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's reporting 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,
Mass-Care: The Massachusetts Campaign for Single Payer Health Care
33 Harrison Ave - 5th floor
Boston, MA 02111