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The New Health-Care Debate

1992 echoes loudly, but today's story isn't just back to the future
November 27, 2007

A 2005 survey by the Kaiser Family Foundation found that twice as many people rely on the media for information about health care as rely on doctors or friends or family combined. In 2007, with health care a major issue in the presidential campaign, people will lean on the press even more. Covering the complexities of the health-care debate is not easy. How can journalists make them clear? For the first in a series of Q&As with accomplished journalists on the main domestic issues of the campaign, CJR spoke to Julie Rovner, who covers health policy for National Public Radio. She was interviewed by Trudy Lieberman, who directs the health and medicine reporting program at the City University of New York’s graduate school of journalism, and is a longtime contributing editor to CJR.

How do you contrast the public discussion of health care as we approach the 2008 election with the discussion in 1992?
During this last year, I’ve been walking around saying, “Wow. It’s 1991!” So much of it feels the same. You’ve got businesses complaining about health-care costs and a worried middle class. On the other hand, I think the big difference is this sort of cynical “been there, done that, didn’t work” feeling that wasn’t there in 1991. And the numbers have gotten so much bigger. We’ve gotten so many more zeros. The costs have gone up that much more. The number of uninsured has gone up that much more. The number of solutions we’ve tried and that have failed has gone up that much more.

Is the public less likely to be swayed by commercials, such as the famous “Harry and Louise” ads, which helped derail the Clinton health-care plan in 1993?
I don’t think they’re less susceptible. People don’t understand the health-care system, and I think that’s one of journalism’s big challenges.

Is the public likely to be influenced by the mantra that the U.S. has the best health-care system in the world? How should journalists put that phrase in perspective?
Every candidate is going to say it. To some extent, it’s true. There are a lot of things that the United States leads the world in—developing new technologies and treatments and drugs. And there are a lot of things that the United States lags behind in, like life expectancy, infant mortality, the number of uninsured people, and access to quality-of-care measures.

Is the public ready to embrace cost-containment, as the Canadians, Germans, and French have?
No. That’s what I’m sort of looking at—when I’m watching these presidential candidates, one of the things I’m trying to measure is which of them is actually ready to suggest that people might have to make sacrifices. I don’t see that yet. Right now they can all rattle off the easy answers: we’re going to improve information technology and we’re going to have electronic health records, and they’re going to save money. We all know the buzzwords, and they all know the buzzwords—their talking points. You need to drill down below that.

What do we really mean by the word “reform” in health care?
At NPR we’re not supposed to use the word “reform.” Reform is actually a word that has subjective meaning, and therefore, we really shouldn’t use it. Our Washington editor tries to ban it and fails most of the time. We don’t tend to reform things. We do tend to make smaller changes.

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Candidates have already begun to use phrases like “No European-style rationing.” How should journalists put that in context?
Any health economist will point out that we in the U.S. currently ration health care, on the basis of economics. If you have insurance, you get more care than if you don’t. If you have money, you get more care than if you don’t. We ration care. We simply ration it economically, rather than by queuing. You don’t have to go very far to find someone to say that.

Are we beginning to have queuing? A recent story from Orlando told of women unable to get mammograms, particularly diagnostic mammograms. There are not enough services. Is that not queuing?
Yes. There are also geographic disparities. We are starting to get queuing because there are starting to be shortages. There are places where it’s difficult even for people with insurance to get primary-care doctors. People with insurance wait months now to get appointments, to see specialists, to get mammograms. We’re getting to the point where we have the worst of both worlds.

How should reporters check the claims made by interest groups that don’t want to concede that anything works well in other countries?
That’s a really good question, and I wish I knew how to better cover what’s going on in other countries, short of going there. Do I believe some of these scary things I see from some of these groups, that everything in France and Canada is awful? No. The one thing we do know from other countries is that even if their systems aren’t perfect, the people are very happy with their systems. And the health outcomes of people in other countries are better than our health outcomes.

What will happen if we don’t make any changes?
Seventy-eight million baby boomers who are rapidly approaching Medicare eligibility will start consuming a lot of expensive health-care services. That is the potential tidal wave of cost that we’re looking at, and that’s the main reason that doing something about the health-care system is an imperative.

Is there a way to sort the candidates’ positions on health care into different buckets for journalists?
The Republicans have been pretty easy to sort because they’ve all been saying the same thing, which is, “more private market.” The Democrats tend to be different: you’ve got your single-payer advocates, the individual-mandate advocates, and the rest say, “Let’s build on the existing system.”

What can we expect in special-interest lobbying?
The usual players will be involved—the insurance industry, the doctors, the hospitals—but there will be a new player, the IT industry. I think Microsoft is a player we haven’t seen before. They want to lay the railroad track for the interoperable health-information network. Both hardware and software providers are throwing lots of money around.

How can journalists do a better job of covering the debate over the next few years?
Mostly by putting things in context. Do truth-squading when candidates start going after each other with charges and countercharges. Is that really true? Or did the candidate leave something out? Those are great stories; they’re really popular, and they’re fun to do. If I were to make one big recommendation to journalists covering health care in this election, it would be to work at translating the substance.

What should reporters be reading to stay current?
I read Health Affairs. The Alliance for Health Reform has been doing some really good briefings and they post the transcripts. The Congressional Budget Office, in their estimates of bills, has been doing a good job of explaining these things. They can read hearings online at thomas.loc.gov. Kaiser does really good stuff.

What will be the big story, and what will be the sideshow diversions?
The big story will be whether there will be some sort of change in the health-care system, trying to cover the uninsured and controlling costs. The big diversion might be Bush’s tax cut, which is set to expire in 2010; that could be a problem in 2009.

How do you go beyond the anecdote to make a story accessible? Anecdotal leads have almost become a cliché.
I think that you may want to write about the decision-maker. Go with the agony of the person who actually has to decide, the small-business person, although that’s starting to get cliché, too. Something other than the patients themselves. If I knew the secret, I would be doing it.

It seems to me that there needs to be a new way to think about these stories, in terms of the writing, in terms of the presentation.
Remember that at its core, it’s really about decisions over how we structure the system—basically government versus private sector. And within that, it’s, “Do we have a whole new delivery system, or do we build on what we have now?” Those are the two big decisions. And then within them, there are a zillion more decisions. But if you keep those overarching decisions in your head, it’s a little bit easier. The world is a different place than in 1993. This is going to be more “how” rather than “whether” we change the system.

People’s eyes glaze over when a story contains difficult concepts, such as risk selection. How do we keep readers from tuning out?
Find something that makes a great metaphor. For a story on s-chip, one of the issues was, “Will people drop private coverage and take government coverage?” It’s hard to explain. Jon Gruber, an economist at MIT, talked about tuna and dolphins. You want to catch the uninsured tuna without also catching the insured dolphins, but the two swim together and are in similar financial situations. I managed to do an arcane story in a way that listeners could understand.

How do we use numbers so people don’t tune out? I use as few as I absolutely need to and hope for the best. One of the best pieces of advice I can give is to find yourself a really good explainer. Maybe you’ve got a professor at a local college. There are lots of people who know about this and are really good at explaining. And it’s not just the five or six people who we national reporters like to use. Go find them.

Reporters often tell us that editors don’t see policy stories as very sexy.
Editors should look at the polls. They suggest that health care and health insurance are right up there after Iraq in terms of what the public wants to see addressed. 

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.