Why Has the Press Failed Us In Reporting on Health Care Reform?

Dear
Bill Keller and Clark Hoyt,

For the first time in the span of a
generation,
national health care reform is back on the horizon, and I'm writing to
you to
step back for a moment into the history of the Times'sreporting on
health care reform. Last year I began a
research
project with two researchers from Harvard Medical School, Drs. David
Himmelstein and Steffie Woolhandler, to look at the history of major
state
health reforms such as TennCare, the Oregon Health Plan, MinnesotaCare,
and
many others. A sweeping health reform bill had been passed into law in
Massachusetts in 2006 that was being hailed as a unique,
first-of-its-kind
bipartisan strategy to achieve universal or near-universal health
coverage
without raising taxes or adding new regulations on the health care
industry. We
initially set out to find how unique the Massachusetts health reform
law really
was compared to previous state efforts, and to see if by analyzing the
outcomes
of those earlier reform efforts we could learn some lessons about what
to
expect in Massachusetts.

What
we found surprised us, and a summary write up of our findings was
published in
the International Journal of Health Services.
We found that, aside from the "individual mandate" in Massachusetts
requiring
many of the uninsured to purchase their own private health plan or face
tax
penalties, many reforms in other states - indeed, even in our own state
in the
recent past - were almost identical to the Mass plan in their goals and
structure.
They also all failed to achieve their stated goals of reducing the
uninsured
population in their respective states and/or of controlling rising
health care
costs. The most ambitious of these, TennCare in 1994 and a large
Medicaid
expansion in Massachusetts also in the mid-1990s, were able to reduce
the
uninsured in their respective states for a period of several years.
However,
the financing of these plans all proved unsustainable over time,
enrollment was
often capped or benefits eroded, and a few short years after passage
every
state found itself back where it started: with high and rising health
care
costs and a large and growing uninsured population. We titled our
article
"State Health Reform Flatlines.

What
we found even more surprising than this history of failed reform
efforts,
though, was media coverage of the legislation. Articles by our most
respected
news organizations hailed state reform after state reform as
pioneering, likely
to serve as models for the nation, and designed to control costs and
extend
health coverage to the uninsured. No reasonable reader of the news
available at
the time these laws were passed would expect that they might fail
entirely to
reduce the uninsured over time, or that they might not succeed in
controlling
costs at all.

Florida
in April 1993 launched the first of what would be many "managed
competition"
plans for controlling costs and extending health coverage, a scheme
that would
serve as virtually the only cost control component of Bill Clinton's
proposed
health reform bill of 1994. The New York
Times wrote "The Florida Legislature approved a sweeping overhaul
of the
state's overburdened health-care system early today, making Florida the
first
state in the nation to combine free market competition and government
regulation in a way similar to the Clinton Administration's plans for
controlling soaring medical costs... Florida's plan, which will try to
cover most
people eventually and at the same time to control health costs, is
taking place
on a larger scale than anything seen elsewhere."
Managed competition did not control costs in Florida or anywhere else,
nor was
the uninsured population reduced.

Exactly
one year previous in April of 1992 Minnesota passed its "HealthRight"
plan -
later renamed "MinnesotaCare." USA Today
wrote of it: "Minnesota is about to embark on a plan to solve the
health-insurance
crisis that could hold lessons for other states and the nation...
HealthRight...
will begin signing up families with children in the fall and will be
fully open
to Minnesota's estimated 370,000 eligible uninsured by 1994."
The Associated Press wire coverage of the law repeated state estimates
that
almost 40 percent of those uninsured should be covered by 1997, and
quoted the
head of the National Conference of State Legislatures calling the bill
"the
first complete reform proposal in the United States." MinnesotaCare did
not reduce the percentage of uninsured in Minnesota even in the
short-term.

A
few other quotes should be enough to convey the sense that there is a
recurring
problem in the news we receive on health reform in America. A Vermont
bill also
passed in 1992 elicited this opening description in the New
York Times: "Gov. Howard Dean, the only governor who is a
physician, signed a law Monday in Bennington that sets in motion a plan
to give
Vermont universal health care by 1995."
The Oregon Health Plan of 1992, which attempted to reduce benefits for
Medicaid
beneficiaries in order to expand coverage to the uninsured, was
described in a Washington Post article as "The most
far-reaching health care reform in the nation."
The New York Times began its coverage
by stating that "The Clinton Administration today approved Oregon's
proposal to
guarantee health services for poor people by rationing care."
Neither Vermont's reform nor Oregon's reduced the percentage of
uninsured in
the state, and the poor in Oregon were not covered.

These
are selective quotes: the broader coverage has often provided good
descriptions
of what the laws are intended to accomplish. Moreover, they have
included
extremely effective reporting on the politics
of the health reform process - particularly when the process is
contentious, or
where well-organized groups have mobilized opposition. However, in the
United
States we have a long history of reforms that have survived the
political
process only to fail economically, and it is clear in retrospect that
the media
sources - both local and national - with large market share have not
done their
due-diligence in reporting on the economic viability of health reform
efforts.
I believe this would be borne out by analyzing coverage of many other
significant
reforms in Washington, Tennessee, Massachusetts, Hawaii, Maine,
California,
Utah, and nationally.

This
becomes particularly clear by comparing coverage of health care reform
with
medical reporting in virtually any paper. The Christian
Science Monitor on April 8, for example, carried a story that
is typical of this approach to health politics reporting entitled
"Healthcare
battle brewing: political groups gear up: A public insurance
alternative is
likely to be the most contentious of the reform proposals."
The story states that the Obama administration hopes to introduce a
Medicare-like public buy-in plan available to individuals and
businesses as an
alternative to private health coverage. It goes on to cite the Heritage
Foundation's opposition to the plan, the support of groups such as
MoveOn.Org
and Democracy for America, and public polling from Harvard Professor
Robert
Blendon. The article follows a "he-said/she-said" format, with the
Heritage
Foundation contending that such a plan would not allow private
insurance to
compete on a level playing field, advocates urging that it will bring
down
costs and hold the private insurance industry accountable, and the CEO
of
Families USA urging that both sides attempt to find a common ground.

What
is missing from this narrative of contending arguments is a discussion
of
evidence about the likely impacts of a public plan option. There have
been
forms of public-private health insurance competition implemented under
Medicare
for a number of years, and there are many other countries that allow
competition between public and private health insurers. Peer-reviewed
studies
of public-private competition are not hard to find, nor are experts
with
varying opinions. Compare the CSM
discussion with almost any medical news story in the New
York Times Health Section on the same day: there is a report on
a new study by two Stanford professors assessing the impact of George
W. Bush's
AIDS Relief program in Africa; two studies about the impact of light
exercise
for heart failure patients; three reports on the role of "brown fat" in
burning
calories; and others. In short, medical reporting and the coverage of
public
disagreements revolve around evidence, there are standards for credible
sources, and it is common to read about the limitations of available
evidence.
Although I am personally an advocate and an organizer coming from a
single-payer health care perspective, what strikes me most after
reading
hundreds of news reports on health reform is the lack of academic
perspectives,
held to academic standards, concerned with basic questions of the
economic
efficacy and sustainability of health policy proposals.

At
the state level this has often been exacerbated by bi-partisan
legislation.
Many of the reforms that have failed to achieve or even approach their
stated
goals have been passed with support from the Democrats and Republicans
holding one
or both legislative houses or the governor's office. This has a
particularly
chilling effect on politics-based health reform coverage. Reporting on
the
Oregon Health Plan, for example, focused almost exclusively on the
attempt to
ration services for Medicaid enrollees - would this plan harm the
disabled or
the poor, was it just? - while the basic question of whether the law,
even taking
rationing for granted, would succeed in reducing the uninsured in the
state,
went unasked. In Tennessee, similarly, the spectacle of almost one
million
Medicaid enrollees being moved into managed care plans occluded the
basic
question of whether the proposal to extend coverage to another half a
million
uninsured residents was economically viable, or if it would succeed in
reducing
the state's uninsured over time - these latter goals being the entire
point of
moving Medicaid recipients into managed care plans in the first place.

This
shortcoming has also been exacerbated by the subject material.
Increasing
access to health care is what makes health reform morally compelling
for most
people, but financing and cost controls are what make efforts to expand
access
sustainable or unsustainable. These are topics not well-suited to
personal
interest stories, and they are often bewilderingly complex. In Massachusetts alone, residents have been
promised universal health care or dramatic reductions in the uninsured
at least
four times in the last twenty years. A few years after each reform
passes, the
dry logic of costs and financing has left residents back where they
started,
and yet when the politics of health reform begin again we are provided
with
very little information in the public sphere to sort out the snake-oil
from the
genuine, sustainable reform proposals.

I
write to you not because I believe the New
York Times is particularly at-fault in leaving its reading public
unprepared to determine the viability of different health reform
proposals, but
because the scope of the Times's
coverage has meant that it has reported on a wide range of state and
national
efforts, which gives us a good window on the history of health reform
coverage
in the United States. This year, many national commentators are
measuring the
ongoing process of health policy development against the failed Health
Security
Act of the Clinton era. This has led many advocates to be particularly
concerned with crafting politically viable proposals. I believe this
makes the
burden on reporters to effectively assess whether the proposals are
likely to
achieve their stated goals sustainably all the more important.

I
would urge the Times not to report
health policy disputes in a he-said/she-said format divorced from
evidence-based standards. Reporters should challenge interviewees to
source
their economic claims, include those sources in their write-ups, and
not shy
away from evaluating the quality of evidence offered from different
perspectives. Furthermore, we have learned time and again that where
there is
political harmony, there is not necessarily economic rationality. The
burden of
evidence-based evaluation of health policy cannot stop at the borders
of
political skirmishes.

I
thank you for your consideration of this open letter,

Sincerely,

Benjamin
Day
Executive
Director
Mass-Care:
The Massachusetts Campaign for Single Payer Health Care
33
Harrison Ave - 5^th floor
Boston,
MA 02111
Phone:
617-723-7001

Email:
info@masscare.org