Could the Media Derail Health Care Reform?

This article originally appeared on Health Beat.

By now you've probably heard the calls for speedy action on health care reform during the Obama administration's first 100 days. Some prominent observers even say that the president-elect should get the ball rolling during "his first days in office."

The possibility of imminent health care reform is certainly exciting, but a word of caution: just because some of us might be ready for health care reform doesn't mean that the media are ready to cover it properly. And that could have important implications for how reform plays out.

Right now, health care reform is an abstract goal that everyone wants -- excitement and anticipation are high. But as the substantive process of health care reform gets under way, two things will happen: first, ideas will be crafted into policies -- concrete plans of action and complex administrative measures, and second, politicians will become involved in the reform process. Policy can get pretty complicated; so the public will rely on the media to help it navigate the ins and outs of the issue. Once politics begins to shape policy discussions -- that is, once politicians enter the picture -- it's all the more important to keep the focus on policy, because it's at this point that policies have a real chance of being implemented. Americans should know their options. 

Style Over Substance

Unfortunately, reporters aren't health care policy experts. In fact, they rarely ever talk about the issue. In a December report, the Kaiser Family Foundation found that, out of 3,513 health news stories in newspapers, on TV and radio, and online between January 2007 and June 2008, health care policy made up less than 1 percent of news stories and just 27.4 percent of health-focused stories. Instead of talking about issues like coverage, prescription-drug care, costs or public programs, the media prefer to report on specific diseases and conditions (cancer, diabetes, obesity and heart disease) and potential epidemics (contaminated food and water, vaccines, binge drinking). Together, these two topics made up 72.6 percent of health coverage.

This is less than ideal. When Congress begins to talk about health reform in earnest, the important news that will affect all of us will be about policy and institutional changes. The media need to be good at covering this stuff -- yet as the Kaiser report shows, newscasters, reporters and editors have very little experience (or interest) in discussing such issues. Worse, history shows that when health care reform efforts are actually under way, the media ignore policy in favor of more sensational stories.

During President Bill Clinton's efforts at health care reform in the 1990s, for example, media reports disproportionately focused on politics rather than policy. In their 1998 book Politics, Power, and Policymaking: The Case of Health Care Reform in the 1990s, Missouri State University professors Mark Rushefsky and Kant Patel found that that in 1993 and 1994 -- the height of public debate over Clinton's plan -- the New York Times reported just 257 stories about policy considerations (proposed reforms and solutions, analyses of options) and a whopping 549 on politics (personalities, disagreement, partisanship). When the nation's health care system was at stake, spats received more coverage than substance.

More bad news: When policy was in fact being changed, the media were nowhere to be found because this process wasn't politically dramatic. In 1995 and 1996, at the behest of Clinton, Congress actually passed incremental health care reform. These changes included a limitation on insurers' ability to exclude patients on the grounds of existing conditions and greater protections for HMO patients. But because these reforms didn't involve public name-calling and proceeded through conventional legislative processes, the media all but ignored them. Rushefsky and Patel found that in 1993-94, major TV networks did a total of 583 stories on health care in their evening broadcasts; in 1995-96, this number dropped to a mere 93. The Times also reported 284 fewer health care stories during this period than it did in 1993-94, when conservatives were at the Clintons' throats over "HillaryCare" (a term that perfectly exemplifies how letting personalities trump policy can derail reform). When progress was actually being made, the media were nowhere to be found. Real change was, in the words of Rushefsksy and Patel, too "dry and lengthy."

History Repeats Itself? 

Unfortunately, today's health care reform isn't going to be any more titillating. Comparative-effectiveness research hasn't become any simpler to explain, reimbursement practices are no less tedious to analyze, and the trade-offs that will be necessary to contain costs no less complicated.  Any way you slice it, health care policy is tough stuff, and the media don't seem all that ready, or willing, to cover it appropriately. If we're not careful, once health care reform gets under way, we may again see the media turn to their favorite sport -- calling the political horse race.

Indeed, there are already some troubling parallels between the ‘90s and today's health care landscape. In the late 1990s, health care reform only became big news after underdog candidate Howard Wofford won Pennsylvania's Senate seat with an unexpected 55 percent of the votes -- on a platform of national health insurance. The health care reform story started with politics first and policy second.

Similarly, it's hard to imagine that we'd be hearing so much about reform today if Hillary Rodham Clinton hadn't ran for president, thus feeding legions of political reporters a ready-made narrative of HillaryCare's return. And do you really think we'd have seen a media debate about the importance of individual mandates if Clinton hadn't made the issue a centerpiece of her political attacks on Barack Obama during the primaries?

To be fair, the media do cover health policy outside of campaigns. In fact, Kaiser found that the biggest individual health-related story was the fall 2007 congressional battle over the State Children's Health Insurance Program. And there has been some high-quality policy reporting in recent years, such as the New York Times' "Fixing Medicare" and "The Evidence Gap" series of articles. Clearly, the media can write well about health care policy if they want to; the question is, once health care reform becomes a political issue -- and not just an intellectual policy discussion -- can reporters stay focused? That's not so clear. After all, although SCHIP received a lot of coverage, much of it focused on whether Democrats were "using kids as props" and on the issue's electoral resonance.  

You can already see some juicy political narratives emerging around Obama and health care -- before he was even elected, Obama's health care plan was being called "ObamaCare." Currently, the media are focusing on health care reform as a bitter political fight while warning that the Obama story may turn out to be a case of 'the bigger they are, the harder they fall.' Indeed, the president-elect hasn't even taken office, and the media are already warning that "health care reform [is] up in the air" because "opposition likely will arise," and that "Obama's bid for health care reform could sink or soar" (well, duh). Others warn of too-high expectations in order to set up a dramatic arc of "euphoria" followed by "big disappointment," and the "bursting [of] Obama's balloons."

Meanwhile, how many of these stories have spelled out, in detail, the rules of reform under Obama's proposal? Relatively few (although you can learn about it here). 

There's no question that health care reform won't be easy; Obama definitely has his work cut out for him, and the public should know it. But already the media seem to be licking their chops at the political controversies they see in the near future. Discussions of health care reform are already being wrapped in Obama's political persona, with reports cautioning that partisanship may slay the Uniter and that the Chosen One may come up short. If we're seeing this sort of coverage now, you have to wonder if the media will have the wherewithal to focus on policy once health care reform becomes a long, procedural slog as legislators debate some of the 115 discrete options for reform that the Congressional Budget Office has recently outlined. 

But it's important that the media rise to the occasion. As Rushefsky and Patel put it, "the mass media may not tell us what to think, but they are very successful in telling us what to think about." News helps us figure out what's important and what's at stake. A dearth of good policy stories will mean that the public isn't understanding the challenges, trade-offs, compromises, etc., that really shape health care. The public will misunderstand the terms of the debate as purely a clash of parties and personality -- as a question of whether "ObamaCare" will succeed -- instead of story about structural changes and policy choices that will affect all of us. We shouldn't focus on how much we like or dislike the politicians involved in health care reform; the focus should be on the strengths and weaknesses of their proposals.

Unfortunately, as Health Affairs Editor-in-Chief Susan Dentzer notes in a new New England Journal of Medicine commentary, "journalists sometimes feel the need to play carnival barkers, hyping a story to draw attention to it." But instead of constantly focusing on political soap operas, journalists should be "credible … communicators more interested in conveying clear … information," and they should write stories that, "rather than being rendered in black-and-white, use all the grays on the palette to paint a comprehensive picture of inevitably complex realties."

The Upside

So is there any chance that the media will in fact report such realities when it comes to health care reform? There are reasons to hope. The Times' best work and the Wall Street Journal's solid reporting on the health care industry offer models for other reporters. Many of these stories interweave policy analyses with accounts of personal, very human stories, proving that talking about policy doesn't have to be boring.

Better still, today's reporters have unprecedented access to a wide range of health care policy experts who actually know what they're talking about. Thanks to the Internet, people like Merril Goozner, Matthew Holt, Roy Poses, Kevin Pho, Bob Laszewski and Ezra Klein (to name just a few) have a stronger voice than ever, and they're helping to shape the public debate. We also have folks like Gary Schwitzer at the University of Minnesota regularly reviewing media reports for accuracy and comprehensiveness (in fact, Schwitzer's and its grading of medical health stories provides a good model for reviewing health care policy stories). In other words, it's easier than ever for a reporter to write a good health care policy story, because there's an organized community of people itching to help them.

In terms of politics, there's also good reason to believe that we won't see a total replay of the '90s. Back in 1993, conservatives were on the verge of a major revolution. The health care debate was just as much about Republicans' newfound clout as it was about that particular battle. In contrast, today's GOP is on the verge of dissolution, meaning that at least one high-drama political narrative is no longer relevant.

Another factor is that, for the most part, the American people want Obama to succeed. They want change, and health care reform is one of their top priorities. Yes, this confidence could mean that voters will be more easily let down when things don't go as planned; but it could also mean that people are willing to give Obama the benefit of the doubt. If support for Obama remains high, two things are possible. First, opponents of reform may be quickly cowed, thus saving some of the political clashes that would distract the media; and/or second, the media may simply feel that it's not good business to fan flames of controversy when the public is invested in success. Either way, public enthusiasm dulls the shock value of political sniping.

In the meantime, the health analysts of the wonk world are going to have to speak out louder than ever and not be afraid of holding the media's feet to the fire when it comes to policy issues. Media-watchdog operations should make an effort to incorporate reviews of health care policy reporting in their work. Third-party health care policy fact-checking is going to become more important than ever. Further, journalists who do know how to report on policy should lead seminars for those that don't, and foundations and other organizations should be convening these sorts of events regularly. Our best bet is to put the media through a sort of health care policy boot camp, and soon. We want to do all we can to make sure that policy is in the front of reporters' minds as health care reform plays out.

Granted, the media will never ignore a partisan dustup, and the more political health care reform gets, the more this sort of popcorn fare becomes a possibility. But if the media draw attention away from policy when reform is under way, it obscures the issues at a most critical time: when policy is actually being made. Our goal as a civil society and, more fundamentally, as a group of people whose health care system may well be rebuilt, is to make sure that titillation doesn't trump the issues.


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