How to cover the looming war over Medicaid

In the batch of stories appearing after Indiana healthcare consultant Seema Verma was appointed to head the Centers for Medicare and Medicaid Services, one of the most important health posts in the federal government, a piece in Mother Jones by Stephanie Mencimer got right to the point: “States under Republican control have already provided a good preview of what a GOP replacement of Obamacare might look like,” she wrote. “And if they’re any indication, Trumpcare is likely to be more expensive and more complicated than the current system while covering fewer people and micromanaging them more.”

She was talking about Indiana, one of seven states that refused to expand their Medicaid programs as called for by the Affordable Care Act, but have devised their own programs, usually with strings attached for receiving coverage. Verma, the architect of Indiana’s arrangement, was candid when the state’s Health Plan 2.0 went public two years ago. The story, Verma said, was not just about the program details, but was “really about changing the traditional Medicaid program.”

So with a shakeup of Medicaid now on the table–as part of what’s expected to be more sweeping changes to Obamacare under the incoming Trump administration–reporters once again will be forced to try to make sense of a health-care world that leaves many of them baffled. What follows is the beginning of a cheat sheet to help them in covering Medicaid’s complexities.

  • Use stats sparingly.  Readers stumble over too many numbers, especially when they’re bombarded with them in the first few graphs. CNNMoney’s piece gave us numerical overload. The third graph says 73 million people are on the program that costs $509 billion while the federal government pays 62 percent of the bill and states pay 38 percent. The fourth presents four more numbers to process. Unless they are super compelling, a bunch of stats at the beginning are a nonstarter for most readers.
  • Probe the unanswered questions. There are lots of them, though one of the biggest may be what happens to people kicked off Medicaid? Earlier this year the Indianapolis Star reported that the state erased some 2,200 people from the Healthy Plan roles because they didn’t pay their required premiums. Why did the 2,200 people leave? The Star didn’t say but hinted at the problem, recounting the troubles Frandal Wright had making his $1 monthly contribution.  Tracking down more people like Wright would tell a lot about the effectiveness of new-fangled Medicaid.
  • Banish the euphemisms. Health policy stories are larded with them.  “Stabilizing funding,” “cost effective,” “fiscally responsible,” and “flexibility” are examples that showed up in the stories I looked at. NPR in a story from Kaiser Health News passed along two of them.
    • Beware of satisfaction surveys. The Washington Post and other outlets reported the Lewin Group found that 80 percent of Health Plan 2.0 respondents were either very satisfied or somewhat satisfied with their experiences in the plan, a stat that conveys a strong endorsement of the program. Caution is in order, and good reporting requires digging deeper into the survey results. What is their satisfaction compared to? What is the frame of reference for survey respondents? If participants had never been insured before, it might not be unusual for them to express some degree of satisfaction. Avoid plucking out  conclusions from a study without knowing more than you’re likely to get in a report. And consider who is sponsoring the survey. I’d bet on an independent firm rather than one paid by an organization with a big dog in the fight. The Lewin Group conducted the study for Indiana’s Medicaid program, the biggest dog of all.
    • Use caution with anecdotes. Leading with an example of someone who has benefitted from a program can tilt the scales in favor of the program while offering up a couple of paragraphs about someone unhappy can tip them the other way. Mencimer’s story was effective because she didn’t use them. “It’s tempting to think we can recognize which anecdotes are most representative of the ‘real story’ when we hear them but we really can’t,” wrote health policy researchers Katherine Baicker and Amy Finkelstein on the Health Affairs blog recently.

One final caveat: Keep an eye on what’s not discussed. What’s not part of the narrative the media pack is chasing? In this case it’s Medicaid and the middle class. So far most Medicaid stories have focused on uninsured kids. But Medicaid is the largest funder of all long-term care services, and even families that begin to pay privately for loved ones in nursing facilities have to turn to Medicaid if their money runs out.

What happens in a Medicaid redo? Will there be less money in those “cost effective” state programs?  Or will long-term care help disappear? Thousands of families facing the dilemma of long-term care could use a little clarity from the media on this one.

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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.