‘Sick’ mixes health policy history, short narratives for chilling picture

By Naseem Sowti
Ocala Star-Banner
From the Summer 2007 issue of HealthBeat

It’s a struggle to make health policy stories interesting.

It takes a “real person,” the right expert who can explain the issue, and just enough numbers and hard data to support the story, yet not make it overwhelming.

However, “Policy can be interesting if you give it plot,” said Jonathan Cohn, a senior editor at The New Republic, who has mixed all these ingredients in his 300-page book, “Sick.”

In his book, Cohn has skillfully woven the history of the U.S. health care system with today’s issues through strings of real people stories.

The book draws a chilling picture of the country’s health-care system. And at the end of each chapter, you can’t help but think, “This could be me.”

The book is divided into four sections. The first three are about private insurance. The next two cover Medicare and Medicaid. Two chapters are about safety nets. And the last chapter is about mental health care.

Cohn, a former media fellow at the Kaiser Family Foundation, talked about the process, challenges and pleasures of writing his first book in a recent phone interview.

Why did you decide to write this book?

I had been writing about health care policy for a while but had reached the limit of what I could do in a magazine article. At the same time, I kept talking about it – and people were sick of listening to me. I had to find some other outlet.

Also, there’s a fair amount of (healthcare) history out there, but a lot is in academic literature – and isn’t well-connected to what’s going on today. At the same time, for all the great journalism out there, by necessity it’s usually pretty narrow. So I had this idea of combining the two – the original narrative journalism with the history – to make a broader argument about what’s happening to health care.

And, really, that’s the most important reason I wrote this. I thought I had something valuable to say.

How did you find an agent?

Through sheer luck, I had come to know a book agent many years ago. She’s terrific – knows the business inside and out, but thinks about substance the way a journalist does. I hadn’t spoken with her in a really long time, but when I wrote her with this idea of doing a health care book, she said she was interested and that we should talk. This was in late 2001. (The manuscript was completed in September 2006.)

And then you had to write a book proposal?

Yes. I had thought what I sent her originally – a five-page outline – was a proposal. No way. She said this is a great inspiration. Now you have to turn it into a real proposal. And that’s what I spent the next two years doing. The final proposal was around 50,000 words.

Not all agents push their writers to go into such detail. In my case, I think, it had a lot to do with the fact that I’d never written a book and that the topic didn’t seem too sexy. I had to prove I could pull this off.

One thing I learned: The point of the proposal is to sell you and the general concept, not to lay down a roadmap you’re obligated to follow. Many books end up looking quite different than their original proposals. Mine certainly did.

Was it difficult to find a publisher? How does that process work?

Here’s how it works, as best as I can tell: Each publishing house has many editors. Once you’ve finished your proposal, your agent will approach editors that might be interested. Hopefully, a few will be – and they’ll want to talk with you about the idea. If they like what they hear, they’ll try to get a green light from their superiors to bid on the proposal.

Ideally, several editors will jump in, sparking a bidding war. When the bidding war stops, you get to pick which publisher you want. Most people go with the highest offer, though you might pick a lower offer if you think the editor or the publisher is a better fit.

I have to say I was pretty nervous when the process started. I’d spoken to some editors on my own while working on the proposal – people I’d met over the years – and none seemed that excited. But my agent found several who were interested and several ended up bidding.

Talking about the advance, how did you support yourself financially, especially before getting the advance?

I had a Kaiser (Family Foundation) fellowship, which the foundation graciously spread out over the course of two years – so that I could keep working halftime at my magazine (The New Republic). The magazine was really accommodating, too: I could disappear for six weeks and come back and make up for it later.

Let’s talk about the outline. How did you decide on the format of the book?

I’m a compulsive outline writer. I was constantly pulling out legal pads and jotting down schematics of how the book would play out.

There were a few issues to figure out. First, the basic structure. Going in, I knew I wanted to use narrative journalism as a way to write about policy. But would it be one long narrative – or a series of shorter narratives? I decided on the latter.

Another issue I had to settle was voice. In a book like this, you can be totally dispassionate – or be very opinionated. I guess I decided that, when it came to tone, less was more. I was telling stories here and, if I did my job right, the stories would make the argument on their own. I didn’t need to get up on a soapbox, at least until the very end.

How was the reporting process? How did you pick the cities and how did you find your sources?

I eventually settled on this model of using one person’s narrative as the focus of each chapter. But then I had to actually find these people. It was probably the single hardest part of the research – and the reason it took so long.

I was able to find some people by zeroing in on cities and states where I knew an issue had been in the news – like managed care abuses in Texas, or fraudulent insurers in Florida. For Medicaid, I knew I wanted to write about Tennessee’s TennCare. From there, my strategy was to interview as many people as possible – finding some through clips, the rest through local organizations. Staff at local clinics and outreach groups were particularly good at introducing me to people. Unions too.

How was the writing process?

It was hell. Some people are very disciplined, with set routines; they know that if they set aside four hours, they can churn out so many words, and so on. I am not one of those people. Plus I had a lot of different demands on my schedule. (Cohn had to balance work, reporting, research and family with writing.)

I wrote a lot of the book late at night or while traveling. I learned to write in coffee shops. I became an expert at sniffing out free wi-fi.

The first chapter was the hardest. I was basically inventing the format as I went. I angsted over every paragraph. It took me about five months. But once I did that, the rest came quicker.

How else is writing a book different from writing an article?

For one thing, the publisher would set deadlines, but didn’t necessarily expect me to meet them – at least until late in the process, when the marketing and publishing schedule was set in stone.

The rules on attribution on sourcing also aren’t that clear. It seems like everybody has their own standards. I tried to err on the side of caution, diligently confirming whatever I could and being as transparent as possible in my notes. (Cohn has included his notes and sources in 50 pages at the end of his book.)

You also do your own editing and factchecking. Book editors will weigh in on the big conceptual stuff, but their job is as much about the business end as the editorial end. So you need to find friends who will read your stuff and give you feedback. I also got help from medical and policy experts, many of them at Kaiser. Several graciously read whole chapters to make sure everything is right. My dad, who is a doctor, read the whole book.

Why should health-care reporters read this book?

This is shaping up as the biggest domestic policy issue of the next presidential campaign. And, if nothing else, I hope this book is a good introduction (to the U.S. health care system). The history may seem particularly helpful: Everything we’re talking about has happened before. That’s good context whether you’re writing about this locally or nationally.

I also think the book makes some important arguments. Middle-class people have a false sense of security about health insurance. The book’s message is that “this could be you.”

It also makes an argument for doing things differently – dispelling a lot of the myths about how universal health care works in other countries. (Hint: It works well, at least in the good ones.)

Of course, I’d also like to think it’s just a good read.

Sick was published in 2007 by HarperCollins. It will be out in paperback in April 2008. Cohn is writing a “pretty big” afterward, heavier on policy, in light of the upcoming presidential elections.

Naseem Sowti is a health writer for the Ocala (Fla.) Star-Banner.