Commentary Magazine


Sick by Jonathan Cohn

Diagnosis & Cure
Sick: The Untold Story of America’s Health-Care Crisis and the People Who Pay the Price
by Jonathan Cohn
HarperCollins. 292 pp. $25.95

From the plight of the uninsured to the sorry future of Medicare, the failings of American health care make constant headlines, and have become a theme on the presidential campaign trail. Publishers, too, have not failed to spot the trend, and at least a half-dozen books on the subject have hit the shelves in just the past year.

It thus seems odd for Jonathan Cohn to have chosen, as the subtitle of his new book, “The Untold Story of America’s Health-Care Crisis and the People Who Pay the Price.” That story is far from untold. But Cohn’s contribution does stand out. A young editor at the New Republic and a regular contributor to many publications of the Left, he offers a uniquely thorough diagnosis of the problems we face, even if his prescription seems very unlikely to heal the patient.

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Cohn spent five years traveling around the country to do the reporting for Sick. Each of the book’s ten chapters is named for a particular locale and tells the story of a person or family whose experience exemplifies a problem with the American health-care system.

In Gilbertsville, New York, for instance, we meet the Rotzlers, a family that seemed to do everything right and yet found itself without insurance at just the wrong time—the great fear of many middle-class families. In suburban Orlando, we learn about Janice Ramsey, who started a company with her husband but found that because of her diabetes they could not afford health coverage. In Chicago, Marijon Binder, a retired nun who thought a Catholic hospital might give her a break when she could not pay for her care, learned otherwise when she was dragged into court.

Another chapter provides an especially vivid indictment of health-maintenance organizations (HMO’s). Here Cohn introduces us to Steven and Elizabeth Hilsabeck of Austin, Texas, a couple repeatedly thwarted by the seemingly arbitrary decisions of an HMO bureaucracy as they seek physical therapy for their son Parker’s cerebral palsy. Still other chapters illustrate the second-class standing of psychiatric patients in the health-insurance system, the vagaries of employer-based coverage, the overcrowding of urban hospitals, the looming collapse of the charity-care system, and the shortfalls of Medicaid.

In the middle of each of these vignettes, Cohn steps back to describe the history behind the problem. He shows how, in the early 20th century, private health insurance began as a way to keep hospitals from going bankrupt. Some of these hospitals eventually began to form group plans, one of which chose a blue cross as its advertising logo, thus launching what remains the dominant brand in the industry. Cohn also describes the accidental origins of the nation’s employer-based system of paying for coverage, which arose from the wage controls of World War II. He traces the failed efforts in the 1930’s and 60’s to pass universal health care, and shows how the resulting political battles gave rise to Medicare and Medicaid. Finally, closer to the present, Cohn describes the booming popularity of HMO’s in the 1990’s as a response to rising costs, and shows how they quickly fell into disfavor because, for both doctors and patients, they entailed a loss of control over medical decisions.

In a brief concluding chapter, titled “Washington,” Cohn seeks to tie together all of these troubling stories and histories in order to make a case for publicly funded, universal health care. His proposed solution resembles the French system, which (unlike, for instance, Britain’s entirely state-run apparatus) maintains key elements of private insurance under an umbrella of government regulations and subsidies. Though far from perfect, Cohn argues, such a system would be “fairer, more equitable, and simply less painful” than what American health care has become, especially for the poor and the chronically ill.

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Cohn manages his stories to great effect, ably describing people left without options or hope in their hour of need. He has also highlighted the right problems. But Sick suffers from the usual flaws of argument-by-anecdote, as Cohn himself seems to recognize. His stories, he writes, “are not so much representative as indicative”; and as he grasps for both populist sympathy and broad social conclusions, he is sometimes guilty of condescension toward his particular subjects.

The book’s deeper flaw lies in Cohn’s failure to deal seriously with the question of reform, an issue to which he devotes remarkably little time and energy. Only nine pages at the end lay out what should be done about the problems described in the previous 200. And what he does suggest feels less like a response to the complex picture he has painted than a hastily ironed-on ideological patch.

Cohn is right, for example, that France’s health-care system works far better than Britain’s (the favorite target of critics of socialized medicine). But he hardly explains why, or how. More importantly, he fails to show how such a system would answer the particular problems detailed in his stories of woe.

His chapter on HMO’s is telling in this regard. As Cohn himself points out, HMO’s actually achieve their stated aims. When they were at their peak in the 1990’s, “the cost of health care rose more slowly than at any other time in recent memory.” Moreover, studies of those covered by HMO’s suggest that, overall, they suffered no ill effects. But, as Cohn further notes, “because few Americans were accustomed to restrictions on their access to doctors or treatments, managed care was always less popular with consumers than it was with employers—a status the promoters of managed care insisted was undeserved.”

Cohn is not so sure this reputation was undeserved. The basic premise, he writes, was

that sound economics would also produce sound medicine—that cost control as practiced by HMO’s and encouraged by employers would improve the quality of health care even as it saved money.

But behind the statistics about cost and the abstract measures of health, there were real people whose real stresses were made worse by the seemingly arbitrary rationing of the system. Thus, for families like the Hilsabecks of Austin, whose son needed costly treatment for his cerebral palsy,

it didn’t work out so neatly. And as the years went on, the Hilsabecks began to wonder whether this new health-insurance system was designed to put the wonders of American medicine within reach, or to push them farther away.

Though Cohn does not appear aware of it, this passage captures the dilemmas not just of American HMO’s but of every government-managed health-care system, including France’s. The rationing that has so upset Americans covered by HMO’s, and that has made the HMO among the most detested institutions in the country, would run far deeper and wider under the kind of public system Cohn ends up proposing. The French may put up with such limits, but our own experience with HMO’s offers ample evidence that the American middle class would swiftly revolt, thus draining energy from any effort to make the system better serve the uninsured and the poor.

Moreover, Cohn’s certainty that the officials who make decisions about what to fund under a French-style system are “accountable to voters”—and thus, supposedly, responsive to their health-care needs—could only sound sensible to someone who has never lived under such a system. Nor does he entertain the possibility that such arrangements might be a fiscal burden to government itself. Here he could have cited the French health minister who told a parliamentary commission two years ago that “our system has gone mad” and “profound reforms are urgent” to avert financial disaster.

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A real solution to the problems that Cohn describes would have to begin from what works in America. Our current system of private insurance provides high-quality care for those who are covered while also supporting groundbreaking medical research and scientific advancement that benefit the entire world. Its obvious shortcoming is that millions do not have access to it. Fixing the system requires not that we supplant and control private coverage but that we make it more available, using government to bridge the existing gap.

Cohn does not take such modest, piecemeal reform seriously. He considers it little more than a political diversion, promoted by conservatives who consider universal health care “an imposition on liberty that weakens individual initiative.” Here his ideology gets the better of him. The chief objection to universal health care for the U.S. is not that it would defy some abstract principle of liberty, but that it would be both economically ruinous and culturally unsustainable. There are, simply, more practical ways to improve American health care, and none of them takes the French example as a starting point.

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