After passage of Health Policy, a team of Washington Post staffers who had covered the topic tirelessly wrote “Landmark: The Inside Story of America’s New Health-Care Law and What It Means for Us All.“
In this piece for AHCJ, member Joanne Kenen interviewed two of the authors. Ceci Connolly wrote the inside story of how the bill survived many “near-death experiences.” Alec MacGillis wrote several chapters on how the law would affect individuals, small businesses and insurers. Edited and condensed excerpts of Kenen’s conversations with Connolly and MacGillis follow:
AHCJ: You covered the Clinton plan and you covered this story. At what point did you begin to realize there could be a different ending?
Connolly: There were several points, from shortly after President Obama took office – and several points where I was certain it was all but dead. After the Massachusetts special election that Republican Scott Brown won, I was pretty convinced, as was just about everyone I talked to in Washington, that they were not going to be able to rescue it, largely because Democrats were so spooked.
AHCJ: You started your account with then-candidate Obama’s poor performance at a health care forum in March 2007. When did he start to “get” health care?
Connolly: By about May or June of 2008 I thought he had made a significant leap in his understanding of the complexity of the issue. He was talking in greater depth and comfort around the intersection of quality and cost issues.
A low point for the President was the July [2009] prime time news conference. It was almost entirely health care. At the end there was the Henry Louis Gates question. As I watched that night, it felt that he was losing his grasp on the health care agenda. If not for the [distraction of the] Gates controversy, it could have been more damaging. It set up the horrible August that the administration went through and they knew it.
AHCJ: Can you talk about how the Obama administration, more than Clinton’s, linked cost, coverage and quality?
Connolly: They absolutely wanted to link them, and to repackage the terms of the discussion. They did not want it to be a discussion only about coverage. Coverage is primarily about the uninsured, who tend to be poor people. The Obama team was very savvy about understanding that they needed to make this a political issue that was either going to be attractive to – or not frightening for – the middle class. And that’s where they decided to hone in cost and quality. But I don’t know that most of the members of Congress or most of the American public has fully embraced the idea, [prevalent] in policy circles, that we don’t get what we pay for in this country.
AHCJ: You have reported on health care system innovators like Geisinger Health System. What do they tell you about the future of reform?
Connolly: That falls into a “good news, bad news” category. There are incredible innovators in the U.S. health care system. We know most of them. We’ve been writing about them for a number of years, how they have maintained quality and kept control of costs. The “bad news” is that those models are not being replicated in any large scale fashion. As a journalist, that has continued to puzzle and surprise me for many years now. If someone builds a better car at lower costs, all the other car companies are pretty quick to copy it. Same for laptops, cell phones, any product that you can think of, people constantly figure out a way to improve the quality and lower the cost. That has not been our history in health care. We’ll have to watch whether and how government and the private sector look at fabulous health care innovators and begin to adopt and expand their practices.
AHCJ: Looking back at the political debate now, what strikes you?
Connolly: The public option! Why did we fight about it so much? Most reliable nonideological experts believe that at best the public option would have an impact on the margins. I was always a little curious about why the White House enabled, or at least allowed, that bitter emotional debate to drag on. It was largely a Democrat vs. Democrat fight.
AHCJ: If you were covering health outside Washington, what would you focus on?
Connolly: Community health clinics and Medicaid will receive large infusions of federal money. That will have a dramatic impact on every community in America, and will be worthy of scrutiny. How well do those programs get up and running or expand? Who do they serve? Will that immediately throw us into a primary care shortage?
AHCJ: Alex, you weren’t really a health policy reporter into you got thrown into it. How did you perceive the story then, and now?
MacGillis: I began when it was all “bend the curve” – when [then OMB director] Peter Orszag was trying to make it all about cost control. I knew that, at heart, it was a coverage bill.
Now I see it mainly about coverage – but not just covering 30 or 40 million uninsured. It’s about regulating an industry that for too many people is a Wild West, about people with poor coverage or who are not covered, or not covered well, or live in states where there is next to no regulation of insurance.
AHCJ: How did you pull “Landmark” together so quickly?
MacGillis: I came up with a chapter list, and each had a different audience in mind. That’s why there’s some overlap in the chapters, for different audiences.
But it was a little frustrating co to have a publisher come to us and say “People have no idea what’s in this bill, it’s a big mystery.” I and other reporters had been writing about it all year and we were doing our best to explain it, and it was a little disheartening for editors to say that.
There was an element all year of people exaggerating the complexity – saying it’s so complicated is a way of getting around taking the limited time needed to figure out the basics: Expand coverage. Make it easier to afford. And require people to get it and insurers to take everyone. That’s the three-legged stool. Other people were trying to make it more complicated.
AHCJ: What are the stories going forward?
MacGillis: Watch and see what the providers do in response, to what extent they are trying to organize themselves [in Accountable Care Organizations or other new models]
Watch your insurance marketplace. You are already seeing various insurers dropping out of the individual market and citing the law as an excuse.
There’s a wildly varied landscape of state regulation, around the rules and the capacity to enforce the rules. What, if anything, is your state doing to get ready?
Joanne Kenen edits the New Health Dialogue blog and writes about health care for several magazines.
