In 2009 and 2010, the Obama administration waged a very public fight to pass a bill to overhaul America’s health-care system.
Its goals, on paper, were admirable: universal coverage, no more targeting for preexisting conditions, and depending on who you asked, curbing costs.
Unfortunately for the administration, and the Democratic Party, health-care reform would devolve into a narrative about a morally questionable legislative process, a midterm election anchor, and a botched implementation.
In a sweeping and spirited new book, America’s Bitter Pill, journalist Steven Brill chronicles the surprisingly juicy tale of reform. Brill, whose Time cover story last spring about costs of care caused quite a stir, has focused an unsparing eye on a countless number of politicians, bureaucrats, lobbyists, activists, and industry types. The result is an exacting and always readable examination of how a good idea turned sour, how the public got screwed, and who is to blame.
Brill begins his story during the 2008 presidential campaign, when health care became a point of attack for the Obama team against Hillary Clinton. Upon taking office, to the surprise of many, the president kept an overhaul a priority.
There were a remarkable number of forces, in Brill’s mind, at work to put health care on the docket in Obama’s first term. The first was that while candidate Obama—unlike Clinton—was relatively new to the national rope line, campaigning introduced him to endless horror stories about health care in the U.S., catapulting the issue forward in his mind.
The second is the role of Ted Kennedy, who spent much of his political career fighting for universal coverage in the U.S. Kennedy was one of Obama’s most visible and most powerfully influential endorsers. When Kennedy died in 2009, his pet cause became a legacy issue for his party and his president.
Third, Massachusetts and its former governor, Mitt Romney, had just provided a blueprint for bipartisan legislation that achieved universal access.
Fourth, another senator, Max Baucus of Montana, was doing the unthinkable and making a push within his committee for sweeping reform.
Fifth, the zeitgeist said it was time for an overhaul: Industry lobbyists could sense it, and so could activists.
Describing the machinations behind the drafting of the bill, Brill focuses more on the Senate, whose version of the legislation would largely be the one ultimately passed into law. But while much of the political outrage at the time focused on the Senate and the deals cut with Sens. Mary Landrieu (“The Louisiana Purchase”) and Ben Nelson (“The Cornhusker Kickback”), in Brill’s telling it is Congress that should be lauded and the administration that was morally bankrupt.
Congress certainly saw its share of political horse-trading and legislators were clearly looking out for their constituent interests. But Capitol Hill was also full of passionate, deeply informed staffers, exemplified in the book by Liz Fowler (although she was trashed in the press) and Anthony Clapsis. Senators are consistently commended for being on top of the issues. Brill praises Republican Chuck Grassley, for instance, even though he did not vote for the bill, but for requesting changes that would in the end prove prescient.
Neither Obama nor his staff impress Brill much. According to Brill, the president was willfully ignorant about health-care policy in the 2008 campaign, feckless when he did get involved in the legislative process, and grossly negligent when it came to implementation.
A reader could easily be sickened—or at least made a little queasy—while reading about the administration’s secret negotiations with the pharmaceutical trade group PhRMA, insurance companies, and hospitals to get money for ads supporting health-care reform (created by David Axelrod’s former firm). Whereas Senate staffers like Clapsis are portrayed as holding the industry representatives’ feet to the fire, the White House staffers are shown consistently coddling and reassuring pharmaceutical and hospital lobbyists. “[Obama] had given the Tea Party activists Exhibit A in crony capitalism,” Brill writes. Later, however, he would soften, when he says “I don’t think so” about whether or not we should blame Obama and Baucus for cutting the deals.
Speechwriters and political staffers are given precedence over policy and economic teams—notably when Obama pledged that “If you like your health-care plan, you will be able to keep your health-care plan, period. No one will take it away, no matter what.”
The farther the story moves into the implementation phase, the uglier it gets. It begins after the bill is passed, as deadline after deadline was missed. When the U.S. Chief Technology Officer Aneesh Chopra asked the White House domestic-policy staff if they needed help with the website, he got one reply: “STOP!”
Brill is especially caustic about the president’s conflict-averse management style—because Obama did not want to hear about problems and conflicts involving implementation, execution of the law and the design and management of the website fell to “the usual players eager to protect the turf that came with their titles.” The website, as Brill tells it, became a battle over which group had “Office” in front of its title versus “Center.” It is a story of mind-numbing government bureaucracy.
It fell to CMS, which oversees Medicare, to implement the federal exchange. Within CMS a variety of offices were tasked with different parts. One of them, the Office for Consumer Information and Insurance Oversight had the job of coordinating the insurance companies participating in the exchanges. According to Brill, the OCIIO was also being fed information from the Office of Communications, Office of Information Services, and Office of Acquisition and Grants Management—but the others were all Office’s so they couldn’t be bossed around.
Then, when the GOP took the House in 2010 and began looking at ways of defunding implementation of reform. So, the OCIIO was made into a Center for Consumer Information and Insurance Oversight so that its funding would be controlled by CMS not Congress. However, that meant it was demoted below the other Offices working on health care, and that the individuals supposed to be running the establishment of the federal exchange found themselves without clout and now answering to the other groups.
Ironically, the administration looks admirable in the aftermath of its own failings. It cut ugly deals and followed the Senate’s lead, but the Obama in Brill’s book is also a man with backbone when it came to sticking with healthcare. “We should admire him for it,” Brill writes. And despite recent whisper campaigns against her, Brill also gives a nod to top adviser Valerie Jarrett’s efforts in the final push. After the Tea Party movement changed the tenor in Washington, Brill writes, “Valerie Jarrett went into high gear, too, something she did not receive much credit for in the press” by working legislators, interest groups, and companies incessantly.
This is all contrasted by what Brill holds up as a success story: How Kentucky’s Democratic Gov. Steve Beshear and the state’s leading health-care civil servant Carrie Banahan together engineered a near perfect rollout in a state plagued by health problems and poverty.
Part of the joy of the book is that Brill, unlike some other recent authors, such as Chuck Todd or Bob Woodward, is very much an outsider. His methods are those of a citizen with resources and connections trying to hold powerful individuals accountable for the folks at home. As a result, his book brims with unconventional insight delivered in prose completely uninfected by the worn out tropes and tired lingo of the Sunday shows.
Brill’s type of smart contrarianism leads him to some compelling and revealing conclusions. For instance, Scott Brown’s win in Massachusetts was possibly a boon for Democrats, since it forced the House to largely acquiesce to the Senate bill and thus avoided a lengthy reconciliation process that might have derailed the bill.
Fueled by a nimble intelligence, levelheaded insights abound: The length of the health-care reform bill is logical, Brill points out, given that it is reforming something the size of the economy of France. Obama’s ban on hiring lobbyists, long decried as hurting and insulating his administration in Washington, instead “turned out to be a blessing in disguise”: A lot of White House staffers had previously held senior positions on Capitol Hill, which gave them better relations with and understanding of the legislative branch.
And while Brill is not one to suffer fools gladly, he never fails to portray the politicians he writes about in complex terms. Max Baucus, for instance, comes across as motivated both by constituent horror stories and a vain desire to pass a landmark bill after a largely unremarkable career
This is not to say that Brill has yoked himself to some ideal standard of objectivity. Far from it. His explanation for this is largely legitimate—that health care is personal, and thus it is nearly impossible to be objective. It is unsurprising, given his Time article last year, that his biggest disappointment with the reform going forward has to do with its cost. Thus, the insurance industry is largely treated with kid gloves in his book, and much of his ire is reserved for medical-device manufacturers, hospitals, and drug makers, which he believes are behind the ever-escalating costs. The deals cut by the Democrats with those groups are egregious—not necessarily for good-governance reasons, but because they let the players responsible for what’s wrong with the system off the hook. In his updates in the end of the book on the rules issued by agencies regarding the law, Brill’s disappointment is palpable over issues such as allowing people to stay on bad plans and preventing insurance companies from narrowing their networks.
While Democrats patted themselves on the back in 2010 for achieving a longtime liberal Holy Grail in overhauling the health-care system, Brill’s book is a stark reminder that, if anything, reform has only begun.