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What Does The 'War' Over Obamacare Reveal About Our Governing Bodies?


This is FRESH AIR. I'm Terry Gross.

Obamacare, the Affordable Care Act, was passed in 2010. Since then, there have been many unsuccessful attempts by Republicans to kill it. The left has been pushing to have the government insure everyone directly through what's described as "Medicare for All." Now this debate is happening during a pandemic, when health care is at the forefront of people's minds.

My guest, Jonathan Cohn, is the author of the new book "The Ten Year War: Obamacare And The Unfinished Crusade For Universal Coverage." It's about the politics and special interest groups that shaped the Affordable Care Act, the ACA. He writes, figuring out how to fix American health care has never been entirely or even primarily about what kind of system would work best; it's also been about what kind of changes can actually survive the political process. His book focuses on that political process, dating back to the 1920s. He's been reporting on health care since the late '90s. He's a former senior editor at The New Republic and is now senior national correspondent at HuffPost, where he covers politics and policy and has been focusing lately on COVID.

Jonathan Cohn, welcome back to FRESH AIR. It's been a few years. Great to have you back.

JONATHAN COHN: I'm so happy to be back on the show.

GROSS: In the book, you describe the ACA as a highly flawed, distressingly compromised, woefully incomplete attempt to establish a basic right that already exists in every other developed nation. It's also the most ambitious and significant piece of domestic legislation to pass in half a century. It's not nearly good enough, and yet so much better than what came before.

Jonathan, having tracked the political process of health care legislation, do you now accept not nearly good enough as a giant step forward in a way that you wouldn't have had you not witnessed the difficulty of the political process of getting Obamacare passed?

COHN: Definitely. You know, when I started writing on health care, you know, back in the late 1990s and coming to this and seeing all the problems of our health care system, you know, of course, your mind starts to think, well, what kind of system should we have? And if you care about universal health care, if you think health care should be a right like it is in the rest of the world, you think, well, we need a system like that. And so your standard is getting to that system, some kind of national health insurance system where everybody is covered and no one really faces the prospect of financial hardship because they've gotten sick.

Then, you know, I had a chance to actually watch the political process chew over this and see in real time how the idea of universal coverage gets translated into a proposal that then becomes a series of bills that then go through Congress that get signed and is being implemented and fighting resistance efforts at repeal. And, yeah, you get an appreciation for how hard this is. I mean, any kind of large-scale public policy reform is difficult. Health care reform is especially difficult. And I think it did give me some appreciation for the importance of partial success and partial victories, even when they don't accomplish everything you might want and even when there are big parts of them that you think, gosh, that's regrettable; I wish this looked different.

GROSS: Do other countries that have national health care systems, including England, Canada, Europe - did they go through a similar political process with special interest groups and lobbies and everybody wanting their own thing in or their own thing out that ends in a big compromise in a complicated bureaucracy, or did they have another approach?

COHN: Every country is different. And the basic rule of thumb here is the earlier that you set up your health care system, the easier it is to do because you're operating - there's a blank slate. The pieces are not in place, and you can set it up in a way that seems rational and works for your country.

The longer it takes, as you go later on in history, well, now you've got a health care industry building up. There's doctors. There's hospitals. People have got their insurance arrangements in place. And inevitably, you're going to have to disrupt some of those things. You're going to have to take some money out of people's pockets and move it somewhere else. And that is very hard to do politically. And so it gets complicated.

Here in the U.S., this is a big reason we've never gotten to fully universal coverage. Inevitably, it's going to - you know, to do it properly, to get everybody insurance, to make sure it's good insurance, to finance the system, get costs under control - one way or another, you know, you're going to be taking money away from the drug industry and from the hospital industry. You're going to be changing some people's insurance arrangements. And every one of those changes is a fight. It's a struggle. And it's just really hard to do.

GROSS: And it ends up in a lot of compromise.

COHN: It does end up in a lot of compromise. And that is how the Affordable Care Act came to be and why it looks like it does.

GROSS: So Republicans, you know, had been trying to defeat it before it was passed and continued, you know, after it was passed. Where do we stand now? It wasn't, to my knowledge, a major issue in the 2020 campaign. Have Republicans given up on trying to unravel or cancel Obamacare?

COHN: You know, I thought so many times the Republicans were done with fighting Obamacare and then proven wrong. I hate to say anything definitively. But it is very clear in the last two elections - the 2018 midterms to 2020 presidential election - Republicans did not emphasize Obamacare repeal and, in fact, did their best to convince people that they were not trying to take away protections for preexisting conditions, that they were not trying to take away Medicaid coverage I think because they learned after trying to repeal it and then the 2018 midterms that that is extremely unpopular, that the public does not want to give up what they got with the Affordable Care Act. And so I think Republicans are now much more reluctant to make a sort of frontal assault on it, which doesn't mean they don't think about health care.

I'm sure we will continue to see them try to change the health care system in the same way they now try to change Medicare. I mean, they don't say they hate Medicare anymore like they - some - a lot of them did originally. But they're trying to privatize it. They're trying to cut its funding. I imagine that is where we are probably going.

GROSS: So President Biden has undone some of Trump's undoing of the ACA. So what has Biden done so far to strengthen the ACA?

COHN: So on Day 1, the Biden administration got to work undoing changes that the Trump administration had made to the Affordable Care Act. You know, the Republican effort at repeal failed, but the Trump administration was very good at finding small, technical ways of changing the law so that, for example, the financial assistance that people got buying insurance was lower. And this involves things like adjusting the formula for actuarial value. And just sort of saying that phrase I think puts people to sleep, but it's important. And there are, you know, a dozen or so of these changes that the Trump administration made.

And on Day 1, basically, the Biden administration came in and said, we're going to reverse these. We're going to change these. And actually, we're going to turn those dials back, and we're going to do things like fund outreach. So that's already underway. And that can all be done mostly through just pure executive authority. That's just changing regulations. It takes some time to do, but they don't need Congress.

The second thing, and this is part of - you know, there's a bill, the COVID relief bill, moving through Congress right now, the big one with the checks for people and the assistance for vaccinations. Inside that bill is a boost to the subsidies for people who are buying insurance at or one of the state-run exchanges like Covered California.

This is something that the architects of the law always wanted to do but never had the power to do because I think they recognized early on the bill was underfunded, and there's just not enough assistance for people. People need more help buying insurance. So there would be more money for people who get subsidies now, and more people would become eligible for subsidies. People who make a little too much money to qualify for assistance now - they would get help, too. So that is in the bill. It's only temporary. That's the asterisk there. It's a two-year bump. So even if it becomes law, if they want to make that permanent, they would have to come back and extend it. But those are two very concrete steps that are now already in motion.

GROSS: Does Biden have other plans to try to expand the ACA?

COHN: Well, you know, in his campaign, he talked about adding a public option. And people who remember the original debate about the Affordable Care Act remember this was a very big part of the original proposal and was a bit of a compromise to please progressives who, remember; for all - historically had always wanted something like, you know, what we call Medicare for All, a single-payer system, the government insuring everybody. Well, that wasn't in the cards politically.

But the idea was to have a sort of optional government-run program for people who want to go into it and that this program would, you know, would work like Medicare works and, because of that, you know, in principle, in theory, would be more efficient. It would be cheaper. So it'd be a cheaper option for people. And, also, it would, you know, introduce some new competition - right? - for the private sector 'cause if you're a private insurer and you're competing with this public insurance option that's cheaper, you're going to lower your rates, too. That did not make it into the bill. It is not part of the law. Biden has said he wants to have one of those.

And interestingly, and this is important, it's an actually more ambitious version than the original in the sense that it would be open to anybody, even people who have employer insurance right now. He would basically say, if you want, you can jump over to that public option. And for that matter, you can also jump over to a private insurance plan that's subsidized through if that's a better deal for you. And together, those two changes - that actually could deliver a lot of price relief. In other words, people would see - would be able to save money on their premiums for people who now have employer policies that are starting to get expensive and they're sweating out the premiums. So that could be a pretty big difference.

GROSS: So this is a pretty broad question, but why did Republicans make health care coverage, government health care coverage such a big target? I mean, everybody wants health care. Of course, some people prefer to do it through private insurance, through employer insurance. But what were some of the motivations behind such strong Republican opposition? And, you know, how much of it do you think was ideological - you know, a belief that government should not be funding this? How much of it do you think was, like, you know, budget hawks saying, we just can't afford to spend this; it's a bad idea; we're going to go into debt? And how much of it was money, like lobbyists who, you know, support Republicans who didn't want the ACA to pass and threatened to withdraw their funding?

COHN: Let's start with the philosophy. I think philosophical differences are a big part of it. I mean, ever since we've been debating universal health care, conservatives have - in this country have fought it. And it makes sense given, you know, conservative views in this country. I mean, what don't conservatives - what does universal health care require? Well, it requires government spending. It requires either having the government displace the private insurance industry or regulate it very closely. And, of course, it was going to require finding new money to fund this through taxes. Well, conservatives - they don't like taxes. They don't like regulation. They don't like government spending. They don't like having the public sector do what the private sector could do. So you're going to always run into some resistance in this country up against conservatives.

Having said that, there was certainly a period not that long ago when you had a significant number of Republicans who, although generally, you know, they don't like taxes, they don't like regulation, nevertheless bought into the idea that we should have some kind of universal coverage system and really focus on, OK, well, how can we do this in a way that kind of fits what we prefer about how the world works? So maybe we do it through private insurance instead of public insurance. And we do - we don't make it so generous so it doesn't cost so much money. And you kind of go down the list.

And, you know, what was interesting was the premise of the Affordable Care Act when they kind of got - when the Democrats got power was they hoped that they crafted a plan that they thought had a lot of those elements and that looked like things conservatives had praised before in the hopes that that would get at least some Republican buy-in. And, of course, it didn't. And I think that's where you get into the other factors at play. Some of this was the Republican Party, the conservative movement in this country became more extreme in its opposition to the welfare state. And, you know, and this was a sort of ongoing change. A lot of this - you know, and then amplified by groups funded by the Koch brothers, for example.

And then some of this was, frankly, just about opposing the Democrats, opposing Obama. And, you know, that's a whole other conversation - well, why was the opposition to Obama so intense? - and something I try to talk about in the book. But I always say, you know, I'm not surprised that Republicans generally opposed, you know, the Affordable Care Act. I'm surprised they all did. I'm surprised they did so intensely. And it's just hard to escape the idea that the opposition to Obamacare was as much about the Obama part as it was about the care part.

GROSS: Let me reintroduce you here. If you're just joining us, my guest is Jonathan Cohn. His new book is called "The Ten Year War: Obamacare And The Unfinished Crusade For Universal Coverage." We'll be right back. This is FRESH AIR.


GROSS: This is FRESH AIR. Let's get back to my interview with Jonathan Cohn. His new book, "The Ten Year War," is about the politics behind the passage of Obamacare, the Affordable Care Act, and the subsequent attempts to dismantle or repeal it.

So the pandemic is a true test of any health care plan or any national health care plan. How is the ACA functioning during this COVID pandemic?

COHN: A pandemic really holds up a mirror to our health care system. And so, you know, one way to look at it is we still have millions of people uninsured. We have people with insurance with really big deductibles, can't get to the doctor. So, you know, in one way, you could say, gee, this shows all the inadequacies of the Affordable Care Act. The flip side is if you imagine a world where we don't have the Affordable Care Act in place, there would be so many more people who didn't have health insurance. There would be so many more people with insurance that had, you know, high deductibles, couldn't get to a doctor.

You know, it's kind of remarkable we don't have - you know, it takes a while to get really good statistics on insurance coverage. It doesn't - it looks like the number of people without insurance has not dramatically increased, which is pretty remarkable given the number of people who have lost their jobs. So that's a pretty clear sign that the Affordable Care Act is doing its job. There's a lot more to be done. But it's working, you know, like it's supposed to work.

GROSS: So another example of how it's an imperfect plan, but it's better than not having it, in your opinion?

COHN: Exactly. Exactly.

GROSS: So there are certain weaknesses in the ACA. Can you give an example of something that you think is a weakness that is a result of a compromise that had to be made in order to get the bill passed?

COHN: Yeah. I mean, I think the most obvious one is the amount of money that went into the funding, the overall funding of the health care legislation. When they were debating this, there was a commitment that outlays, you know, the sort of amount money you spend that the Congressional Budget Office measured. It couldn't be more than a trillion dollars over 10 years. And there's no magical economic value to a trillion dollars. That's just - that's where, basically, it was thought to be politically sellable. As the debate went on, there was just a lot of pressure to hold that number down, mostly from more conservative Democrats, partly because they'd also - they had said they were going to be fiscally responsible. They weren't going to spend money they didn't have.

So every dollar they were going to spend, they had to find somewhere else. It had to be new taxes, or it had to come out of the pockets of the drug makers or the hospitals. The problem is, if you only spend - if you can't spend more than a trillion dollars over 10 years, you end up in a situation where you're spending less now to help people buy insurance. And so that's why today, especially when you get into the middle-class people who are buying insurance on their own, you have a lot of people who are looking at very high premiums, really big deductibles. And, yeah, they have insurance. Yes, this is better than not having insurance. But, boy, it's a lot of money. It's not very affordable. And - you know, and that is why - one of the big reasons we're still here 10 years later saying, what do we need to do to fix our health care system?

GROSS: What is an example of a compromise that Nancy Pelosi made in the House, because she had a lot of trouble getting enough votes?

COHN: Yeah. Well, the most famous one, it was on abortion rights. You know, she's a staunch defender of abortion rights, has been for, you know, her career. When - you know, as she was moving a bill through, it became very apparent they did not have the votes unless they convince a group of Democrats who oppose abortion rights. And, you know, the actual - you know, the big issue came down to federal funding of abortion rights, which always comes - of abortion, which comes up every time there's a health care bill.

The architects of the legislation, they felt like they had structured it in a way that basically, you know, the money was siphoned off. And, you know, money that came from the government couldn't be used to actually pay for abortion. But a group of Democratic House members said, no, that wasn't good enough. And she basically had to say, fine. We'll give you this restriction that threatened to make abortion very unavailable for people buying private insurance. She did not want to do it. Some of her closest allies did not want to do it. But she basically said to them, we have to make this deal because if we don't, this bill doesn't pass.

GROSS: Harry Reid was the Senate majority leader at the time. What's something that he did either to compromise or to convince Democratic senators to sign on to the bill in order to get the ACA passed?

COHN: Well, Harry Reid had a tough job. They needed 60 votes. And they had 60 members of the Democratic caucus, could not lose a single member. The most famous compromise he had to make was on the public option. Progressive Democrats really wanted that. They felt like they had given up so much already. But a number of Democrats were against it. The most vocal of them was Joe Lieberman from Connecticut. And Lieberman basically made very clear, he said, I will not have a public option. If there's a public option in this bill, I will join a Republican filibuster. And you won't be able to pass this. And Reid tried his best to come up with some compromise. He set up a committee with moderate and liberal Democrats. They thought they had an alternative. Lieberman came out against that as well. And he had to drop it. And analogous a little bit to what Pelosi went through with abortion, Reid had to go to his progressive members and say, look, I did my best. I tried to do this. I don't like it. We don't have a choice.

GROSS: If you're just joining us, my guest is Jonathan Cohn. He's the author of the new book called "The Ten Year War: Obamacare And The Unfinished Crusade For Universal Coverage." Jonathan, we have to take another break here. And then we'll talk some more. So we'll be right back. I'm Terry Gross. And this is FRESH AIR.


GROSS: This is FRESH AIR. I'm Terry Gross, back with Jonathan Cohn, author of the new book "The Ten Year War: Obamacare And The Unfinished Crusade For Universal Coverage." The book reports on the behind-the-scenes politics that led to the passage of the ACA, the Affordable Care Act. It's also about the decades of attempts to provide health care coverage to Americans dating back to the 1920s.

How did Harry Reid, the Senate majority leader at the time, get the support of Bernie Sanders? And Bernie Sanders, as everybody knows, has made universal health care or, you know, "Medicare for All," a signature issue for him? And this this was a real - this was a distance away from what Bernie Sanders has wanted and advocated for for years. So what did it take to get Bernie Sanders to sign on?

COHN: Yeah, it was a big distance. And Bernie Sanders had a demand, although I think it says a lot about Bernie Sanders, the nature of the demand. When we talk about demands senators make, you know, some - oh, you know, I want a tax break for an industry in my state or, you know, extra Medicaid money for my state or what have you. Bernie Sanders said, if you want my vote, I want money to go directly to what are called federally qualified health centers. And these are basically clinics all over the country. They - it's part of a program that started in the 1960s that exclusively give health care, either free or discounted, to people who either don't have insurance or can't pay their medical bills.

And basically, his special interest favor was something that would get health care to the sort of most financially, medically needy people in the country. It was a lot of money. So it was not - it required shuffling things around in the bill. It was not an easy thing to accommodate necessarily. But the end of the day, it was all about getting health care to people who need it, which, of course, was the No. 1 purpose of the legislation. So I think Harry Reid felt, the White House felt, everyone felt like, OK, this is something we can definitely live with.

GROSS: And so that was written in?

COHN: It was written in. And that funding has, you know, has done enormous good when you look at the impact of the law. If you really want to see the impact of the Affordable Care Act just vividly, you know, find a community clinic in your area, one of these federally qualified health clinics, and ask them what the last few years have been like. Between that extra money and just in general, more people getting Medicaid, which they take, these clinics, they can serve many more people. And they've added all kinds of important services. You know, they do addiction counseling. They do diet counseling, things that help them, you know, not just help treat illness, but keep people from getting sick. And especially when you're dealing with communities where you have such high rates of diabetes, hypertension, people aren't getting cancer screenings - this it makes an enormous difference. And it's really a place where you really see what I would say is the best of the Affordable Care Act, where it's really done the most good.

GROSS: What would you say is one of the biggest compromises that Democrats made with the pharmaceutical industry in order to get the bill passed?

COHN: So one of the big, you know, the big ideas for how Democrats were going to pass health care reform was they were going to negotiate with all of the industries. And they were going to go to every industry and basically say, look, you work with us. We'll work out some kind of deal where you'll give up something. We'll pay you a little less here or there. And in exchange, we will not - you know, we will not go to - we will not be as aggressive as we could be with you. And in exchange for that, you won't fight us on the bill. And this was all - came out of the failures in the past. And the saying was sort of, you know, on the bus or in front of the bus or, you know, on the menu or at the table.

So with the drug industry, the original idea was they wanted - there's a whole series of things they wanted to do. They wanted to spend less on drugs through Medicare and Medicaid. And there was talk of - you know, there was talk of having the government start to negotiate prices directly with the drug companies, which is something that happens in other places in the world. And the drug industry basically came back and said, look, we will - we're OK with you paying us less somewhat through Medicare and Medicaid, but we're not going to accept the kind of reductions you want. And by the way, no way we're going to accept government negotiation of prices. If you do that, we're done. And not only are we done, but you can look forward to us using our war chest to finance advertisements against this legislation. And we'll tell every senator and congressman who listens to us - which is, by the way, most of Congress - to oppose this bill. And your bill will be dead just as surely as the past ones were.

So Democrats basically had to agree. At the end of the day, they did reduce payments to the pharmaceutical industry relative to what they would have been, but not by that much. And in addition, they took government negotiation of prices off the table, you know, for the moment. They always could come back to it later. And in fact, here we are 10 years later. We actually are talking about it again.

GROSS: So just standing back a second and assessing the route that the ACA took to being passed and what went on behind the scenes, what impression did that leave you with about how our government functions, how the political process functions?

COHN: So I think it functions badly. And I think a fair amount of that is the way the sort of institutions of our government, especially the Congress, especially the Senate, are set up really thwart change and thwart progressive change in particular. And that is because of the sort of bias towards small states that's built into the way the Senate is designed. You know, a senator from Wyoming has the same amount of influence as a senator from New York. And because of the way the country's population is distributed, that pulls everything in a much more conservative direction. You throw the filibuster on that - so you actually need 60 votes, not 50, to pass something - and it's just very hard to do anything. And, you know, I think going forward, that's why I think progressives, if you're thinking about the future, how to pass reforms, they really need to attack those impediments to change or otherwise they're going to run into the same struggles that the Democrats of 2009 did.

GROSS: So the Republicans had stood for repeal and replace. The replacement part never really got drafted even though President Trump had kept promising it's coming soon, a couple of weeks. It never materialized. Do you think that the explanation you just gave of Republicans becoming better at generating outrage than generating legislation and really knowing the art of legislation, do you think that explains in part why replace never got formulated?

COHN: I think that's a really big part of it. You know, I - by comparison, I compare the years leading up to the Affordable Care Act's enactment to the years leading up to the attempt to repeal. And when you look at how - why did Democrats get their legislation across the line? Well, a big reason was they spent 10, 15 years looking at where they had failed in the past and having these very complex, difficult debates internally about how to design a plan that would work, that could - they could sell politically, that they could get through Congress. So they were really ready. They'd done a ton of homework by the time, you know, 2009 comes around and they have the ability to actually pass legislation. You compare that to the Republicans. You know, in the period between 2010 and 2017, they had seven years really to do that, to sort of go through the same process, to really kind of say, all right, what does our replacement look like? How do we pass it? And, you know, health care is hard, right?

And once you get past the slogans, you immediately discover all the trade-offs, all the parts of, you know, someone's going to feel some pain in order to give someone else some benefit. And they never did those - they never did that work. You know, there were a handful of intellectuals who had plans. There were a handful of members of Congress who had bills. But they really didn't focus on it all.

They landed there early 2017 ready to go. And they don't have a plan. And, of course, you know, have they had done that exercise, they might very well have discovered that, gee, our slogan that we're going to repeal Obamacare and replace it with something that's way better and still true to our conservative principles, well, that wasn't going to happen because at the end of the day, there was no such. But you couldn't - not even in theory, it just wasn't possible. But they never realized that because they hadn't done the homework.

GROSS: Let me reintroduce you here. If you're just joining us. My guest is Jonathan Cohn. He's the author of the new book "The Ten Year War: Obamacare And The Unfinished Crusade For Universal Coverage." We'll be right back after this break. This is FRESH AIR.


GROSS: This is FRESH AIR. Let's get back to my interview with Jonathan Cohn. His new book, "The Ten Year War," is about the politics behind the passage of Obamacare, the Affordable Care Act and the subsequent attempts to dismantle or repeal it.

So a lot of people are pushing for universal health care. And some people see the ACA as a step in that direction, and I think others see it as a bureaucracy that takes us in a way further away from universal health care. And of course, some people don't want universal health care because it's more government interference in health care. But do you think that the U.S. will ever have universal health care?

COHN: I do think we'll get there eventually. I think it will take time. You know, the people who wrote the Affordable Care Act, certainly were trying to get to universal health care. That's what they believed. And I think they would see and I would agree that it's a big step on the road towards universal health care, both in the sense that we've covered many more people. So the number of people who don't have insurance at this point is much lower than it was.

But also, we've really established some of the key principles. They're sort of widely accepted politically. Again, you know, you just see that in the fact that Republicans these days, who are the opponents of Obamacare, nevertheless say but, you know, just to be clear, we think everybody should have a right to insurance regardless of preexisting condition. Well, that was not a reality 10 - more than 10 years ago. So that has changed. So we've gotten closer clearly. You know, how we get the rest of the way, you know, to what extent it involves building on the architecture of the Affordable Care Act versus tearing that architecture down, putting something new in its place, I think that is the debate going forward.

GROSS: You've been writing about health care coverage and health care, you know, policy for basically your whole adult life. What's kept you doing that?

COHN: Well, you know, I would say two things. First of all, the problem never gets solved. So there is always, you know, it's an ongoing effort to sort of figure out what to do about it and to understand it. It's such a complex system. I mean, I have been writing about health care for a long time, but I learn new things every day. There are vast swaths of our health care universe I don't understand and I'm still trying to learn. And of course, conditions change. And sometimes, you know, you need to write about the changes and figure out, OK, what's new now? How do we need to rethink what we thought before?

The other reason is, you know, I'm a - you know, having spent so much time over the years talking to people who have struggled with medical bills, who've gone through real hardship. And it hits you every time that it's not that these people have made all the right decisions necessarily, it's not that they've always put themselves in the best positions, but the end of the day, they're - people, you know, are unlucky and they suffer because of it. And, you know, I - you know, I'm not afraid to sort of say that. I think just as a moral principle, if you're facing an injury or a serious illness, you shouldn't also have to worry about paying your bills. It's bad enough to have to worry about the illness or the injury. That's hard. Anyone who's ever been through that, anyone who's been - had a family member go through that, it can be incredibly traumatic. It's difficult. It's hard.

The least a society can do is to say we may not be able to cure you, we may not be able to make you better, but the very least we're going to make sure that, you know, you don't have to worry about going bankrupt, paying your bills. And we don't do that as a society. Now, other societies do that. And, you know, until we get to that point, I imagine I'll keep writing about this.

GROSS: Your mother died after a long illness. She was in a nursing home. And she died during the COVID pandemic, so you were not able to be with her or to visit her. I'm very sorry for your loss. So - but I'm going to ask you a more technical question here. I don't know how much you had to deal with her bills and with the nursing home doctors and nurses. It's so hard when you have somebody who you care about and you can't see them and they're in a hospital or a nursing home. What did you learn about our health care system from the period when you were able to visit her and then in COVID when you couldn't?

COHN: Yeah. Well, thank you for the sympathy. I learned a lot. You know, as someone who writes about health care, to be on the other end of it, sort of experiencing this and navigating this and trying to navigate the health care system - in that case, this is, you know, the technical term for nursing home care, assisted living, that's all called long-term care. And it's a real mess. It has - every problem of our health care system is exists in the long-term care system and it's worse. It's hard to figure out who pays what bill. You're constantly dealing with the networks. You think your insurance covers something, and then you discover that it doesn't. And you have to get on the phone and fight. And the amount of time you spend on this, you know, which is time you want to be spending with your loved one - and, you know, these are - you know, and anyone who's gone through this particular experience knows this is incredibly hard. You have some incredibly difficult decisions you have to make. You're constantly second guessing. And again, having to sort of spend your time, your emotional energy, dealing with insurance bureaucracies, dealing with all these payment questions. It's just - it makes it such a greater burden at a time when, even under the best of circumstances, it's an incredible burden.

GROSS: Another issue related to nursing homes and to hospital care and to home health care is that a lot of the nurses and home health care workers, I think, are really underpaid. And I think it's a weakness in the system. We expect, we demand so much of them. And some of them are making so little in return. And I think it sometimes shows up in the care that you get.

COHN: Unquestionably. People who provide direct care, that is such a hard job. It requires a combination of skills that you learn and talent that some people have. And they're paid ridiculously low, frequently without benefits. The facilities themselves are frequently understaffed. You know, it was - it's been heartbreaking to me during the pandemic to see how many, not just residents of long-term care facilities were suffering, but staff, who, you know, especially, you know, obviously, at the beginning, they didn't have enough protective gear. Some of them still don't have enough protective gear but were being asked to bear such a burden, you know, both taking care of these people who lived in these facilities and also, frankly, provide a lot of the emotional support for families like mine that couldn't be there physically.

Absolutely, they need to be paid more. You know, this is - you know, but if you look at it as a policy problem, you will quickly discover that, you know, this is one - this is a hard problem to solve because there's exactly one way you solve it, and that's you spend more money on it. You know, we need to spend more money on long-term care. This is something in this country we've never done. There's a whole complex set of reasons for that, a lot of it tied to who the people are who traditionally do this work, the fact that it's people who are easily discriminated against. But, yeah, we need to pay these people more. We need to pay these people a lot more.

GROSS: Lately, you've been covering the pandemic. What are some of the changes the Biden administration has been making or plans to make regarding the pandemic?

COHN: Yeah. So there's no one silver bullet. I mean, really, what they've done is they've sort of come up with a list of all the little things you need to do to improve vaccine distribution. And they are basically working on all of them. So - you know, they run the gamut. I mean, we're seeing them set up these mass vaccination clinics, for example, big parking lots and stadiums. We're also seeing them pay attention to supplies for the vaccine makers, making sure that the vaccine - you know, vaccine production is very difficult. It requires certain kind of machines. It requires certain raw materials. And so they're using what's known as the Defense Production Act to make sure that the supply orders have priority. They're trying to do a much better job of communicating with the state, saying, look, this - you can count on getting X vaccines for the next three weeks.

And that's a big deal because a lot of the problems we're seeing in terms of being able to get shots, not people get shots, is that there's just - there's a lot of miscommunication between the states and the local departments and the hospitals. And that comes from the fact that the states are not sure what they're getting a week from now. So it's hard to make plans. So they're working on all of these things. They're also paying a lot of attention to equity. You know, they're making - you know, it's not just how quickly shots are getting into arms. But are they going into everybody's arms? In particular, are they going to the sort of people who are most at risk? I mean, it's sort of - it's sad. But, you know, in general, higher income groups are doing a much better job of getting shots than lower income groups. But lower income groups, in general, they're the essential workers. They're the ones in overcrowded housing. They're at the greatest risk. So the Biden administration is trying to do something about that.

GROSS: Well, Jonathan Cohn, thank you so much for talking with us. It's a pleasure to talk with you again.

COHN: Thanks for having me on the show.

GROSS: Jonathan Cohn is a senior national correspondent at Huff Post and author of the new book "The Ten Year War: Obamacare And The Unfinished Crusade For Universal Coverage." After we take a short break, John Powers will review the new film "Minari," which won the top jury prize and top audience prize at last year's Sundance Film Festival. This is FRESH AIR.

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