Growing up in a family of doctors, Jonathan Cohn developed an interest in healthcare that seems like a natural fit for the longtime policy reporter. But Cohn, who began his career at the wonky American Prospect after graduating from Harvard, says he found his speciality almost by accident while working as an editor at The New Republic in the late 1990s. 

Cohn wanted to write more, but needed to find a topic where he wouldn’t bigfoot any of the magazine’s reporters. It turned out nobody was interested in healthcare, a topic whose importance Cohn came to appreciate after his time working under Prospect founder and healthcare guru Paul Starr.

“I want to shine a spotlight on where we’re failing as a society, and bring to people’s attention the struggles that people are facing so we can do something about that,” Cohn told Blue Tent in a recent phone interview from his home in Ann Arbor, Michigan. “Unfortunately, if you’re looking in America, where are you going to find that? You find a lot of that is healthcare.”

At the time, Cohn’s beat had been largely abandoned by other journalists. It was wonky, complex and hopelessly inert, especially after the Clintoncare debacle of 1993–94. But Cohn began slowly to build his expertise and came to find a cadre of still-committed reformers, like Sens. Ted Kennedy and Max Baucus, who would later be key figures in the biggest story of Cohn’s career, the passage of the Affordable Care Act. 

Now, with more than two decades of healthcare reporting under his belt, Cohn has published his magnum opus on the subject, “The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage.” The book is an exhaustive history of the fight for healthcare reform, and a window into one reporter’s devotion to a singularly complicated, frustrating and vital topic in American politics.

Taking a human approach to policy

Cohn’s focus on healthcare alone is enough to distinguish him among most of his colleagues, but since his early years in journalism, Cohn has also brought a unique angle as a rare voice removed from Washington. Since the 1990s, Cohn has been telecommuting, first from Boston, where his wife was in graduate school, and then from Ann Arbor, where she teaches at the University of Michigan.

“For me, this has always been about the policy itself and its impact on real people. So being outside of Washington has actually been incredibly helpful,” Cohn said.

Cohn’s focus on the human side of policy is reflected in his journalism, especially his first book, 2007’s “Sick,” which focused on the real-world impacts of American healthcare rather than the political theater. Though as “The Ten Year War” makes clear, Cohn is no stranger to the theater, either; he has regularly traveled back and forth from D.C., cramming in reporting and source-building into three or four-day bursts, “pack[ing] a lot of coffee into a day,” as Cohn put it.

He was in the East Room the day Barack Obama signed his signature healthcare reform into law, and as he notes in “The Ten Year War,” Republicans were simultaneously launching their first attempts at repeal, possibly before the ink on the president’s signature had even dried. But the GOP weren’t the only ones making early plans.

“I literally thought that day, maybe I should just write a book on how this thing became a law,” Cohn recalled.

Ten years of war in Congress, in the courts, and on the page

Over the next few years, Cohn worked on his idea in bits and pieces as an aspiration, most notably in an 11,000-word story for The New Republic on the ACA’s legislative process (much of which is included in “The Ten Year War”). He covered the bumpy Healthcare.gov rollout, as well as the GOP’s countless legal and legislative assaults on the law. In 2015, he left TNR for HuffPost, and was still on the healthcare beat three years later, when the late Sen. John McCain famously gave a “thumbs down” to stop a repeal of the ACA from landing on Trump’s desk.

It was that year when Cohn finally made his pitch for “The Ten Year War,” a decade after the push for Obamacare began. He got the go-ahead from his publisher, with an initial plan to do a quick book of about 75,000 words. Cohn knew the story in his bones, but his editor encouraged him to “do it right” and add new reporting, leading Cohn to start getting in touch with old sources, even the Clintoncare team. He uncovered more connections than he had previously known between many of his story’s principals and the injustices of American healthcare, and set out to write a story that could weave these narratives into the complex policy fight. Cohn also wanted to remind people how difficult the fight had been.

“What I feel like is already being lost—even though it was only 10 years ago—people forget what it was like, and they forget how hard it was,” Cohn said. “Which is not to say the people behind it made the right decisions all of the time or most of the time, but I knew those people, and I knew what they were trying to do. And I wanted to convey a sense of the struggle and what people were going through.”

In Cohn’s telling, the story of the Affordable Care Act is a tale of both incredible achievement and heartbreaking disappointment. Given the political calculus of the time, for Democrats to pass any legislation of the ACA’s magnitude was a herculean reach, as they faced an obstinate Republican party and had to wrangle numerous skeptical members of their own caucus. Moderate Democratic senators star as both villains and heroes, from former Connecticut Sen. Joe Lieberman, who stonewalled more ambitious reforms, to Baucus, the Montanan who could have blown up the whole process, but committed to getting something done.

Coursing through all of these narratives about the legislative process is the tantalizing possibility of the road not traveled, namely a public option. But as Cohn demonstrates, Obama himself had little interest in pushing for the policy, devoting himself to the exchange system Mitt Romney helped innovate as governor of Massachusetts. Senate Democrats also watered down the bill in a vain attempt to win over their Republican colleagues, failing even to attract votes in the committee process. At other points, leadership considered scrapping what they had and starting over through the budget reconciliation process, where the 60-vote filibuster requirement was reduced to a bare majority. But lawmakers were fearful their legislation would be picked apart by the Senate parliamentarian and committed to the path on which they had begun.

Expertise as a double-edged sword

Cohn says he tried to thread the needle between crafting a contemporary history for future scholars and a slightly breezier human story. In the former, “The Ten Year War” largely achieves its goals, laying out an authoritative set of facts and anecdotes, backed by copious sourcing and detailed explanations of research and reporting in the book’s fifty-plus pages of endnotes. But as Cohn noted in his interview with Blue Tent, he’s a policy writer at heart; the book’s profiles of lawmakers and administration officials can at times become tedious and repetitive, though they bring much-needed color and humanity to his detailed policy reporting.

“The Ten Year War” is an ambitious book, but also a careful one—with the author keeping his own views under wraps, sometimes in ways that strain credibility. For example, Cohn declines to explicitly second guess many of the decisions in 2009 and 2010, from personnel choices to negotiation tactics, that possibly resulted in a weaker healthcare bill. Later on, Cohn attempts to bottle up his point of view regarding the infighting on healthcare between Hillary Clinton and Bernie Sanders in 2016. Cohn describes the candidates as merely “arguing past one another.”

In reality, the two candidates were advocating two massively different visions of both democratic change and political economy, and in both reading “The Ten Year War” and talking with Cohn, it’s clear that he is skeptical at best of the Sanders vision for Medicare for All via revolution. In the book’s conclusion, Cohn makes a few more forceful arguments, but still tries (unconvincingly) not to take a position on the recent push for Medicare for All. He writes that the differences between single-payer and other progressive plans “aren’t so important in the grand scheme of things,” emphasizing that the final goal is “universal coverage,” a phrase that many Medicare for All advocates associate with opposition to single-payer.

In a lengthy follow-up email in response to these critiques, Cohn confirmed his own doubts about establishing single-payer healthcare in one fell swoop, but explained his attempts to stay impartial as a series of difficult judgment calls.

“The Ten Year War” is not a polemical book, and Cohn did not set out to make an argument. But as a leading expert in his chosen field, it would seem Cohn has command of enough knowledge and expertise to make more subjective judgment calls for both contemporary readers and future scholars. He has written a history that is masterful in both its scope and brevity, but there are far too many places where Cohn’s informed opinions are hiding in the narrative, seemingly fearful of being seen too explicitly.

To advance, progressives must avoid “defeatism”

As Cohn’s book is being released, the fight for universal healthcare has taken something of an intermission. Advocates of a public option and expanding Obamacare are taking stock of what can pass a 50-50 senate, while the Medicare for All movement tries to plot a course of action post-Bernie Sanders. “The Ten Year War” ends on a hopeful note, calling the Affordable Care Act “not nearly good enough, and yet so much better than what came before it.”

“I would say on healthcare specifically, I’m more optimistic than pessimistic,” Cohn said. “It’s so hard to know what politics for the next two years looks like, right? There are just so many variables.”

Despite their victories in 2020, Democrats may have to keep playing defense on healthcare for years as they face conservative courts and possible electoral backlash in 2022 and 2024. Cohn outlined a doomsday scenario in which Democrats lose support and Republicans take another run at the ACA, but he also discussed the possibility of an economic and COVID recovery under Biden, helping Democrats get a rare boost during the 2022 midterms. That could put enough wind in their collective sails to make a serious push for a public option. 

In either scenario, Cohn believes that progressive “defeatism” is poison to any hopes of eventually achieving universal coverage, a goal that he believes could take many years and many pieces of legislation.

“I think it’s going to be very hard to get there, for all of the reasons it was hard to get this far, and those realities haven’t changed,” Cohn said. “So what I hope can get across is that I hope there’s a way to shoot for that, aim for that ideal, aim for that place where we have a truly universal coverage system, where nobody has to go bankrupt because of medical bills, where everyone can get the care they need when they need it. But we can also recognize if it takes a couple of steps to get there, we can recognize those steps as important steps forward.”