Dec. 14th’s lower court ruling that the Affordable Care Act (ACA) is unconstitutional has again thrust health care back on the national agenda. It also gives journalists a chance to redeem themselves from what I have argued has been poor news coverage that helped fuel the public backlash against the law from the beginning.
A lot has changed since the law passed in 2010. Perhaps most important the public has come to believe that people should be able to get health insurance, even if they have preexisting medical conditions. A Kaiser tracking poll before the November election found 75% of Americans said it was “very important” that protections for preexisting conditions and ensuring guaranteed coverage remain. The fact that so many candidates, including Republicans, aired commercials citing their bona fides when it came to preexisting conditions reinforced the potency of that issue among voters.
While further reform will be challenging given the current political climate, serious consideration of the issue is taking root as a wave of new lawmakers sweep into power on the promise of guaranteed coverage for all. This is a debate journalists ought to be illuminating for readers.
A shift in public attitudes
Despite last Friday’s ruling, there’s no going back to the old world of health insurance, a point that many Democrats were beginning to make clear. The drive for a more inclusive health care system will continue–regardless of continued efforts by opponents to strike down the ACA.
Since the failure of Congress in 2017 to kill the ACA, which many members promised they would do, I’ve detected a shift in the public’s attitudes toward some kind of national health care system. T. R. Reid, former Washington Post reporter and advocate for universal health insurance, who worked on the failed 2016 campaign in Colorado, told me he has observed the same shift in the public’s thinking: “There is much acceptance. The striking change came after people saw Congress struggle with it and fail. Everybody can see what we have is unworkable.”
Are journalists up to the challenge?
Whether journalists are up to the challenge of chronicling a new and vicious debate remains to be seen.
Coverage of the now-suddenly crucial public debate over alternatives to the ACA has so far been relatively scarce with the public pretty much in the dark about the various plans being formulated by interest groups.
A few days before the midterm elections, a story with a clever headline appeared on the sites of California Healthline and Kaiser Health News: “Quick: What’s the Difference Between Medicare-For-All and Single-Payer?” A few voters offered an opinion. One thought the government should play a larger role. Another said he wanted private health insurance companies out of the picture. But most voters approached for the article did not want to be interviewed, saying they didn’t understand the issue. Paul Her of Sacramento summed up their predicament: “I just don’t know enough.”
If reporters in Colorado, Illinois, or Virginia asked the same question, no doubt they’d get the same answers. To most Americans, what a new kind of health care system would look like is as murky as swamp water.
‘It’s time to reframe the public debate’
Nevertheless, there may be a way through the swamp, argues former Medicare administrator Don Berwick and colleagues in the policy journal Health Affairs. “It is time to reframe the public debate,” they wrote, and noted the election was “evidence of renewed public interest in expanding access to health coverage and controlling costs,” the twin shortcomings of America’s health insurance system. If the country’s 106-year-old debate over what I’ll call a national health insurance system is rekindled in the coming year, as Berwick believes it can be, journalists have a huge role to play.
What kind of reporting is needed? Berwick et al outline some key policy questions: “knotty issues such as determining the covered benefits of the plan, exploring alternative revenue sources and cost controls, deciding how providers would be paid and at what prices, how to pave a practical transition pathway from current health plans, how to craft a soft landing for the employees of the current insurance industry, and more.”
The reticence of journalists at this point so far is hard to explain. Is it that reporters are afraid to tackle the subject, or are they still suffering a hangover from the last round of health reform? During the run-up to passage of the Affordable Care Act, I felt reporters were generally not interested in writing about alternatives to the brand of reform the health policy establishment had chosen to push through Congress. As I’ve written many times, journalists were reluctant to carefully examine the bill and critique its built-in shortcomings, which contributed to many of today’s problems and some of the initial public discontent with the law. And in a few cases supporters of the ACA tried to choke off coverage of what then were called single-payer advocates.
One prominent health care blogger wrote to my editor at the Columbia Journalism Review suggesting we should avoid giving “single-payer too much ink” because single-payer advocates “don’t understand (or don’t want to understand) the economics of health care. Single-payer won’t happen—not now. Their refusal to accept that fact is muddying the waters.” In a CJR post about this, I also share how John Rother, then AARP’s chief lobbyist, approached the late Saul Friedman, Newsday’s popular columnist on aging issues, also asking him to stop writing about single payer. Rother told Friedman:
“Folks who oppose the Obama approach on the grounds that it’s not ‘good enough’ are just playing into the opposition. We can’t afford that. I certainly hope you recognize the need to get something important done on health reform this year, and won’t join the opposition.”
Hopefully journalists will be more open-minded this time around in explaining what’s happening and what’s at stake.
Outlining the steps needed for change
One of the best pieces I’ve seen so far in this latest public discussion about changing the country’s health care arrangements appeared in The Nation over a year ago. Written by Nation Institute fellow Joshua Holland, it moved way past the what’s-it-going-to-be-called stage–which is what the Kaiser story was about–to the steps needed for significant change and the challenges involved.
For example, Holland pointed out that Medicare for All, which seems to be the current front-runner label, is a partly privatized arrangement.
More than one-third of beneficiaries are in Medicare Advantage plans run by profit-making health insurance companies that have been deliberately overpaid by the federal government with the goal of eventually privatizing the entire Medicare program.
Is that what supporters and the public mean by Medicare for All? Or do they mean the traditional Medicare program where the government, not private insurers, still provides the benefit? Are they talking about the guts of Medicare—a social insurance program that people paid into during their working years and earned the right to a guaranteed benefit beginning at age 65?
We have guaranteed lifetime coverage now, says Nancy Altman, who heads the advocacy group Social Security Works. “It ends at the grave but doesn’t start until 65. We have to start at birth.”
Medicare and Social Security are social insurance programs, but our vocabulary of social insurance has “become increasingly replaced with a vocabulary of welfare and redistribution,” says Yale professor emeritus Theodore Marmor. “By the end of the 20th century, the category of social insurance had seemingly lost its place in the vocabulary of American politics.”
Holland, who supports universal coverage, is a realist in his perspective and writes that the term single-payer can also be misleading: “Most countries with ‘single-payer’ systems rely on some combination of public insurance, various mixes of mandatory and voluntary private insurance (usually tightly regulated), and out-of-pocket expenditures (often with a cap).” Canada is often held up as a single-payer system when in fact, each of the provinces is a payer and contributes funds to finance the program just as the federal government does. Whenever I’ve tried to explain the German system of “sickness funds” and why the country does not have a single-payer system but everyone has insurance, journalists’ eyes have tended to glaze over. One nice explainer is this detailed piece from The Atlantic.
It doesn’t so much matter in the coming debate exactly how other countries achieve their universal systems, but what are the undergirding principles those countries have that America does not. The principle of social solidarity comes to mind. It’s the social solidarity in Germany, Canada, and other countries that binds the population together and makes it unthinkable that any citizen would go without medical care. In the U.S. it’s acceptable in many states for its residents, especially those who are poor, to go without care. The ongoing debate over Medicaid expansion and the imposition of work requirements as a condition for coverage and thus medical treatment is a prime example. Politico noted in its coverage of Medicaid expansion in Idaho that a spokesperson for the conservative Freedom Foundation admitted more people on Medicaid “puts us on a path to single payer system,” which his group opposed.
What are the country’s common principles?
Journalists also must address the common principles the population shares or purport to share that a revised system would reflect. This can be a good starting point for future coverage. The country needs to agree or come close to agreeing on common principles before reporters can explain the different ways of achieving them. Unless they are clear, there’s a good chance the public will become thoroughly confused before a real debate even gets started.
Last week Vox published a guide to eight plans that have been introduced in Congress. Some eliminate private insurance and cover everyone while others let people buy into Medicare or Medicaid or let people continue to choose private insurance. It’s a good start and more efforts like that are needed–perhaps with even more translation than Vox offered to help people understand all the jargon.
It’s California resident Paul Her–and his statement to Kaiser that “I just don’t know enough” –that we should keep in mind as we set out to cover the next and predictably contentious debate over the kind of health system we want.