The scene, less than a paragraph long, is one of the most intriguing in “The Ten Year War,” an account by journalist Jonathan Cohn of the forces that gave birth to the Affordable Care Act and the forces that have tried to get rid of the law ever since. It is a striking image and not well known: the new second-in-command talking down the idea of attempting the very health-care changes that would, barely a decade later, become a central tenet of his own successful presidential campaign.
The scene also attests to the strengths and weaknesses of Cohn’s encyclopedic telling of the story — and the backstory — of the 2010 law whose lengthy tentacles have reshaped much of the U.S. health-care system. The author, a seasoned health-care reporter, demonstrates sourcing and meticulous research that usher readers inside a lot of rooms where federal health policy was debated and decided during more than the 10 years of the book’s title. Yet Cohn is so wedded to the steady cadence of his chronology that he seldom lingers to reflect on truly revealing or portentous moments — such as Biden’s cautious and disregarded initial West Wing counsel to Obama — while giving equal weight to nuances and subplots that only an ardent policy wonk might savor.
As a fellow journalist writing about health-care policy, I guess I need to classify myself as part of the wonk tribe. Having covered many, though not all, of the people and episodes Cohn recounts, I found myself lacking a reliable barometer to fathom how this book will strike people who approach it without prior immersion in its subject matter. I discovered four footnotes to my work, along with ones citing other health-care reporters. And Cohn repeatedly credits a book, “Landmark: The Inside Story of America’s New Health-Care Law and What It Means for Us All,” which several Washington Post colleagues and I hurried to write in the spring of 2010 about the passage of the ACA and what it might yield over time. Cohn’s account covers much the same ground, plus the intense antagonisms against the law during the decade since then — and its resilience in the face of so much political fire.
Cohn’s enormous cast of Democratic and Republican politicians in the White House and Congress, his parade of lobbyists and policy experts were for me a kind of old-home week. But I wonder whether some readers might feel a bit overwhelmed, as each actor in the running drama is introduced with a neat two- or three-paragraph backdrop, synopsizing the basis for their perspective. Many of these characters appear only once or twice in the 334 pages of text. Even for those who recur, Cohn shows us their actions far more than the meaning for them of the events in which they are players. Only nine pages from the book’s end do we learn that the author interviewed Obama last year in his post-presidential office near Georgetown and “asked about his state of mind at key points in his career and the Affordable Care Act’s lifetime.” Obama told Cohn he regarded this law, so identified with his presidency, as “a politically viable starter home from which you could then build.” The “starter home” metaphor also appeared in a speech Obama gave in Miami weeks before the 2016 election that brought Donald Trump to the White House. Though not original to Cohn’s interview, the characterization provides a window onto the mind-set of the 44th president. It would have been nice if the story offered more such interior views across its pages.
But helping readers form an emotional attachment to a few key players in this long health policy saga was not Cohn’s method or his apparent goal. Instead, his purpose appears twofold: One is to provide a detailed account of the political sausage-making that produced the most significant changes to U.S. health care since the creation of Medicare and Medicaid a half-century earlier as part of Lyndon Johnson’s War on Poverty. For readers with a fondness for the health policy weeds, Cohn’s story will treat them to bundled payments, Congressional Budget Office scores, insurance rate shock, skinny insurance plans and Senate Republicans’ last-ditch attempt at skinny repeal.
Cohn’s other purpose is to use this law as a prism through which to see the terribly bitter politics that divides our main parties — and the internecine conflicts within each party. “The Affordable Care Act,” he writes, “is a case study in how policymaking works today, and the deep dysfunctions of American politics that will surely infect any similarly ambitious reform efforts in the future.”
The book is divided into three acts. Despite all the insider-ish information Cohn assembled, he curiously chooses to start the story with an episode known to anyone who has even loosely followed the ACA’s ups and downs: the Republican senator from Arizona, John McCain, stricken with the brain cancer that would soon kill him, returning to the Senate floor to cast the decisive “thumbs-down” vote that in 2017 thwarted the GOP’s dream of repealing much of the law. After that introductory moment, the book’s opening act looks back to 20th-century precedent and context, including a good account of Massachusetts’s 2006 passage of a health law that became, in large part, an ACA role model. Much of the telling of the earlier reform attempts, and the political winds ultimately obstructing most of them, resembles that of a classic book, “The Social Transformation of American Medicine,” by Princeton sociologist Paul Starr, whom Cohn credits generously and says was his long-ago editor.
The second act here is the span between Obama’s election in the fall of 2008 and the March 2010 passage of the ACA. The final act is the eight years after the law passed, when critics challenged its constitutionality all the way to the Supreme Court and congressional Republicans kept trying to repeal most of it — both strategies coming close but not succeeding, at least not yet. The story ends before Biden moves into the White House, so we get only the most glancing sense of the current president’s devotion to building upon the ACA to widen access to health coverage and care. It would have driven home the paradox of Biden’s 2009 go-slow advice to Obama.
Perhaps the most impressive feat of this detailed retelling is that Cohn gets virtually everything right. From an Obama White House aide, Jeanne Lambrew, unpopular yet admired among many of her colleagues, to a liberal consumer health advocate, Ron Pollack, building strange-bedfellow coalitions with the insurance and drug industries, I kept reading along and nodding, yes, that’s how it was. Cohn’s rare lapses mainly truncate the Trump administration’s moves to weaken the ACA through executive branch tools.
Cohn’s work is impressive, too, in its fundamental fairness. At the outset, he makes clear he believes that the law at the heart of his story is “a worthwhile piece of legislation — flawed, yes, but on balance something that would do a lot more good than harm.” Yet he is evenhanded in showing missteps by both political parties. He largely finds Democratic voices to criticize that party’s blunders — such as the dreadful computer flaws in the fall of 2013 that marred the first sign-up period for ACA health plans, a mistake Obama calls his “most aggravating self-inflicted wound.” And he finds Republican voices to criticize GOP miscalculations, including the party’s failure to produce a real replacement plan for the law it reviles. In the book’s final pages, however, Cohn allows himself a jarring shift into personal opinion, telling progressives how they “must” strategize going forward.
And for all the main actors and bit players in the ACA wars to whom we are introduced, Cohn’s Washington-centric focus all but leaves out any empathetic portrayal of ordinary Americans whose lives have been touched by the Affordable Care Act, for good or ill. His few detours out of Washington mainly are to glimpse congressional town halls, jammed with citizens denouncing Republican lawmakers for working to take away most of the law. On the book’s final page, Cohn tells us that the winners from the law “aren’t just statistics. They are real people.” He then devotes one brief paragraph each to an anonymous barista at a Michigan coffee shop who broke his foot, an anonymous California girl with a heart condition, an anonymous North Carolina community college student whose arm was injured in a car accident — all of whom afforded care because of the law. It would have been good to meet them across the narrative — even to know who they are.
The Ten Year War
Obamacare and the Unfinished Crusade for Universal Coverage
By Jonathan Cohn
406 pp. $29.99