Groundhog Day

Why this year’s health-care debate sounds like the one in 1993
July 15, 2009

Last fall, soon after Barack Obama was elected president, Sheila Burke was waiting to discuss Obama’s campaign promises, via Webcast, with students specializing in health reporting at the City University of New York’s Graduate School of Journalism. Burke, a health-policy expert who now teaches at Harvard’s Kennedy School, laid a spreadsheet on the table and whispered to another guest. “See,” she said, “we had all these provisions before,” and ticked off the similarities between the current effort to pass health-care reform and those in the past. Burke declined to show me the document, saying that it was proprietary and belonged to former Senator George Mitchell, the Senate majority leader during the Clinton-era reform effort.

But whether Mitchell, Burke (who was Senator Bob Dole’s chief of staff during the 1993 debate), or any of the other health-care heavies from the old days want the déjà vu reality of reform, circa 2009, made public, it has become dismayingly clear that that is exactly what is happening, despite abundant rhetoric to the contrary. “The idea that we’ve made a great breakthrough just isn’t so,” says Jonathan Oberlander, a health-policy expert at the University of North Carolina. “Most of the plans today are direct descendants of what was proposed for the ’93-’94 debate. The debate reminds me of one of my favorite movies, Groundhog Day.

With few exceptions, like the fine series last summer by NPR that explained how a number of other countries handle health care, the press has done little to challenge this reality or help to broaden the health-care debate. Rather, it has mostly passed along the pronouncements of politicians and the major stakeholders who have the most to lose from wholesale reform. By not challenging the status quo, the press has so far foreclosed a vibrant discussion of the full range of options, and also has not dug deeply into the few that are being discussed, thereby leaving citizens largely uninformed about an issue that will affect us all.

The consequences of the failure to have a robust debate are likely to be even greater than they were sixteen years ago. In 2009, the government projects, the cost of medical care will consume 17.6 percent of the nation’s Gross Domestic Product, compared to 13.7 percent in 1994; the number of people without insurance is projected to hit 52 million next year, up from 37 million in the early nineties. A new report from the Robert Wood Johnson Foundation indicates that the number of uninsured could grow to more than 65 million in the next ten years, and that business health costs could double. These numbers suggest the need for drastic measures. But the politically acceptable solutions do not involve radical restructuring. Instead, they build on an existing foundation that relies mostly on for-profit commercial insurers to provide the coverage and for employers to pay for it. The word “universal” has come to mean covering more people with private insurance, not a national health system where every citizen is entitled to medical care and pays taxes to support it.

Absent from the debate are not only single-payer systems like the ones in England and Canada, but other systems with multiple payers, like ones in Germany and Japan—or, for that matter, any discussion of why a system that relies on competition among private insurers in The Netherlands hasn’t resulted in lower prices for consumers, as advocates claimed. What’s common to all these systems is that everyone is entitled to health care and pays taxes to support the system, and medical costs are controlled by limits on spending. The specter of a system that takes a significant bite out of stakeholder profits in the U.S. is the real reason the debate is so restricted.

Reform efforts have danced around this impasse for decades. In the early 1990s, for instance, health experts promoted a pay-or-play scheme—an arrangement in which employers would be required to either offer their workers health insurance or pay into a fund to subsidize those who had none. There was also serious talk of an “individual mandate”—a requirement that everyone have insurance—and of making workers pay taxes on health benefits from their employers. (Both proposals are now on the short list.) Experts in the earlier debate also pitched a public plan under which people not covered by their employer would be enrolled in a government plan. The Clintons did not embrace that idea, but President Obama supports it. Early on in their respective campaigns, both Bill Clinton and Obama rejected the idea of single-payer, code for national health insurance. Indeed, single-payer is further off the table than ever despite enclaves of noisy advocates who have been virtually shut out of the political process.

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Then, as now, there were outside conveners trying to influence political and public opinion. In the Clinton days, it was the Jackson Hole group—businessmen, insurance executives, and academics who met in a Wyoming lodge to hatch proposals for managed competition. Today it’s the Herndon Alliance, which includes former single-payer supporters, advocacy groups, unions, and think tanks that have rediscovered the public-plan option and fashioned language to sell it. They’ve taken their cues from Democratic pollster Celinda Lake, who found in a study paid for by the alliance that Americans were happy with their private coverage and would resist a Medicare-for-all solution. Doing what Frank Luntz has done for Republicans, Lake invented new buzz words—“quality, affordable health care”—and counseled Democrats to pair them with reassurances to the middle class that they could keep the coverage they had. Alliance partners have enforced the kind of language discipline that would make a Republican proud. Almost every statement about health care from a politician or advocacy group uses the words “quality” and “affordable.”

Exactly why the press is reprising its docile approach to this debate is a complicated issue that necessarily involves the long-standing question of how journalists define their role in society—whether they are leaders of the national conversation or mere amplifiers of it. In 1993, Holly Taylor, a health reporter at The Berkshire Eagle, in Pittsfield, Massachusetts, stood up at the annual meeting of Investigative Reporters and Editors and asked why the national media were reporting that managed competition was the only solution to the health-care crisis. Taylor told me at the time: “What I found frustrating was that everyone was writing about managed competition as if it were a fait accompli.” This year, it’s the same story. At the annual meeting of the Association of Health Care Journalists, Duane Schrag, a reporter at the Salina Journal in Salina, Kansas, echoed Taylor’s frustration after listening to a talk about health-care reform by Oregon Senator Ron Wyden. “I was just struck by how accepting the audience was of a solution that represents an encapsulation of the status quo with the same players and the same current costs,” Schrag says. Why, I asked him, did he think journalists weren’t pushing back? “Perhaps the media were caught up in the good news that after sixty years there’s a breakthrough and all the stars are aligned,” he says.

Schrag’s observation is astute. It isn’t just that the debate is the same and the press isn’t acknowledging it—the coverage actually suggests that things are different. “Not Yesterday’s Health Fight”, read the headline on an April column by The Washington Post’s E. J. Dionne. Robert Laszewski, who writes a popular blog called Health Care Policy and Marketplace Review, told me reporters keep telling him, “‘Bob, it’s different this time.’ And I say, ‘No, it’s not really different.’” As Schrag suggests, the media’s master narrative tells us that the debate is different because, unlike in the Clinton era, all the stakeholders are playing well together. Insurers, especially, are more cooperative, supporting coverage for everyone and agreeing to give up medical underwriting, a practice that has denied coverage to people at higher risk for health problems. “The health insurance industry is working on a transformation that could come right out of Extreme Makeover,” wrote AP reporter Ricardo Alonso-Zaldivar in March. In December 2008, a Boston Globe headline proclaimed: “Lobbies Backing Health Reforms, Insurers Change Their Tune From 1993-94 Debate.”

But look at what The New York Times had to say in December 1992: “In Shift, Insurers Ask U.S. To Require Coverage for All,” read the headline on a story in which reporter Robert Pear quoted Judith Feder, a Clinton transition team official, who described the apparent support for universal coverage and cost containment “as a major turnaround” for the industry.

It’s true that in early 1993, many of the same stakeholders—insurers, employers, and the American Medical Association—were supportive of comprehensive reform. Only when they realized what the Clinton plan required—spending limits, stricter regulation, a mandate that businesses provide coverage to employees, etc.—did they sour on it. Only then did the insurance industry unleash its infamous Harry and Louise ads that were so effective at turning public opinion against the legislation. A similar broad consensus exists now, but the press has misread it, argues Harvard pollster Robert Blendon. He says that “reporters covering Washington believe that the debate is over.”

One thing that is different this time is the Obama administration’s strategy. Instead of delivering a specific plan, the president outlined eight lofty principles—including the goal of universal coverage and making coverage affordable—and is leaving it to Congress to fill in the blanks. (By mid-June, there were signs that Obama had decided to assume more of a leadership role in the debate.) The press has reported this strategy as Obama learning from the Clintons’ mistakes. But this frame misses a larger point: the lack of concrete legislation to be picked over and explained—coupled with an accelerated timetable for action set by congressional leaders and the president and the dominance of rhetoric about how the “stars are aligned” for reform—have so far precluded a thorough debate.

As in the early nineties, the press is covering the process of reform, not the substance. Stories have yet to explore the consequences of an individual mandate, which some key members of Congress have proposed, and have dismissed it as though it were not controversial—which it certainly will be. Journalists have not explained how a public plan might work and who might be eligible—despite the hype, it’s unlikely everyone will be. They have not questioned the cost-containment measures the administration and Congress are promoting. Although Obama has talked a lot about lowering the cost of health care, cost-containment measures with teeth—like global budgets and spending caps—are nowhere in sight. There is not ample evidence to support the claim that health-information technology, preventive care, and disease management—the centerpieces of Obama’s cost-containment strategy—save much money, but the press coverage has managed to convey the impression that they would. Louise Russell, a Rutgers research professor and a leading scholar on preventive care, has written extensively that preventive care actually costs money, rather than saves it. Academics know her work, but the press has either ignored it or simply not discovered it. Instead, reporters go to the same sources over and over for more quotable conventional wisdom.

Since the beginning of the presidential campaign, I have found scant coverage of how real people would fare under the kind of reform envisioned by the health-care cognoscenti. In fairness, until June there was no bill to measure. But we have known enough about what was coming that it should have prompted some reporting along these lines. What will happen, for instance, to the owner of a South Bronx taco restaurant who finds he must pay thousands of dollars for insurance or face severe penalties for not being insured? Or to the factory worker who must pay taxes on her health insurance, just as her employer makes her pay more for fewer benefits?

In the fall of 1993, I wrote in CJR: “So far, neither the press nor the Clintons have built a consensus among the people who have to use whatever system Washington rebuilds.” The same is true today. Neither Obama nor the press have built a consensus for reform. It’s hard to assemble one when the public doesn’t know what reform actually means. An engineering doctoral student from the University of California at Berkeley and a Manhattan hairdresser recently asked me the same question: What is single-payer? And last spring, my journalism students at CUNY asked people on the streets of New York what they knew about the differences between a public-plan option and private insurance. “I didn’t know there is a difference,” one said. Another added: “Public, everybody knows about it; private, nobody does.”

President Obama says he wants a bill by October, so the press still has a chance to help the rest of us make sense of these crucial policy decisions. But they will have to do it quickly. It really is Groundhog Day for health-care reform. 

Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for CJR's Covering the Health Care Fight. She also blogs for Health News Review and the Center for Health Journalism. Follow her on Twitter @Trudy_Lieberman.