Sarah Kliff, an investigative reporter at The New York Times, stands as one of America’s preeminent health policy experts. On March 4, Kliff participated in a discussion, which was sponsored by the Woodrow Wilson School, entitled “Obamacare Turns 10: Where Does Healthcare Go Next?” The next day, she sat down with The Daily Princetonian to discuss COVID-19, the price of healthcare, and former President Barack Obama.
This interview has been edited and condensed for clarity.
DP: You gave a talk yesterday entitled “Obamacare Turns 10: Where Does Healthcare Go Next?” Where are we 10 years after Obamacare?
SK: Yes, I think Obamacare is largely standing and intact, which was not guaranteed because, ever since it was passed in 2010, it’s constantly been facing threats of repeal from Republicans, from Supreme Court challenges.
But it is working, and it’s become the base for what a lot of candidates in the primary want to build on to different degrees, ranging from Joe Biden’s public option to Bernie Sanders’s Medicare for All system. I think it’s seen as largely standing and largely accomplishing its goals, but also not doing everything Democrats wanted on healthcare, which is why you see this debate happening in the primary season right now.
DP: In that spirit, are you of the mind that the next great step for American healthcare is building towards something like what Sanders proposes?
SK: I think there’s certainly more work to be done on the costs of healthcare. I wouldn’t come out and say it’s like the Sanders plan or the Biden plan.
I think we definitely do see as a lot of Americans struggling with their healthcare bills. I’ve written stories about band aids that cost $629, or a single MRI that’s, like, $25,000. People are really struggling with those bills, and I think that’s why you see from Senator Sanders, from Vice President Biden, all these proposals that would go pretty far in extending the government’s role in healthcare and extending coverage to millions more Americans.
I think it kind of grows out of the fact that one of the things Obamacare didn’t tackle was the unit price of healthcare.
DP: I remember reading a story of yours about a band aid that costs that amount of money. How does that happen?
SK: If you look at our peer countries, basically all of them have decided to regulate healthcare prices. They kind of think of it like a utility, something similar to electricity or water. It’s so important to their citizens that they’re going to step in and regulate the prices; otherwise, the providers could take advantage of the power they have — being the only ones who provide this medical services — and really charge high prices.
We in the United States have made the decision to not regulate healthcare prices. Hospitals are kind of picking their prices, and even nonprofit hospitals have a lot of incentive to charge high and bring in a lot of revenue.
DP: So when you see something like that, is there really zero justification for it?
SK: There might be some justification. Obviously, hospitals can’t stay in business if they’re not bringing in any revenue. Where it really starts not making as much sense to me, though, is you just see huge variation between hospitals. You can look at two hospitals across the street from each other and one might be charging five times what the other one is for a very similar procedure. That suggests to me that this is not a rational market.
I think this is actually a big challenge that Medicare for All drafters would have to deal with — what is the right price? You don’t want to drive hospitals out of business, right? But you also don’t want patients completely underwater with these big bills. What is the best middle point where you keep hospitals up and running and you keep patients able to afford their bills? And that’s really a question that I don’t think Senator Sanders has answered quite yet.
DP: I feel like I see very little examining how ideas in the modern healthcare debate would go about influencing college students. Could you speak to that a little bit?
SK: A big one right now is health insurance benefits for young adults. One of the things the Affordable Care Act did was require insurance companies to cover young adults on their parents’ plan through age 26. That’s a big one — before Obamacare, a lot of plans would run out either when you graduate from high school or when you graduate from college. I think the debate around that is a huge one that would affect college students.
This might be a little more far afield, but it came up in a conversation I was having with an epidemiologist this week. I’ve been also thinking about the coronavirus on campus.
Not to be alarmist, but one of the places a researcher I talked to told me he worries about coronavirus spreading is in college dorms, with such close living conditions. What we know is that these viruses, like the flu, generally spread much quicker in areas where you can’t isolate yourself. He flagged to me college dormitories, [as] it’s one place where it’s really hard to keep someone in isolation because you’re living in relatively close quarters.
Luckily, what we seem to know about coronavirus is that it’s not that bad for younger adults. It’s not ACA [Affordable Care Act] specific, but as we’re dealing with this emergent outbreak, it’s something I’m going to be keeping an eye on. What does this mean for college campuses, where you have a lot of people living in relatively tight quarters?
DP: Could you expand on that? I was going to ask you about that — what does it mean for college campuses?
SK: Generally, the risks should be lower on a college campus because you have a relatively young, healthy population. That being said, in any age group there are some people who are immunocompromised with some kind of chronic condition who could be at higher risk. Even if you look at a disease like the flu, it’s generally most deadly among the elderly.
Anthony Fauci, the [NIAID] Director, was saying at a press conference this weekend [that] “we don’t expect a lot of healthy younger people to die, but we can’t say for certain that there won’t be a few.” You see this with the flu — the deaths are concentrated among the elderly, but there are also some deaths of perfectly healthy people. The one thing I think is specific to college campuses is just the close quarters. Let’s say there was a case somewhere on campus and there was a desire to have students self-quarantine — that might be challenging if you’re sharing a dorm room with another person or you share your bathroom with an entire floor.
DP: One of the things that I’ve been really interested about in this spread of coronavirus is that I feel like we lack a reliable and consistent source of information. What are your thoughts about the manner in which this outbreak has been handled by the White House and the CDC?
SK: One of the things that’s so hard is it’s just so unpredictable right now. A lot of us journalists, we just don’t know how bad this is going to get, [and] the federal government doesn’t know how bad this is going to get. There are academics doing research in real time, trying to figure out the fatality rate of coronavirus — more and more numbers are coming out, but they can be kind of different from each other. That makes it really hard to think, “what is the threat and how seriously should we be taking it?”
In my own experience reporting on the CDC, I’ve had some trouble getting answers from them with the questions I have. Most of my questions and most of my coverage is about the medical billing of coronavirus. Are patients going to be charged when they go to get tested? I recently wrote a story about some patients who were put in mandatory isolation by the government now have outstanding medical bills. In that particular case, I haven’t been able to get the CDC to respond to my questions about whether those bills will be covered or not. That’s just my individual experience reporting on them, I found sometimes it’s hard to get answers.
That’s not totally unusual for a government agency, but it does make it challenging for reporters like myself to do our best job to inform the public when you’re having trouble getting information from the agencies you cover.
DP: Is that abnormal? Was the Obama CDC similar in that regard?
SK: I never covered a pandemic outbreak under the Obama administration. There was Ebola under the Obama administration, but it was just kind of different. We weren’t quite as worried about the spread. I just don’t have a good basis of comparison to say whether this is similar or different than before, because this situation just feels so different from anything I’ve covered.
DP: Pivoting just a little bit, in the the grand hope for medical reform in the United States, do you feel like there exists a clock? Are we running out of time for fixing the system?
SK: I think what you see looking at our country and looking across the world is that this happens in stages. The United States created Medicare and Medicaid in 1965. We created, you know, the children’s health insurance plan for low-income kids in 1997. The ACA came in 2010. And that’s not unusual; most countries build their healthcare systems step by step. The thing that does get harder is [that] the longer we let the healthcare industry get bigger, the more effective lobbyists they become.
The more entrenched they become, the harder it becomes to effect change. Canada created their single-payer system in the 1960s when healthcare was probably something like 3 percent or 4 percent of GDP. In the United States, our healthcare system is 17 percent of GDP. It’s just such a big structural force — I don’t think it’s impossible to create a system like Canada’s here, but I think it would be more challenging and there’s more things you need to undo in trying to create that system.
DP: Do you have any fun, interesting, wild anecdotes about a public figure? It could be, like, “oh my god, I saw Obama on the street one time and he recognized me.”
SK: Since you mentioned Obama, one of my favorite weirdest moments of reporting was when Ezra Klein and I interviewed President Obama in 2017. I think it might have actually been his last interview with the press, about the future of the Affordable Care Act. It was very clear that he enjoyed talking about health policy; he was really getting deep into the details.
We got like half an hour in, and we realized we’d only asked two questions, because his answers were so long. It was supposed to only be an hour and at about an hour in, I think his staffers were kind of, like, signaling to him to like wrap up, but he didn’t seem to want to wrap up here.
So he kind of looked at Ezra and I and was like, “Do you guys have more time?” And we’re like, “Really? Yeah, we’re good. Like, you’re the president. If you have more time, we will definitely work around it.”
So that was just a very fine memory. It felt very gratifying after covering this law for so long to get to talk to him about his views on it and have a really long discussion with him about healthcare. It was pretty surreal.
DP: Thank you so much.
SK: Yeah, I’m looking forward to reading it.