhere. So we have this crazy system that was always going to make it complicated.

[4:57] Throw in the fact that, in general, it’s hard to implement a healthcare system. They’re discovering now, even in the states where they’re going to do the best job of this, who know what they’re doing. There are technological challenges, for example ‑‑ getting information technology to work so that if you go to buy an insurance policy on your own, you’re one of the people that you don’t get it from your employer so you have to go get insurance on your own.

[5:25] In theory, this is going to be very simple. You’ll go to a website. On the website, you’ll enter in your information about who you are and how much money you make and the website will tell you where you go to get your coverage, what choices you have. It’s supposed to be like Travelocity or Expedia. Well, you know, it’s actually really hard to make that work. And the IT system. That’s got nothing to do with ideology, it’s just technological.

[5:52] Then you throw in the fact that you have a lot of states where you have officials who are to varying degrees fighting the implementation of this law. This is hard enough where you have frightened people who want to do this, who has the ability to do it.

[6:07] You look at a place like Maryland where the governor is behind this, the state legislature is behind this. They have very experienced people running this. They’ll tell you, this is a struggle for them. They’re going to get it done by January 2014. It’ll probably work pretty well there. But you then need a…you look at other states, you think well, what on earth happened in Oklahoma?

What’s going to happen in Tennessee? Or you know what’s going to happen here in…I know, in Michigan. Here we have a state where there’s mixed support. The governor has one [indecipherable 0: [6:28] 06:38] reasonably favorable toward the Republicans in the state legislature, or it’s…and it could be a real mess.

[6:45] I think you mentioned the Medicaid expansion, with governors and state lawmakers choosing to be part of this Medicaid expansion.

[6:53] I think over time… most of them will come around. But the Medicaid program, again–you know this better than anybody–you know how different it is from state to state. Whether you have a good Medicaid program really depends on what state you live in.

[7:11] I suspect Obamacare is going to end up looking like that, at least for the first stage, where if you live in Maryland, you live in California, if you live in Minnesota or New England or New York, it’ll probably work pretty well, and if you live in some of these other states, you could be in for a pretty rocky ride.

Harold: [7:31] Yeah, we’re going to shift over to the President’s inaugural address, because you and both watched it. I was there, although I was there in an exclusive seat basically stuck behind the port‑o‑potties watching a Jumbotron. [picture] You had a much better view, but what did you think of the President’s speech?

Jonathan: [7:48] Well, we should clarify. My much better view was from my couch, watching a TV, which was warmer. Although I think there’s a value to being there, so even if you were behind a Jumbotron and freezing, I’m a little envious.

I loved his speech. I wrote a pretty glowing review of it, and I don’t always say that about the President’s speeches. I thought his first inaugural address was rhetorically [mediocre].Just as a writer, I didn’t think it was a great piece of writing. It didn’t have a theme. It didn’t really make…it didn’t really make a clear argument.

Then substantively, this is part of the side of Barack Obama that I–and I know a lot of other people–like least: which is this “we’re going to get past partisan differences, bring the country together.” In principle, I think that’s a wonderful notion. In practice, I think it was both ill‑suited for the situation. [8:44] At that point in time, we needed a speech about where to…not so much about how we were going to work as a political system but what kind of country he wanted to create. I didn’t think it had enough of that in it.

[9:00] Also, as we saw in the first term, particularly those first two years, the whole way, he was dealing with an opposition that wasn’t willing to play ball. So it was just ill-timed,. It looked not-that-great at the time. In retrospect, you go back and read that speech, it really just feels like not a great speech. It didn’t work.

[9:16] I thought this speech was the opposite. Rhetorically, as a piece of writing, it had a very clear, coherent message. It had an argument. And it was an argument that I thought was much better suited to the time.

[9:31] It was an ideological speech, a philosophical speech, and as I said at the time, it was important not just for what it told us about where President Obama sees us going in the next for years, really for just looking back at the last four years. Like here’s what I did. Here’s why I did it. These laws that I fought for, these ideas, not just healthcare reform, but financial reform, the Recovery Act, saving the auto industry, these were not just a patchwork of ideas. These were part of a coherent effort to create an America in which, when we are vulnerable, when we are insecure, when we face crisis–we band together, and we help each other. We’re part of one country.

And it’s interesting. When you think about it, I think it is…there’s a common thread to that, to his first [indecipherable 0: [10:24] 10:29] . You’re on this idea that you had about bringing people together. But it’s bringing people together for the sake of mutual protection. In policy terms, for the issues you and I deal with, we think of it in terms of social insurance. Everybody pays into Medicare so everyone has insurance when they retire. Everybody has Social Security, same with Obamacare.

But it’s much broader than that. And I thought it was highly significant that he managed to link that to the remarkable strides we’ve taken on things like same sex marriage, the implication of Stonewall and Selma together. And to me, it was more powerful and it was really about this is the America I want to have. This is the America I’ve been trying to create.

[11:13] I think in that sense, it was similar. It rose to the level of the addresses we remember from Franklin Roosevelt, from Ronald Reagan. Of course, thematically, if you think of a pendulum, where Roosevelt was on one end, a more liberal vision, and Reagan was a more conservative vision. This was saying, “We’re done with the Reagan revolution. We’re done with that. Reagan defined a certain time. Well, we’re defining a new time, where it’s not so horrible to say that government can do some good…”

Harold: [11:50] It’s funny, I took my daughter to the inauguration. [Lincoln Memorial pic] Actually, the night before we went to the Lincoln Memorial, which is really the temple of American democracy. We walked around the mall a little bit, and to be with the crowd of people who were just jammed into the inaugural. None of us could see. [12:12] The crowd included regular people of every shape, size, sexual orientation, race, ethnicity, religion, handedness, whatever. You really got a sense, “This is the America we are becoming.” A lot of people who basically felt like guests in our own country felt this. Actually, we’re not guests anymore in the same way. To see the president present this dual message of social protection and social inclusion was something that was just really powerful.

[12:42] It’s funny, the 2012 election on the surface was really a terrible policy debate. I didn’t learn anything listening to the two candidates on the surface debates. But the election ended up actually being about deep stuff, It really forced people ‑‑ especially after the president blew the first debate ‑‑ in some ways, I think, actually, [the victory] became sweeter after that. I still am baffled that the President did so badly in that debate. A lot of people from all sorts of different walks of life said, “Oh, my God. He actually might lose this thing.” And they actually got in and started to try to help. The election ended up being about the things that you just identified.. especially with the 47 percent comment and other things, and the attacks on Obamacare.

[13:34] I think that when health reform was debated, we all got so wonky about it, because we kind of had to, because it’s complicated and you have to talk about what is a health insurance exchange? How does Medicaid work? How can you keep your insurance? To explain all 2,000 pages of the thing, you have to get into the weeds. But you lose that broader thread of, we’re trying to protect each other against these risks that would just crush any one of us if we had to face it on our own.

[14:01] Then all of a sudden, Mitt Romney presents this real contrast to make this a really significant election. Now, it’s still unlike President Roosevelt or Lyndon Johnson in 1964. Of course. President Obama still has Republicans in the House who basically have an incentive to burn the house down on health reform, but he’s also got these Republican governors who need to make it work that he might potentially be able to work with.

Jonathan: [14:31] You had mentioned you want to talk a little bit about what your hopes for the coming year….

Putting aside healthcare reform, which I think is going to continue to be a huge story, I’m thankful for the many people covering this much more intensely than I am at this point. There are some terrific reporters out there . You and I know who they are. Viewers can follow our Twitter feeds, and you’ll see us linked to them all the time. [15:01]

Actually, I was thinking about this the other day. It’s a much harder story to cover. As complicated and intense as it was when you were passing the Affordable Care Act. It was always a one place story, part of the Washington story. It’s Congress. It’s the President. .Whereas this is now 50 different stories, or 51, because you’re still covering the Washington story.

[15:22] It’s just raw stuff every day. Just last week, there were three separate major developments in the administration, and it’s now a new financing on the regulation of contraception, what coverage you’ve provided.

[15:38] There was a ruling about affordability, which is one of those words that no one understands. You tell them it means who gets tax credits and who doesn’t to help them pay for insurance they don’t get from their employers. That was a big deal, just heard about that today. [16:00] Then on top of that, what’s happening in the states… and this is a massive, strong story.

[15:59] But putting that aside, I’m hopeful that we can get a little bit passed, not that part passed. I feel like it’s been just one incredibly intense conflict, almost without a break. It’s been not a series of skirmishes, it’s been a war with battles that just never seems to end.

I’m not naïve about this, I’m not naïve about this. Republicans and Democrats are going to continue to disagree strongly. This will define what we can and can’t do.

Despite what many people think, that’s not necessarily a bad thing. You have strong points of view here [indecipherable 0: [16:31] 16:35] . Sometimes that means we don’t get stuff done. Well, sometimes that’s OK. There are things we need to get done, like looking at the debt ceiling, but it’s very frustrating.

[16:47] I am hopeful that we can maybe get away to do a little more thinking about some other issues. Looking forward, I’m enjoying the fact that we’re talking about immigration and guns right now, which are mostly removed substantively, thematically, from what we’ve been debating in the last few years.

I’m hoping to look forward to just more writing and reading, and covering things like climate change. aring less about things like life exchange. I’m going to need to deal with that, work and family issues, foreign policy that gets passed the old “who we’re going to bomb tomorrow” thing. [17:20] So, I’m hopeful that the next year, the next two years, there can be a little more variety, I guess is what I’m looking for. I like variety.

Harold: [17:31] You mentioned immigration, and I get hopeful, partly because Mitt Romney self‑deported in the election. His decision to move right on immigration basically doomed him. I think every Republican understands the demographic trend, and it’s amazing what a difference that’s made after the election. [17:54] The Republican party clearly needs to do something about immigration. There’s a health policy matter that’s critically important, because we have all of these unauthorized residents and legal immigrants who are a serious chunk of the health policy problem. Actually, especially in a city like Chicago, where we have this huge flow from Mexico. We couldn’t do anything about that as a health policy matter until the immigration issues were settled. I think actually as the immigration issue is settled that we’ll have a tremendous ripple effect in health policy.

[18:27] I’m much more pessimistic about climate change, because all of the institutional pathologies we saw in healthcare will apply to an even greater extent in climate change. I think any president who looks at what President Obama went through on healthcare is going to look at this and wonder: “Do I really want to stake my presidency on a climate change bill?”

[18:56] Here President Obama actually passed health reform, and it didn’t seem to do him a lot of good, at least so far. I worry we’re going to have a kind of Vietnam syndrome, with presidents looking at our dysfunctional Congress and just saying, “I cannot do something that big, because I just can’t afford to… “

“Staking my political survival on 60 votes in the United States Senate,” is just not where any president is going to want to be, ever again.

[Cross-posted at The Reality-based Community]

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Harold Pollack is the Helen Ross Professor at the School of Social Service Administration at the University of Chicago.