Something was wrong with Betsy Rotzler. As a child she had been so strong she could lift an adult full off the floor; now, she was weak and her back hurt so badly that she couldn't stand to be touched. She needed a doctor—but her husband, Gary, had no job, she had no health insurance and money was too tight to pay out of pocket. "By the fall of 1996, she had gone more than two years without a regular medical exam," Jonathan Cohn writes in his new book, "Sick: The Untold Story of America's Health Care Crisis—and the People Who Pay the Price." By the time Rotzler finally started treatment for what turned out to be cancer that had spread to her spine, it was too late. She died within weeks. "Obviously," Gary Rotzler told Cohn, "I'm sure she was just hoping it would go away."
America's way of providing health care is failing, too, Cohn writes, and its problems also won't go away on their own. He spoke with NEWSWEEK's Mary Carmichael about how to cure an ailing system. Excerpts:
NEWSWEEK: You started writing about the health-care system in the '90s, not long after the Clintons' reform effort failed so spectacularly. Politically, is universal health care a more realistic proposition today?
Jonathan Cohn: Our health-care problems have definitely gotten worse since the 1990s. People are really struggling to afford medical care. But does that mean the public is ready to embrace universal health care? I'm not so sure. People are still afraid of anything that sounds like big government, and there's a lot of residual faith in the private sector out there. Besides, Americans don't always grasp how precarious their situation really is. Back in the 1990s, "Harry and Louise" warned that everybody would end up in big, bad managed-care plans if the Clintons got their way. So the public turned against the Clintons. And then everybody ended up in big, bad managed- care plans anyway.
But what's wrong with believing in the private sector? Isn't that just capitalism?
Capitalism is great. But occasionally, capitalism needs to be saved from itself. And when it comes to health insurance, I think we've seen pretty conclusively that the market doesn't provide what we as a society need. Employers are trying to minimize their health insurance expenses, insurers are trying to avoid taking on unhealthy beneficiaries, so increasingly the people who need the protection of insurance can't get it. I'm not saying we should scapegoat those companies—they're doing what companies do, which is trying to make money. I just think we should recognize that, occasionally, the government needs to intervene and protect people because that's what a decent society does. It's [the] same calculation that took place during the New Deal.
That's also the era that gave us the first health-maintenance organizations. They were idealistic, nonprofit groups then—they're practically unrecognizable as the HMOs of today. What happened?
What happened was, over time, employers and insurers seized on managed care as a way to control costs, while mostly ignoring the quality part. There was this frenzy to lower premiums. On the positive side, it did save a lot of money, and that made insurance temporarily more secure and also showed up in our paychecks. But instead of doing it in a way that protected the people who were at the greatest risk, we just let it evolve by the dictates of the market. And a lot of people suffered.
What makes you think a government health insurance plan wouldn't also start out as idealistic and well-intentioned and then go bad?
Government doesn't answer to shareholders, it answers to the voters. I'm not naïve—government can be corrupt and manipulated, and I'm not trying to say universal health care is perfect. But I think it can be a lot better than what we have now. Look at the Medicare system. It has plenty of flaws, but it's still way better than private insurance.
You profile several struggling people in your book to illustrate what's wrong with the system. Most of them aren't on Medicare or Medicaid; they're middle-aged and middle class. Is that the group that's getting squeezed the hardest?
The people who get clobbered the most are still the working poor and the lower middle class. But the big change we're seeing now is that vulnerability is expanding up into the middle class more than before. It is a mistake to believe that if you're middle class and have a decent job, health insurance won't be a problem for you. You could lose your job, or you could have some medical problem like diabetes that will make you uninsurable. And then when the crisis strikes, it will blow away your ability to recover. You'll have huge bills and bad credit, and you may still be sick so you won't be able to work as hard.
How could the government afford health insurance for all those people?
At the end of the day, if we want universal health care, we're going to have to pay more in taxes. By definition, we're talking about the government assuming a greater role for health insurance. It can't do that without money. But that's only half the story: we'll also be asking private insurance to do less, which means premiums will come down and paychecks will go up.
So what's the bottom line—will it cost society more or less?
If you suddenly give insurance to people who haven't had it, you'll discover they have conditions that aren't already being treated. They'll need more medical care, and that might produce some short-term bump in money being spent. But over the long run, most people think an intelligent universal health-care system would actually be less expensive. Maybe a lot less expensive.
Could preventive medicine help keep the costs down?
The more you encourage healthy behavior, the more you're going to head off big costs down the road. And good universal health-care systems emphasize preventative care. But the debate we've been having about individual responsibility and medical care has been framed in an unfortunate way. It's very nice advice to say we should all eat healthy and work out three times [a week], but good luck doing that when you're a single mom who works 12 hours a day. And don't forget the enormous role that genetics plays in health. Eating a high-fat diet will drastically increase your risk of a heart attack, but so will a family history of high blood pressure. I don't think we really want to start penalizing somebody financially because his grandma has a predisposition to high cholesterol.
Your book doesn't spell out an ideal health insurance plan, but you do speak very highly of the French health-care system.
That's usually where people start to think I'm crazy.
Want to defend yourself?
If you study other health-care systems in Europe and Japan, they all have managed to give insurance to everybody and at the same time spend less money than we do—so, right off the bat, they're accomplishing something that we're not. And while the health statistics vary, overall the medical care seems as good if not better. People cherry-pick certain cancers that the U.S. is better at treating, but I could pick out three or four other diseases, other cancers, or transplants, where other countries are better, including France. The high-end care in Paris is just as good as the best hospitals and doctors in New York City. And you always hear about waiting lines with universal health care—Britain has them, Canada has them. But other countries with universal health care don't seem to have systematic waiting-line problems. And France is one of those.
How do they pull all that off?
Relative to other countries with universal health care, they're one of the highest spenders—though they still spend less than we do. And they spend on what they like. The French love drugs, and they use a ton. They like easy, free access to doctors. So they have that, too. There are lower salaries there for physicians and they don't have as much technology as we do. But that seems to be a social preference. If you like gizmos, universal health care can deliver that, too. Japan, for example, really likes technology. So they have a lot of MRI and CT scanners. More than we do, as a matter of fact.
What about the plans being floated by American political candidates now? Are there any you like?
I wrote an article praising John Edwards's plan when it came out. It's sort of a back door into a single-payer system. I have also written favorably about [Oregon Sen.] Ron Wyden's plan. And there's a political scientist named Jacob Hacker at Yale who's been touting a kind of stepping stone to single-payer called Medicare Plus, where you can buy into Medicare. It's clever. It sets up a natural competition where Medicare becomes the catchall for people who aren't insured, and if it ends up being efficient enough …
Then everyone wants to buy into it.
Yes. And you can see how you could easily graft it onto what we have now. But the bottom line is, any system that gives a strong benefit package to every American, and does so in an affordable way, is better than what we have now. If there's an idea that will make the people in this book better off, I don't think we should turn our noses up at it.