The Obamacare emergency: Can health care reporters rise to the challenge?

Jim Clark, a nurse in Asheville, North Carolina, recently sent a letter to the editor of the Mountain Xpress, a western North Carolina weekly with a circulation of 26,500. In his letter, Clark said he was adding his voice to the chorus that has appealed to the paper for a “more rigorous approach to its health-related articles.” Clark was disappointed by what he called the paper’s “uncritical nature of articles and editors’ feeble response to pleas for more accountability.” He argued that if the paper was unwilling to commit to real health journalism, then it should put a black-box warning at the top of its Wellness section, like those the FDA requires for drugs that pose serious risks to users: “The articles enclosed are manufactured with no quality controls. Swallowing the contents whole may be harmful to the gullible and the highly suggestible.”

Mountain Xpress Editor Jeff Fobes responded politely in an editor’s note. “In the past year, we have made a concerted effort to provide more balanced coverage about health care issues since receiving feedback from some readers asking for a more skeptical and balanced approach in our reporting.” In a phone conversation, Fobes and two of his editors told me the paper was trying harder to explain more to readers about medical claims and treatments, as well as the evidence for them. Wellness Editor Susan Foster said, “We have heard their concerns and are headed in the direction of a more rigorous approach.” That would be quite a switch: Much of the paper’s health content has touched on therapies such as astrology, acupuncture, meditation, yoga, and massage therapy, and is supported by advertising from health care businesses.


“The articles enclosed are manufactured with no quality controls. Swallowing the contents whole may be harmful to the gullible and the highly suggestible.”


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The paper’s response to reader criticism shows how far health journalism has come in the 20 years since the founding of the Association of Health Care Journalists, which was organized to support the press’s efforts to help citizens make better decisions about their health care. If readers like those in North Carolina are pushing their local news outlets for better coverage, then score one for AHCJ’s mission. “We know that everyone is not an evidence-based premier journalist yet, but we’ve raised the bar,” says Executive Director Len Bruzzese. “Compared to what we had, we have a healthy crop of reporters.”

Right now, the stories that health journalists tell are critical. Threats to repeal and replace the Affordable Care Act have created a tumultuous moment in which millions of Americans may be impacted by changes to their health care and insurance that they may not wholly understand. However, at just the moment the public most needs their help, health journalists may be poorly poised to provide it.

 

A hard look at the health journalism landscape reveals uneven progress over the past 20 years and serious threats to better coverage and greater public understanding of America’s health care monster, which now represents nearly one-fifth of the nation’s GDP. “There are occasional peaks of excellence, with some stories better than we’ve ever seen, but the valleys between the peaks are becoming wider and deeper,” says Gary Schwitzer, publisher of Health News Review, which was established 10 years ago to evaluate health care journalism, as well as the advertising, marketing, and public relations messages that might influence consumers and patients. Health News Review evaluated 300 public relations news releases during the past two years and found that almost all of them failed to adequately explain the costs of what they were peddling. More than three-quarters of the news releases didn’t adequately explain to customers the potential harms caused by their products, from side effects or drug interactions, even when the consequence might be fatal. Health News Review also evaluated 2,311 news stories published during the past 10 years—many of them based on news releases—and found that two-thirds failed to adequately explain costs and potential harms and benefits to readers.

“It’s a daily drumbeat of dreck,” says Schwitzer. “And the harm done by the drumbeat drowns out the excellence.”

Stories like “Brisk Walk May Sidestep Heart Disease” from HealthDay underscore Schwitzer’s point. What’s the harm in a nice little wellness piece like this? It doesn’t tell people what they need to know, and it doesn’t help them to think critically about the research claim, says Schwitzer. He likens such stories to what software developers call “‘shovelware’—content taken from any source and put on the Web as fast as possible, with little regard for appearance and usability.”

And while Health News Review deals mostly with the medical and clinical side of the beat, the same shortcomings can be found in coverage of policy, where reporters pass quotes from politicians and advocacy groups along to their audience without critical examination. Quotes about protecting and saving Medicare, for instance, do little to inform the public or to help them think critically about the program.


“It’s a daily drumbeat of dreck. And the harm done by the drumbeat drowns out the excellence.”


That kind of lackadaisical reporting has taken a toll, especially when it comes to understanding the Affordable Care Act. Ed Wasserman, who heads the UC Berkeley Graduate School of Journalism, told me, “There are enormous gaps in my own understanding, and I have relied on the media to keep me informed. Extrapolating from [those] gaps…I would have to say the quality of the journalism [about the ACA] is not very high.”

Yes, there have been some instances of outstanding journalism. Kaiser Health News reporter Sarah Varney’s story dissecting why Obamacare was not working in Mississippi remains, for me, the best policy story about the ACA. At Crain’s, Michael Waldhoz investigated why the New York insurance co-op Health Republic failed, a subject few news outlets touched in any depth or detail. A Reuters investigation by Alison Frankel and Jessica Dye that showed how the dark side of the medical funding industry preys mostly on poor people stands out. So do the clear explainers by Vox’s Sarah Kliff, and John Fauber’s gutsy reports in the Milwaukee Journal Sentinel, which unraveled the claims, harms, and lack of evidence for many commonly advertised drugs. But their coverage sets a high standard that is rarely met; such exemplary journalism isn’t the norm.

Complaints about health journalism and its shortcomings are well-known: Reporters on the beat are too few, have too little time to pursue stories, and see meager rewards for quality at a time when clicks and pageviews are the gold standard for journalistic success. Reporters on other beats face the same obstacles, but the difficulty of untangling esoteric medical and policy concepts makes health journalism particularly tough in thinly staffed newsrooms. And now, as the nation faces a major debate over the government’s role in health care and every major health program is placed on the table, the stakes are even higher. “I’ve seen a lot of health policy debates but this one is shaping up to be as great as any I’ve seen.” says Drew Altman, who heads the Kaiser Family Foundation.

 

Digital tools have given reporters new opportunities to mine information that was once hard to gather, resulting in stories like ProPublica’s “Dollars for Docs,” which revealed how the drug industry influences physicians’ prescribing patterns. But similar innovations have enabled editors and publishers to monitor audience response to coverage, which can push against good health reporting. “The pressure for quick-hit digital content works really well for some coverage areas like sports, but not health journalism,” says Markian Hawryluk, who covers health for The Bulletin in Bend, Oregon. “The pressure to get three graphs on the Web leaves no time to call the authors or independent sources or even to read an entire study.”

When the financial imperative for editors is the number of clicks and pageviews, they are more likely to channel health care reportage to less serious, more appealing content—the “shovelware”—rather than more serious, less popular health policy pieces that attract fewer clicks. In December, the Albany Times Union published a good piece about a study from the New York State Health Foundation showing that those state hospitals with a greater market share also had the highest prices. Higher prices didn’t necessarily mean better care, a point usually not well understood by the public. Claire Hughes, the Times Union’s longtime health reporter, made that point, but told me she wasn’t sure her story resonated with the public. By contrast, for a story describing what readers thought when a bad cold was going around, Hughes put a query on Facebook asking if people were having certain symptoms and got 344 responses, more than for most other inquiries.

Rick Berke, the executive editor of the newbie health and medicine site STAT, says when STAT published a story about the dangers of removing your ear wax, it got huge traffic day after day. Still, Berke allowed that chasing traffic is a “fool’s errand.”

“Our energy is best spent producing high-value journalism that you can’t get anywhere else rather than trying to game in advance what may or may not drive traffic,” says Berke. “More often than not, some of our biggest stories have been our deepest dives.”


How do you persuade people to read about repealing and replacing Obamacare when they’d rather read about colds, ear wax, and male contraceptives?


Fool’s errand or not, how do you persuade people to read about repealing and replacing Obamacare when they’d rather read about colds, ear wax, and male contraceptives? Casey Gueren, BuzzFeed’s health editor, says one of the challenges facing health journalists is how to add more information and accuracy in an age of shareable content. The trick, she says, is for a story to be entertaining, shareable, and very well-researched.

Case in point: Several outlets, including BuzzFeed, published simplistic stories about a male contraception study that was stopped by a review panel after numerous subjects experienced side effects to hormone shots. Headlines at both People.com and Cosmopolitan.com referred to subjects’ “mood changes,” which made for snappy and shareable content. BuzzFeed updated its initial story to bring it “in line with BuzzFeed’s editorial standards,” and Gueren wrote a more thorough follow-up story to clarify the reasons for the study’s conclusion. However, by then, simpler and less precise versions of the male contraception story had been shared via social media.

“Commenters wanted to believe what they had already seen on Facebook,” Gueren says. “Women were mad. They didn’t want to hear the bad story, just the narrative that men should be responsible.”

The public’s deeply held beliefs about health care—that a cure for whatever ails them is just around the corner, that American medicine always has the answers—makes it easy to understand why serious policy reporting can fall by the wayside. People would rather read about a story saying coffee might prevent or reduce risk of cancer than cautionary notes from the FDA about how coffee-containing products should be responsibly marketed. Mitch Pugh, the executive editor of The Post and Courier in Charleston, says the top brass at news organizations must decide if policy pieces are important to the health of the community—in other words, that they fulfill “some kind of public service mission.” They have to believe they do, or such stories “will be a harder sell to the powers that be,” Pugh says.

 

When the health reform effort began a decade ago, news outlets decided covering more of the uninsured was important and assigned more reporters to do it. Karen Bouffard at the Detroit News was one. She calls the health beat “a bottomless pit of possibilities” and, with her colleague Joel Kurth, has done some fine stories about dirty instruments at Detroit hospitals. But a round of layoffs at the Detroit News in December gave her the jitters. She survived the layoffs, but is concerned that competing budget priorities and a smaller staff might make the paper lose its appetite for the kind of long, hard-hitting projects she’s doing.

It’s a similar story in South Carolina. Joey Holleman spent 35 years in the newspaper business, most recently as a health reporter at The State in Columbia. He is now a science writer for a small state agency. It was time for a change, he says, but added that he “was weary fighting the journalism battle with ever-shrinking staff.”

Nick Budnick, who covered health at The Oregonian and delivered a great post mortem on the state’s disastrous rollout of the Obamacare marketplace, left the paper in 2015 to join the Portland Tribune, a smaller outlet where he covers mostly criminal justice. He wants to do more digging, especially into Oregon’s Medicaid program. But time is always hard to find for deep investigations of complex programs like Medicaid, and Budnick now devotes only 20 percent of his time to covering health care.


“Our energy is best spent producing high-value journalism that you can’t get anywhere else rather than trying to game in advance what may or may not drive traffic. More often than not, some of our biggest stories have been our deepest dives.”


The diminished ranks of state health reporters leaves a crater in the health journalism landscape. When reporters leave the beat, news outlets lose a ton of institutional knowledge, which goes a long way toward explaining the nation’s byzantine health system. Newly minted graduates of health journalism programs are not gravitating to local news outlets. Pat Thomas, who holds the Knight Chair in Health and Medical Journalism at the University of Georgia, told me the jobs most of her students get are closer to where the stories originate—that is, in universities and health-care companies. “I wish there were more in watchdog journalism,” says Thomas. “But these young people have to earn a living.” Thomas tracked employment for her students who graduated between 2011 and 2016. Of the 39 students she followed, only 11 went on to work in health-related news as staff writers or independent journalists.

People interested in health journalism can, of course, turn to Politico, Kaiser Health News, Vox, or newcomer Axios for policy news, or read The New York Times and The Washington Post. They can go to ProPublica for data-driven projects, or Health News Review for warnings and critical analysis of stories promoting medical treatments. They can visit any number of specialty sites, some run by journalists such as Ivan Oransky, whose Retraction Watch reports on retractions in scientific papers. But those outlets, as good as they can be, are no substitute for strong, consistent local reporting aimed beyond Beltway policymakers and at people in rural Indiana who are struggling to pay for their health care. Such journalism can warn the public about hospitals with high infection rates, or scrutinize insurance rates and state regulators, or track questionable sales pitches for Medicare Advantage plans. It’s old-fashioned consumer reporting, and it is all but extinct. Says the Portland Tribune’s Budnick, “There’s a lot going on that’s not getting covered. The public needs independent journalists poking around on their behalf. When that’s not there, the health-care industry goes to town.”

The AHCJ and The Center for Health Journalism provide fellowships for reporters who have turned out some terrific local stories. A few of the newer outlets like Politico and Kaiser are dedicating resources to covering health in some states. (Kaiser has a California bureau to fill the vacuum left by severe staff contraction.) But such efforts, while important, are not the same as having a reporter at the state house who covers what lobbyists for insurance companies, nursing homes, hospitals, and state regulatory agencies are up to. The Bay Area News Group has downsized from three full-time health reporters several years ago to two, who must supply copy for the group’s six print dailies and 27 weeklies. When longtime TV journalist and anchor Bob Shieffer retired in 2015, he said the greatest threat to the future of journalism is the decline of local political coverage. “Unless some entity comes along and does what local newspapers have been doing all these years, we’re gonna have corruption at a level we’ve never experienced,” said Shieffer. The same should be said for health coverage.

 

Health-care sellers have stepped into the journalism void to help supply health news, but their motivations can make that “help” dubious. Increasingly, as reporters confront their digitally induced time crunch or their own shakiness with difficult concepts, they come to rely on the industry’s press releases, studies, reports, pre-packaged anecdotes, and ultra-polished quotes from “experts.” Sharon Begley, a science writer extraordinaire who now works for STAT, says she gets 50 emails each hour from 6am to 9pm during the workweek, all from sellers pitching products and services. “At the ready is someone with a vested interest in teaching and explaining it to you,” says Begley.

“There’s no reward for being skeptical in the coverage of health and medicine. When someone sends in a quote, it’s irresistible and you use it,” she told me.

Universities and the federal government are becoming as adept as the Pharmaceutical Research and Manufacturers of America (PhRMA) at pushing out messages. Many former health journalists land jobs in university communications shops, where they send press releases touting their employers’ research and whiz-bang treatments at affiliated hospitals to newsrooms. Tom Wilemon, who did especially good reporting at The Tennessean on Medicaid expansion, now works for Vanderbilt University’s communications office, where he recently wrote about a cancer patient who is singing for the Pope. (Wilemon declined to be interviewed for this story.)

Government agencies also have good reasons to help out reporters. The Department of Health and Human Services, which learned how to render state-specific data about Obamacare, sent local reporters the numbers they needed to show how the health law was helping people in their states. HHS had no trouble this summer getting much of the nation’s health press to pass along its message that Obamacare insurance premiums were affordable because people got subsidies that defrayed much of the cost. There was just one problem: Half of the people who bought policies in the same marketplace were not eligible for subsidies and had to pay full freight, a complication that most news outlets failed to mention.


The diminished ranks of state health reporters leaves a crater in the health journalism landscape.


Peggy Peck, editor-in-chief of MedPage Today, believes the well-respected National Institutes of Health may have its own biases too. She cites as an example the SPRINT study funded by the National Heart, Lung and Blood Institute, which stopped the trial early in order to announce results that indicated a clear benefit for aggressively treating high blood pressure. But the announcement came before results were vetted and, although they were later published, Peck says there is still little consensus about how low blood pressure should go. (There’s concern in the medical community that it’s possible to drive blood pressure too low, especially in the elderly, Peck told me.)

“Were results released before final vetting to spruce up the NIH’s image as its funding was debated in Congress?” asks Peck. She observes, “The political imperative constitutes a built-in-bias, one that has been routinely overlooked since many reporters only think PhRMA when we consider bias.”

Journalists eager to build their stories around industry handouts don’t show the same enthusiasm for covering the business of health care, perhaps the most underreported branch of health journalism. Again, from time to time a great investigation pops up. The Wall Street Journal dimmed the light on Theranos, a maker of blood-testing devices, which was a rising star in the business world. There was David Sirota’s dogged pursuit of Connecticut’s insurance commissioner and her conflicts of interest affecting the important Anthem Cigna merger. There was also Paul Demko’s dissection of the Obamacare insurance markets in Politico, and Fred Schulte’s investigations of Medicare Advantage plan sellers who were overbilling the government while the government looked the other way. (Schulte, who conducted his investigations for the Center for Public Integrity, is now a senior correspondent for Kaiser Health News.) But, as with coverage of the ACA, stories of such caliber are too rare.

Wendell Potter left his job as head of corporate communications at Cigna Health Insurance in 2008 after 15 years with the company and became a health media commentator. During his time at Cigna, Potter recently told me, he saw a decline in the number of reporters who would call to ask questions or delve into anything in depth. “Over the years the calls stopped coming, and by 2008 I got very few challenging calls from reporters,” says Potter. “Eventually no one called from any place except the wire services.” Potter is trying to start a new site called Tarbell—named for the famous American muckracker Ida M. Tarbell—that would report unexplored stories at the intersection of health, business, and politics. He says he hopes to have journalism on the site by late spring.

Why so little business coverage? Maybe it’s because balance sheets and cash flow statements are hard for non-business reporters to understand. Maybe it’s the lack of understanding of the health system. Maybe the learning curve is too steep. Or perhaps it’s because more and more businesses are funding health journalism. Blue Cross Blue Shield sponsored a health page at a South Carolina newspaper; local hospitals are big TV advertisers, often sponsoring big specials or weekly “medical minute”-style programs touting one of their lucrative services. It’s rare these days for a news outlet to bite the hand that feeds.

Even STAT, which has the potential to be the country’s go-to place for health and medical reporting, could face possible conflicts down the road. Berke says part of STAT’s goal is to build revenue through subscriptions, which may or may not lessen the need for corporate advertising. For now, STAT’s site features sponsored content and banner ads from PhRMA companies and other health-care sellers. STAT labels its sponsored content, and it’s up to readers to take that into consideration when they visit the site. That may be asking too much from readers; some journalists aren’t even bothered by those ties. When Health News Review’s Schwitzer wrote about the advertising on STAT’s site, a journalist replied to him, “They’re trying to run a business. You’re scaremongering.”


“Commenters wanted to believe what they had already seen on Facebook. Women were mad. They didn’t want to hear the bad story, just the narrative that men should be responsible.”


“There’s no question they are doing good stuff,” says Kevin Lomangino, Health News Review’s managing editor, about STAT. “My concern is, what happens when John Henry’s money runs out?” (Henry owns the Boston Globe and founded STAT.) If subscriptions don’t succeed, that leaves PhRMA and other health-care sellers to support the enterprise. “They’ve opened a window for infiltration from the drug industry which could eventually lead to another opportunity for the drug industry to defend itself,” Lomangino says. A change of leadership at the top could alter the financial structure and, by extension, the product. But even if STAT deteriorated in quality, says Lomangino, it would still be better than the pack, because “generally what we see is not very good.”

Business representatives often sit on boards of foundations that may fund some of the newer state health journalism sites like Georgia Health News and The Connecticut Mirror, which were established to provide residents with health news that shrinking local newspapers were not. What happens when one of these sites criticizes the practices of a local hospital, or another influential health-care business, or a government agency? Will its funding disappear? Health News Colorado folded when its chief funder, the Colorado Health Foundation, changed its funding priorities. As CJR pointed out, reporter Katie McCrimmon’s gutsy reporting was hardly appreciated by governmental officials running the state’s Obamacare marketplace.

Diane Lund-Muzikant, who runs The Lund Report in Oregon, has managed to stay afloat for 10 years and deliver hard-hitting stories about hospitals, insurance companies, and the state’s other big health-care players. She pulls few punches; though she publishes industry press releases, she clearly identifies them as such. Much of her funding comes from donations and premium subscriptions. One of her major challenges, however, is access. Lund-Muzikant often relies on inside sources built up during the eight years she has run the newsletter.

As the health-care industry comes under the sway of a few giant conglomerates, Lund-Muzikant says it gets harder to get the sort of inside information that frequently fuels her stories. I asked whether the kind of journalism she has done to date will continue. “It takes courage,” she said. “The influence of the health industry is enormous.”

 

What should the future of health journalism look like? And is that future attainable?

The answers depend on the future of health care itself. As Joanne Kenen, Politico’s executive editor for health, points out, health care is “so tied up with how people feel about government.” The election results and the continuing debate over the Affordable Care Act show how closely the two are entwined. People have strong feelings about what the government should and should not do, and those feelings can inform how they think about their health care. (For instance, the FDA may say a drug is harmful, but a person may want it anyway.) That makes it hard to achieve consensus on questions about who really benefits from the system, or how costs should be allocated and controlled, or how coverage and care should be allocated. All the domains of health journalism—medical, policy, business, consumer, and public health—circle back to fundamentals the country has yet to address.

Some of those I interviewed, like STAT’s Sharon Begley, are pessimistic. “You have to change the reward system in journalism for things to change,” says Begley. “I don’t see that happening.” That may be, but that doesn’t mean the need for good reporting diminishes, especially now.

A few weeks ago, Marie Lindsey, a nurse practitioner in Illinois, told me that some of the student nurses she teaches don’t know the difference between Medicare and Medicaid and she has to teach them how health insurance works. “It’s hard to have a serious conversation about how to craft a better system if the average American doesn’t understand the basic system we have,” she said. If the public doesn’t understand those programs and their implications—how drugs are regulated and priced, whether over-hyped treatments might be harmful—then how can they understand the political changes that might affect them all?

Lindsey’s students and the rest of the electorate need help. Without good journalists to tell them, health care sellers who have learned to give “editorial guidance” to reporters will step in to do the job. Jack Shafer, Politico’s thoughtful media critic, brought up the tobacco industry, and then told me he’s always amazed at “the ability of corporations to play the game anew.” All this should be reason enough to soldier on.

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR’s healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman.