Covering Health Care Reform

Last June during a panel discussion on health care at the annual meeting of Investigative Reporters and Editors, Holly Taylor, a health reporter for The Berkshire Eagle, asked why the national media were reporting that managed competition was the only solution to the nation's health care crisis. "What I found frustrating," Taylor said later, "was that everyone was writing about managed competition as if it were a fait accompli. It struck me as pack reporting. There was a gap between what we saw locally and what was reported in the national press. I found a lot of local doctors and health care professionals who thought a single-payer system would benefit the most people."

A review of a sample of articles that have appeared in the national press since the beginning of the year confirms that Taylor's observations were on target. The national media had indeed embraced managed competition, a free market solution to controlling health care costs. Thanks in part to the editorial pages of The New York Times, managed competition has been elevated from a theory hatched by insurance executives, physicians, and academics meeting at Jackson Hole, in the shadow of the Teton Mountains, to the leading blueprint for health care reform.

Some thirty-five editorials the Times published from May 1991 through July 1993 boosted managed competition, an arrangement under which consumers and employers would buy health coverage from large purchasing cooperatives, which would in turn bargain with doctors and hospitals to obtain the lowest-priced coverage for the lowest possible cost. (Under a single-payer system, the federal government would control costs by negotiating fees with doctors and budgets with hospitals.) The editorial pages of the Los Angeles Times, the Chicago Tribune, and The Washington Post toyed with managed competition, but for the most part were not forceful advocates. During the same twenty-six-month period, the three papers together published twenty-five editorials that mentioned managed competition.

In 1991, the Times opened with a barrage of editorials that, in effect, softened the way for managed competition. At first, they labeled the concept "managed care," a term that has since come to mean something different: a variety of techniques for controlling costs by reviewing the appropriateness of treatment. Later, the Times called the concept "managed competition," and ran editorials that cast it in glowing terms. The best answer remains: managed competition" (July 22); "The best answer is a system known as managed competition" (August 6); "The best way to reform national health care would be managed competition" (October 29); "The best answer is managed competition" (November 8).

While promoting managed competition, Times editorials occasionally blasted Canada's single-payer health care system, the leading rival, which was beginning to receive widespread attention. In one editorial, the Times asserted that "the rationing [Canada] imposes means that, for instance, women must wait months for a simple pap smear," an untrue allegation that brought an immediate rebuttal from the Canadian ambassador.

In 1992, the Times kept up its drive for managed competition, exhorting presidential candidates to see health care reform its way. During the year it published sixteen editorials promoting managed competition. On September 24, candidate Clinton officially embraced the theory in a speech at Merck Pharmaceuticals, and revealed his plans to organize insurers, hospitals, and doctors into vast networks that would manage medical care for a set per capita fee. He also outlined the need for managed care organizations to adhere to state-set budgets and for traditional fee-for-service doctors to follow fee schedules also set by the states.

Three days later, on September 27, the Times editorialized "Clinton Waffles on health." Clinton's proposal, said the Times, had come up short by coupling managed competition with controls on the $ 800 billion medical market that "would require states to set thousands of prices for fast-changing, complex procedures." Clinton's flirtation with explicit cost controls was brief. On October 10, the Times declared: "The debate over health care reform is over. Managed competition has won. . . . This week the governor released a crystal-clear statement 'managed competition, not price controls, will make the budget work and maintain quality.'" The editorial lauded Clinton for apparently changing his mind about fee schedules and other price control mechanisms, an anathema to doctors, conservative politicians, and the nation's major dailies. "Come January," the Times continued, "[Congress] can start with a managed competition blueprint, dot the i's and send the president, whether his name is Clinton or Bush, a bill 'd be proud to sign."

When January came, the Clintons did more than dot the i's; they launched an all-out search for ways to fashion and implement a plan for managed competition. That search set the tone for the kind of reporting that Holly Taylor was questioning. Hillary Rodham Clinton assumed control of a presidential task force and gathered some 500 academics, government employees, and consultants to craft the nation's new health care plan. Using an elaborate system of toll gates and decision trees, the task-force working groups labored in secret, ostensibly to shield them from "special interests" eager to put their mark on the plan. The names of working group members were not even revealed until late March, halfway through the deliberations.

During his speech at Merck, Clinton had promised a health care plan within 100 days after taking office, and the press began the countdown from day one. "When Clinton said it would be 100 days, it had the effect of throwing the press corps into a frenzy," says Susan Dentzer, chief economic correspondent for U.S. News & World Report. "This bred an incredible appetite to tell the story of the exploding health care plan." Over four and a half months, thousands of stories were written. Between April 1 and June 17, a media monitoring project undertaken by the Kaiser Family Foundation with the Times Mirror Center for the People & the Press and CJR counted 454 stories in The new York Times, the Los Angeles Times, The Washington Post, The Wall Street Journal, and USA Today. One-fifth of them ran on page one. What tale did all these stories tell?

The secrecy, the 100-day deadline, the one-again-off-again decision making of the task force, and the sense that a big plan was about to explode, sent the press on a frantic search for leaks, scoops, and front-page headlines. Those same ingredients also worked to manipulate reporters. The task force resorted to an age-old Washington trick -- releasing trial balloons to favored journalists as a way of gauging how this proposal or that would fly with movers and shakers in health care.

The New York Times, as one of the primary sieves for task force leaks, once again served as a model through the reporting of Washington correspondent Robert Pear. "Robert Pear got leaks, got documents, got scoops, and the Times set the agenda for the next day's coverage," says one reporter who asked not to be identified. A look at the stories Pear wrote during March, April, and May shows that he quoted liberally from "confidential work papers" to produce headlines such as CLINTON CONSIDERS STOPPING MEDICAID UNDER HEALTH PLAN; ADMINISTRATION CONSIDERS 'PENALTY TAX' TO HOLD DOWN HEALTH COSTS; HEALTH PLAN EXPECTED TO COVER PRESCRIPTION DRUGS; WHITE HOUSE PLAN WOULD COVER COSTS OR MENTAL ILLNESS; HEALTH AIDES PLAN TO PLACE MEDICARE UNDER NEW SYSTEM.

These stories, however speculative, put enormous pressure on other reporters to write similar reports. In early March, the Times ran a story headed A.M.A. IS SOFTENING STAND ON CHANGES IN HEALTH SYSTEM, and reported that the American Medical Association was willing to support the idea of spending limits and accept managed-care organizations in exchange for a seat at Mrs. Clinton's table. But the AMA had actually softened its position on managed competition three months earlier at its semiannual convention, a fact noted in a Times editorial on December 10 and in other newspapers. Novertheless, one reporter says she had to convince anxious editors that the story was really old news when they called her at home to find out why she didn't have the latest scoop.

It's not surprising then that some two-thirds of the stories examined by the Times Mirror Center focused on the politics of reform, the structural organization of the plan, who would pay, and what was to be covered. Specifically, half the story leads dealt with components of the Clinton plan, while only 8 percent focused on other plans, a statistic that supports Holly Taylor's observations. Some 60 percent examined the impact of reform from the perspective of politics and the health system in general. Only 14 percent were written from the perspective of ordinary people.

A number of publications that did publish "people" stories focused on who would benefit form the Clinton brand of reform and who would not. But by identifying the winners and losers, the stories read as though the plan had been cemented in place when in reality the details that were known were based on leaks, trial balloons, and option papers.

The May 17 Newsweek toted up the gains and losses for different groups. It asserted, for example, that family doctors who were "generalists will get a boost under a new system that puts a premium on primary care." But what kind of boost -- more money, more prestige, more influence in patient care -- couldn't possibly be known when Newsweek published its box on winners and losers -- and still can't be ascertained. Money magazine carried the winners-and-losers analysis one step further. Its May issue identified fifteen categories of winners and losers, and offered them advice about what to do until reform comes. For the category "You own a business and don't cover your employees," it gave a mixed prognosis: workers might win, employers might lose. But, the story reported, small employers will receive government subsidies "probably when their health care expenses exceed 8 percent of payroll. And HMO fees will be lower than they are now." That would be delicious news for small businesses. But at best, heal care reform may slow the rate of increase in premiums HMOs charge employers, but reduce them in absolute dollars? Not likely.

Another version of the winners-and-losers story dissected the impact of health care reform on special interest groups. The Boston Globe, responding to a trial balloon, examined how Boston's big teaching hospitals would fare if Medicare funds were linked to a hospital's willingness to train primary-care doctors. The story quoted hospital administrators who predicted disaster. The Atlanta Journal and Constitution looked at the impact of health care reform in rural Georgia, and noted farmers' concerns about a global budget cap for health care spending, one method of cost control. If the administration proposed such a cap, rural areas might be penalized, according to a spokesperson for the National Farmers Union. Stories like those also served as trial balloons in reverse, signaling how various interest groups were reacting to the rudimentary proposals leaked from the task force.

If the press assumed that managed competition was the reform of choice, it did little to make the concept understandable. The August "Harper's Index," published by Harper's magazine, found that 60 percent of all Americans said they had never heard the term "managed competition." Of the 454 stories analyzed, only nine focused on managed competition in any detail, and three of those were generated by a press conference called by Representative Pete Stark to release a government report critical of the idea. During the period examined by the Times Mirror Center, The Wall Street Journal ran a piece that speculated whether managed competition would work in poor urban and in rural areas, and The New York Times ran FIXING HEALTH CARE: PRIMER ON 'MANAGED COMPETITION,' which seemed to draw its inspiration from a March 9 Washington Post story, A HEALTH CARE PRIMER: HOW 'MANAGED COMPETITION' WOULD WORK. The latter was one of the better explanations of the theory.

Some publications took a stab at explaining managed competition by portraying health maintenance oganizations (HMOs), which will become more important under managed competition, either very positively or very negatively. Knight-Ridder, for example, moved a story on its wires that showed how four HMO members with chronic illnesses struggled to get the care and services they needed. "Americans with costly and chronic illnesses say they would be the losers under Clinton's plan for health care based on HMOs," the story told readers, but failed to mention that similar horror stories can be found in traditional fee-for-service medicine, a point journalists would do well to remember in discussing the virtues and vices or organized health delivery systems.

Was the public well served by the press in Round One of the Great Health Care Debate? "Readers are totally confused, but it's not necessarily our fault. The process was somewhat chaotic," says Dana Priest, a health reporter at The Washington Post. "What we wrote was a function of what we could get. It's that simple." So far, the press has gotten the minutiae of the process. It has covered a debate about passing health care reform legislation rather than a debate about health care reform.

The problems and issues that have driven the debate this far are still with us. Poor people are still underserved; low medicaid reimbursements prevent them from obtaining necessary care. Working people still can't afford the ever-increasing insurance premiums. Sick people are still excluded from the insurance system. Old people must impoverish themselves before receiving long-term care. Workers still lose their coverage when they change jobs. No one has come up with an effective way to control the costs and use of exploding medical technology. Cost-shifting from government health care programs to the private sector continues unabated. So far, neither the press nor the Clintons have built a consensus for reform among the people who will have to use whatever system Washington rebuilds.

Round Two will feature an all-out war with charges and counter-charges from doctors, hospitals, small businesses, big businesses, insurance companies, and public interest groups, all vying for press attention in an attempt to make sure that they will be included in the new configuration or at least not harmed by it. How well the press will rise to the challenge of focusing on the issues and not on the battles among interest groups is an open question. Some reporters understand the mission. But whether competitive pressures will force them to succumb to the bane of Washington journalism -- mimicking the coverage in The New York Times and The Washington Post -- remains to be seen. Reporting that serves as a bulletin board for Washington policy wonks doesn't help ordinary people understand how health care reform will change their lives.

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