The Affordable Care Act — Obamacare — is the most heralded and condemned legislation of the decade. The labor of accomplishing nothing less than a complete overhaul of the disastrous state of American healthcare has been hindered every step of the way by bellicose partisan discord, rabid lobbying, and the cataclysmic launch of a defective website.
How Obamacare came to exist and why it continues to struggle to achieve its aims is the subject of Steven Brill’s America’s Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System. A comprehensive chronicle of the law’s trajectory — the demand for it, the drafting of it, the implementation of it — America’s Bitter Pill is an assessment of its successes and failures, and of how far we have to go.
You can purchase the book here.
In June 2013, I came up with what I thought was a great idea for another special report for Time. As with that earlier story, this one was born of simple curiosity.
I had gotten the idea for the first article when I became curious because so much of the debate over Obamacare seemed about how we could insure millions of Americans against the stupendously high cost of healthcare in the United States, rather than why the cost was so high to begin with. What and who was behind all of those high prices? Where was all that money going? To find out, I would trace the money and profits behind every line item in hundreds of pages of bills given to seven patients.
Now, I told my editors, I was curious about something else: Launching Obamacare, with its e-commerce insurance exchanges and thousands of other complexities, seemed like the most ambitious domestic government project since Medicare. In fact, it was going to be far more difficult, I pointed out, to pull off than Medicare. Medicare was about getting an identifiable subset of the population to sign up to get something for free. With Obamacare, people had to be sold on buying a confusing product and given exactly the correct subsidy to do so. Even those that didn’t buy — all adult Americans — would somehow have to prove that they had insurance, and employers would have to prove that they were providing it to their workers.
How were they going to do all of that?
So we had agreed that through the summer I would make multiple trips to Washington to look in on how this massive program and its core e-commerce website was being built. I even told my editors that based on the efficient, dedicated people I had seen at the CMS campus in Baltimore while reporting on the vetting and processing of Alan A.’s Medicare bills for the first article, this was likely to be an uplifting saga of unsung heroes. Whatever the political dysfunction in Washington, Obama’s managers and these civil servants were going to prove that big government could work.
The story would come out in late October, after what I thought would be a triumphant launch.
Who’s In Charge Here?
As I was returning from my first round of interviews that plotline started to blur. On the train back to New York, I flipped through the notes I had taken while talking with eight people who were working on the project at the Department of Health and Human Services, CMS, and the White House. I saw that almost as an afterthought or conversation starter I had asked each who was the person in charge of the launch of the federal exchange. I hadn’t paid much attention to the answer, until I sat on the train reviewing the notes.
There were seven different answers:
Jeanne Lambrew at the White House;
Michelle Snyder, who ran CMS operations;
Gary Cohen, who ran CCIIO—the Center for Consumer Information and Insurance Oversight that had been demoted from being an office; he got two votes;
Marilyn Tavenner, the head of CMS;
Kathleen Sebelius, the HHS secretary;
Henry Chao, the deputy director of the CMS technology office;
And David Simas, who was overseeing the marketing and messaging of the launch from the White House communications office.
I also noticed that I had asked a spokesman for CMS, who was taking me around for interviews, who was in charge. Now I saw that he had said, “It’s kind of complicated.” Whereupon he had taken my notebook and drawn a diagram with four diagonal lines crossing one another and forming a kind of lopsided triangle. It was incomprehensible.
Finally, my notes reminded me that when I had asked one person at CMS if I could watch the October 1 launch from their control room or command center or whatever they were going to call it, she had responded, “Which one?” There were actually going to be four or five command or operations centers, she had explained: one for each of three CMS offices, another at HHS, and maybe another at the White House.
When I got home that night I told my wife that I was not so sure I was going to be able to write the launch saga I had sold the Time editors on. The launch looked like it had problems.
If you enjoyed this excerpt, purchase the full book here.
From the book America’s Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System by Steven Brill. Copyright © 2015 by Brill Journalism Enterprises, LLC. Reprinted by arrangement with Random House, an imprint of Random House, a division of Penguin Random House LLC. All rights reserved.