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Shared wisdom

Sometimes all we need is a quick suggestion from our peers to zero in on a good story. Here we turn to front-line journalists for advice, some simple insight to add to our repository of “shared wisdom.”

We have all had the experience of pursuing a story and finding it isn't there. But sometimes there's another one staring right at us. What's your advice to make sure reporters don't miss a great health policy story staring right at them? – Jenny Deam

Jenny Deam

Be flexible enough to pivot.

If interview after interview is pointing you in a different direction, allow your instincts to follow what people are trying to tell you.

Jenny Deam is a reporter for the Houston Chronicle. She recently wrote about the uninsured in Texas.

Many people are reluctant to talk about their health problems on the record, particularly mental health. What’s one thing you do that makes them feel comfortable opening up? – Inara Verzemnieks

Inara VerzemnieksIt helps to establish up front that I am not interested in reducing people to a diagnosis or pathologizing their situation. I explain that my hope is to place their medical concerns in the context of their day-to-day lives, that my goal in telling such a story is to help reveal what so often goes unseen, not just the problems someone faces, but what counts as quiet everyday acts of resilience in the face of medical difficulty.

By centering the conversation around the whole person, and the quiet nuances of a life, I think that offers us a place to begin that can help to relieve fears of being labeled, exposed.

Inara Verzemnieks is a freelance writer and an assistant professor at the University of Iowa. She worked as a newspaper journalist for 13 years and was a finalist for the Pulitzer Prize in feature writing. She recently wrote about “Obamacare’s dead zone” for The New York Times.

What's a smart starting point that reporters often forget when they start a story?

Janine Weisman Read statutes – take the time to read the law. For instance, if you are covering domestic violence, read the domestic violence law!"

Janine Weisman (@j9weisman) is editor of the Newport Mercury in Rhode Island.

What's a useful tip for a health reporter to cover health policy? – Kristin Gourla

Go to the state budget hearings. Hear how money is spent, and why it is spent that way.

You learn what state and federal policies are driving those decisions.

Kristin Gourlay (@kristingourlay) is an award-winning health care reporter for Rhode Island Public Radio.

Where can a reporter find current financial information about not-for-profit hospitals’ community benefits? – Beth Kutscher

Not-for-profit hospitals are required to report extensive community benefit information on their 990 tax forms (see Schedule H). But that data is typically a couple of years behind. However, a good number of hospitals and health systems also include this information in the quarterly financial reports they file for municipal bondholders.

Beth Kutscher, who was recently named California bureau chief for Modern Healthcare, has covered health care finance for several years. During a AHCJ Reporting Fellowship on Health Care Performance in 2015, she investigated the impact Medicaid expansion had on hospital finances.

You did a long project including policy and narrative, and a patient’s family shared voluminous medical records. How did you organize those files? – Sarah Kliff

Sarah Kliff

DocumentCloud was  hugely helpful. The PDFs of the medical records weren’t searchable, but DocumentCloud let me search them, organize them and annotate them.

That helped me identify parts of record where I needed to find a medical expert or researcher to help me understand them – and it helped me stay organized when it came time to write.

Sarah Kliff is a senior editor at Vox, where she oversees policy coverage and writes about health care. She previously worked at The Washington Post and Politico, and is a recipient of AHCJ's 2015 Reporting Fellowship on Health Care Performance.

What do you do when you can’t get a hospital to talk to you? When they just don’t want to, or perhaps they can’t because of pending litigation? – Cheryl Clark

I go to one of their competitors! They are often happy to talk about what they are doing – particularly if they have a success story to tell, or a new safety strategy or innovation to share.

Cheryl Clark is a contributing writer for MedPage Today and is helping launch a new investigative journalism organization called Hashtag30. As senior quality editor for HealthLeaders Media for more than six years, Clark wrote more than 1,300 stories about hospitals' efforts to improve quality and safety and related issues. 

The second ACA enrollment season is over, and the next one is far off. Are there off-season enrollment stories to do in the states? – Julie Appleby

Julie ApplebyYes. Look at the data on your state. Did enrollment go up or down in the second season. Ask why. (Affordability will probably be part of the explanation).

Also how much did your state spend on its exchange? Follow the money.

Julie Appleby, M.P.H., is a senior correspondent with Kaiser Health News and a member of AHCJ's board of directors. Prior to KHN, she spent 10 years covering the health care industry beat for the business section of USA Today.

What are some of the best resources for understanding price variation? – Lisa Aliferis

Bar none: the Dartmouth Atlas of Health Care is the best place to start if this concept is new to you. The California HealthCare Foundation does rock solid research in California. As for journalists, past-AHCJ president Charlie Ornstein at ProPublica writes frequently and exceedingly knowledgeably on this topic.

Lisa Aliferis is a health editor and blogger for KQED in northern California. Her news organization is collaborating with two others to shed light on health care costs. She contributed to a tip sheet about reporting on health care costs.

How do you develop sources within a hospital – and not just the PR office? - Shannon Muchmore

Be human! I let them know I have a job to do, just like they do.

I may say to a nurse, “You need to understand things at your job, so you get them right. And I need to understand them, so I get them right."

Shannon Muchmore (@smuchmore) is the health reporter at the Tulsa World. She is @smuchmore on Twitter and can be reached atshannon.muchmore@tulsaworld.com. See her tip sheet on finding "real" people as sources.

What's a good starting point when you are looking for sources on a new topic or aspect of the beat? - Joyce Frieden

The Alliance for Health Reform has a great resource called "Covering Health Issues: A Sourcebook for Journalists", which gives an overview of subjects ranging from health IT to dual eligibles; each chapter ends with a list of sources. The latest one is from Fall 2013 so some of the source information may be a little out of date, but it's a good place to start. 

Joyce Frieden is the News Editor for MedPage Today.

When you interview someone, how do you know they are giving you accurate information about their own costs – do they understand co-pays and deductibles, etc., in a way that gives you confidence in writing about their costs? – Lisa Aliferis

We asked people to share what their insurance paid and what they paid. That got us around the deductible and co-pay conundrum.

Lisa Aliferis is a health editor and blogger for KQED in northern California. Her news organization is collaborating with two others to shed light on health care costs. She contributed to a tip sheet about reporting on health care costs.

If you were doing a small project on price comparison in your area, what procedures, treatments or tests would you focus on? – Lisa Aliferis

Pick very specific tests or procedures that are widely used to easily enable an apples-to-apples comparison. This is more difficult than it sounds, since even "screening mammogram" can have a handful of different CPT codes. Lower back MRI was a good choice for us: very specific, we could easily pick one CPT code.

Lisa Aliferis is a health editor and blogger for KQED in northern California. Her news organization is collaborating with two others to shed light on health care costs. She contributed to a tip sheet about reporting on health care costs.

What's the first step in understanding the impact of Medicaid expansion on your local hospitals? – Stephanie Innes

Check with the state hospital association because they collect financial data, ask them about uncompensated care, and make sure to ask for their definition of uncompensated care. Get to know the hospital's chief financial officer and ask for a meeting. It builds trust and they are often more willing to share preliminary data.

Stephanie Innes is a medical reporter at the Arizona Daily Star in Tucson. She recently used data from the state’s hospital industry to report on uncompensated care (both bad debt and uncompensated care) and the hospitals’ bottom line.

How did you coordinate and manage the reporting among a group working together? – Laura Ungar


Laura Ungar

My advice to other journalists considering a similar endeavor is to stay in close contact with others on the team throughout the reporting and writing processes. One danger of a big team is duplication of effort, but one big advantage is that you can saturate an area quickly and cover a complex issue in a deep way without spending months. We joked that we could write a book on the ACA in Appalachia given all that we found.

Laura Ungar (@lauraungarcj) was part of a team project of USA Today and The Courier-Journal that looked at how the Affordable Care Act is being implemented in Kentucky. She has been The (Louisville, Ky.) Courier-Journal's medical writer since 2004 and a reporter since 1990.

What are the journalistic red flags with epidemiology statistics? – Alex Wayne

Alex Wayne
Alex Wayne

Journalists should be very careful with epidemiology statistics – in particular, prevalence.

To use one very controversial example, the prevalence of autism spectrum disorders has increased from 1 in 150 children a decade ago to 1 in 88 now, according to the CDC. That statistic doesn't tell us whether the condition is more common than it was a decade ago, only that it is more frequently diagnosed. (Which may be the result of better screening and an expanding definition of ASD, not higher incidence.)

Alex Wayne (@aawayne) writes about health care policy for Bloomberg News.

You used to work in a large newsroom; how do you find "colleagues" now that you are at a small online news outlet? – Katie Kerwin McCrimmon

Katie-McCrimmon
Katie Kerwin McCrimmon

"The conversations through the AHCJ list are akin to strolling through the newsroom except everyone in our online community knows my beat inside and out. I get great ideas, tips for good sources and links to illuminating stories. I also really like AHCJ's relatively new tool to track hospital errors at www.HospitalInspections.org. It's great for me to get specific ideas for how I can easily and quickly use data and public records to better cover health issues at the state level."

Katie Kerwin McCrimmon is the senior writer for Health News Colorado. Prior to specializing in health reporting, McCrimmon worked as an award-winning reporter for the Rocky Mountain News. McCrimmon was the primary writer for a team of reporters who were finalists for the 1995 Pulitzer Prize for spot news coverage of a devastating Colorado wild fire.

Where's the best way to find out the best health spending trends? – Alex Wayne

Alex Wayne
Alex Wayne

The first place I turn is the National Health Expenditure data compiled by the Office of the Actuary at the Centers for Medicare and Medicaid Services.

I particularly appreciate that their projections include a hypothetical set of data that assume the Affordable Care Act doesn't exist. (Table 2a)

Alex Wayne (@aawayne) writes about health care policy for Bloomberg News.

What do we know about the number of people who have been told their plans will be canceled AND who can't get a better deal on the exchanges or with a new carrier? – Alex Wayne

Alex Wayne
Alex Wayne

All we have is estimates of the number of people who've received cancellation letters – 1 to 5 million, according to Goldman Sachs.

Beyond anecdote, there's no data on how many people are actually in the position of having to pay more money for the same or lesser coverage.

Alex Wayne (@aawayne) writes about health care policy for Bloomberg News.

How do you find younger/healthier people who are in the individual market to get their perspective on health reform? – Jason Hidalgo

I usually have the best luck finding them at the local university (I just walk around and ask students if they or someone they know experienced whatever it is I’m writing about). If you’re in a time crunch like I was (I had to find sources within two days pretty much), an online “shoutout” can do the trick. In my case, I just had our online folks run a small post on our website that I was looking for uninsured people who want to talk about their experiences as well as in our newspaper’s Facebook page. The Facebook post was especially productive.

Jason Hidalgo, a business reporter at the Reno (Nev.) Gazette-Journal, recently wrote an extensive series of stories about the Affordable Care Act. He is a 2013-14 Regional Health Journalism Fellow and attended Health Journalism 2013 on an AHCJ-Healthier Beat Fellowship.

What antenna go up when you see a press release about a study with remarkable findings? – Markian Hawryluk

Never trust the press release about a study. If they’re to be believed, we’ve cured cancer, Alzheimer’s and the common cold. Get the study and read it for yourself.

Markian Hawryluk is a health reporter with The Bend (Ore.) Bulletin. He spent 15 years as a health policy reporter in Washington, D.C., writing for trade publications. He has won multiple awards for his health reporting, including the Bruce Baer Award, Oregon’s top prize for investigative journalism. Last year, he was a Knight-Wallace Fellow at the University of Michigan and this year is a member of AHCJ’s 2013-14 class of Regional Health Journalism Fellows. He recently reported on a local clinic that decided to kick out the drug reps – and how it changed their practice of medicine.

How did you use social media to find sources without engaging in the political discourse around this topic? – Jason Hidalgo

What we did was not even mention “ACA” or “Obamacare” in the shout out to minimize the political feedback. We just asked people if they wanted to talk about their experience with being uninsured and being served a large medical bill, since such experiences affect everyone regardless of their politics. One of the guys I interviewed, for example, is a Republican and he ended up making some really poignant comments in one of the videos we did. He was even surprised when I told him how much he would pay under the law and said the ACA is a lot better than he thought.

Jason Hidalgo, a business reporter at the Reno (Nev.) Gazette-Journal, recently wrote an extensive series of stories about the Affordable Care Act. He is a 2013-14 Regional Health Journalism Fellow and attended Health Journalism 2013 on an AHCJ-Healthier Beat Fellowship.

How do you get good quotes from sources? – Tom Wilemon

Do not let the fact that people know little or nothing about the Affordable Care Act get in the way of putting their voices in your news coverage.  The people who do know about the federal health law rarely give good quotes. My favorite quote came from an uninsured woman who simply said, “I eat aspirin.”

Tom Wilemon is a health reporter at The Tennessean in Nashville. He recently wrote a series of articles showing how the Affordable Care Act would affect various groups of people. Wilemon was a 2012-13 AHCJ Regional Health Journalism Fellow.

There’s more and more data available to health care reporters but it can be daunting for people who aren’t used to it. What advice do you have for reporters who want to do more data-driven reporting but aren’t sure where to start? – Marshall Allen

Marshall Allen

I would recommend starting with the tutorial by Jeff Porter on the AHCJ website to learn the basics of using Microsoft Excel and the other instructions on the AHCJ site. I’ve always been fortunate to work on stories with other reporters who are data specialists, but an alternative is to join the NICAR listserve to get help with questions.

As you’re looking at any “findings,” realize that they can be factually accurate and still tell the wrong story. The data is really just a starting point for traditional on the ground reporting, which is where the story gets fleshed out and any findings can be better interpreted.

Marshall Allen is a reporter for ProPublica.

National medical groups often put out policy statements – but how does that filter down to their members at the community level? – David Pittman

David Pittman

Remember that rank-and-file doctors may not always agree with policy positions of their professional organizations (like the American Medical Association, American Academy of Family Physicians, etc.).

Talk to doctors beyond the leadership of these organizations for their perspective on important topics such as delivery system reform, scope-of-practice laws, and other topics.

David Pittman is a Washington correspondent for MedPage Today.

What's one of the big things our readers/viewers need to be reminded of? – Mary Shedden

Mary SheddenI’m always surprised how many readers don’t know what parts of the Affordable Care Act affect them directly. And we journalists get so caught up in the politics of health care reform we sometimes forget to include in our stories the context they need.

I think it’s more important than ever that we explain clearly and plainly to our audience exactly who is affected by the changes coming January 1 and how.

For example, the number of uninsured Americans potentially affected by Medicaid expansion or the health exchanges is much smaller than those who have employer-based health plans. The U.S. Census in September said 15.7 percent of Americans are uninsured; while 55.1 percent had employer-based coverage. (This link alone includes a wealth of potentially meaningful local stories). 

I need to make sure my audience always knows which group it is where they belong.

Mary Shedden is a reporter for The Tampa Tribune/TBO.com

How do you get context in covering health law implementation in your state? – Andrew Kitchenman

Andrew KitchenmanIt's helpful to hear what the national experts have to say, and get perspective on what's going on in other states. When I went to the AHCJ13 conference in Boston, it was particularly useful to learn about how states will be doing outreach before enrollment starts in October.

Andrew Kitchenman is a health care writer for New Jersey Spotlight.

When you started the health beat at the Victoria (Texas) Advocate, what was the first call you made? – Keldy Ortiz

Keldy OrtizThe first call I actually made was to a local primary care doctor, who was willing to take time out of his day to speak with me.

I made that call because I wanted to understand what were the types of things health-wise that were common when it came to seeing patients in the area.

Keldy Ortiz is a health reporter at the Victoria (Texas) Advocate.

As a Twitter newbie, how did you figure out who to follow for good health reform information on Twitter (besides fellow AHCJ members)? – Kevin McDermott

Kevin McDermottA good way to separate the wheat from the chaff on Twitter is from a modified form of networking. Find people on Twitter whose input you trust or comments you admire and find out who they follow. There is still a lot of trial and error involved, but this type of networking can take you down some paths you may not have ventured down otherwise.

Kevin McDermott is a writer, editor and content analyst living in the Washington, D.C., area and working on health care topics from quality improvement to patient-centered outcomes.

How do you find uninsured and underinsured people so you can have their voice and experience in your stories, even when you are on deadline? – Stacey Singer

Stacey SingerI try to build up a list of people with insurance challenges that I can go back to from time to time. I stop by free health fairs and speak to as many people as possible, asking if I can follow up later. I also check with the Federally Qualified Health Centers and similar community clinics, as they always want this story told and are usually very helpful connecting me to patients.

I have had great luck by driving to the warehouse district in my community where many small businesses are and simply knocking on doors. These business owners have had the toughest time finding affordable insurance and I've found they are eager to speak about their difficulties. Advocacy groups can be helpful in a pinch. By having a good list of people to go back to, I have been able to turn much richer stories on deadline. 

Stacey Singer is a health reporter at The Palm Beach (Fla.) Post.

What do you do when you have no idea how to start a story? – Rochelle Sharp

Rochelle Sharp

Interview yourself. Ask yourself what is the essence of the story? Try to express the focus of your story in just a few words. Also, you may try to draft five potential ledes as fast as you can and see what emerges.

Rochelle Sharpe is a freelance writer in Brookline, Mass. She has worked as a staff writer for The Wall Street Journal, Business Week and USA Today and is a Pulitzer Prize winner. She has been named a 2012–13 Knight Science Journalism Fellow.

How do you find story ideas and how do you manage daily stories with longer-term reporting? – John Lundy

John Lundy

In the year that I've been on the health beat, I've become a regular scanner of nursing home reports. I've also learned how to "feed the beast" – do daily stories that can be done in the least amount of time but with integrity – and that allows more time to work on projects.

John Lundy is a health care reporter for the Duluth (Minn.) News Tribune. He was a 2011-12 AHCJ Regional Health Journalism Program fellow.

How do you find sources for stories? – Tony Leys

Tony Leys

Don’t be afraid to ask people about their health conditions. They love to talk.

“Find out when “pie day” is at the senior center. You’ll find lots of people to interview!.”

Tony Leys is a reporter at the Des Moines Register and he was a 2011-12 Regional Health Journalism Fellow.

How do you cover reform in a place like Seattle? – Joanne Silberner

Sept. 1, 2011Joanne Silberner
Covering health reform in the great Pacific Northwest isn’t the easiest thing to do – there’s a pretty high level of apathy here. Maybe that’s explained by the relatively low incidence of adult uninsurance – 13 percent (which puts the state at 37th) and for children under 18 it’s 5 percent, for a state ranking of 46.

Or maybe it’s that people have other things on their minds. As a newcomer to Washington, I’ve been surprised to find that when people ask you what you do, they’re not asking about your job. They want to know what you do for outdoor exercise – do you hike or canoe or kayak? With a state ranking of 47 for adult physical inactivity, the average Washingtonian may be just too busy to sit home and contemplate health care issues. Or they may feel like everything’s under control. The governor signed a law setting up the exchange in May; the state has a $1 million grant from the federal government to plan the exchange and $23 million to establish it.

The very excellent local media, which include The Seattle Times, the all-web Seattle Post-Intelligencer, a very thorough hyperlocal website called Crosscurrent (“News of the Great Nearby”), and some pretty evolved television stations, don’t bother with the new health law all that much.

It’s not that people in Seattle aren’t interested in what’s going on. But the talk here is all about plans for replacing an elevated highway that engineers swear will go down in the next earthquake, which is due soon.

So how do you cover health insurance in a place like this? Seattle citizens have a pretty big sense of “otherness” – you could play on that with a comparison to, say, Florida (and who knows, maybe your editor will send you to Florida during the dark and grey Seattle winter!). And analogies are always a good choice. Years ago I did a radio story on the Clinton-era health insurance exchanges by taking my editor to a store and making him decide – out loud – which type of cookie he wanted from among the many on the shelf. The Pepperidge Farm cookies were more expensive, the Little Debbies were plain and familiar – all the products had passed some kind of government inspection and the store manager only carried products he thought would sell. Sound familiar?

Joanne Silberner is an independent journalist based in Seattle. She covered consumer health at U.S. News & World Report, followed by 18 years at NPR as a health policy correspondent. She has a part-time position as artist in residence in the University of Washington's Department of Communication and hopes to contribute to radio programs.

What's next for covering health reform? – Jim Landers

March 25, 2010
Jim LandersThe thing most people will want to know about this bill, and its local dimension, is the impact on insurance coverage who now gets in, who stays out – and what the local "charity" hospitals think will happen to their patient loads in the ER.

The hospital is the easy bit. On the insured, reporters can try the usual suspects (Kaiser, Commonwealth) along with a couple more in our backyard, Milliman and MHBT. Anyone with a college in town could also get a quick hit about the provision allowing parents to keep their children on their insurance out to age 26.

Stories about paying for it are murkier. There are sources to go to about high-cost hospital care (Dartmouth Atlas especially), along with a new Milliman study.

The bill has lots of stuff about gradual improvements in these. The most evident are the promises by hospitals and pharma to forego $155 billion and $80 billion. There are also the health IT efforts that everybody is pursuing.

The story on a quick turnaround, however, would be to question the high-cost hospitals (see American Hospital Directory for the retail prices) about why that is, and what they're doing about it in light of the legislation. Hospitals are big targets, and someone should always be available to talk.

Jim Landers covers business and international affairs stories from Washington, D.C., for The Dallas Morning News. He writes "Worldview," a column published in the Business News section of The Dallas Morning News. He has worked in Montana, New Jersey, Richmond, Va., and the Washington, D.C., suburbs.

Relevant stories
No country has perfect system, but there are lessons to learn, Sept. 22, 2009
Health bill won't insure us from mounting deficit, Oct. 20, 2009
Congress or no Congress, change is ahead for health care, Jan. 26, 2010

What's next for covering health reform? – Noam Levey

March 25, 2010

Noam LeveyNoam N. Levey covers health care policy for the Los Angeles Times/Tribune Washington bureau. Levey grew up in Boston, where his father was a doctor, and earned a degree from Princeton University in Middle Eastern history. He has written for newspapers in the Persian Gulf, Midwest and California. Since 2003, he has been a staff writer for the Los Angeles Times, covering City Hall, Capitol Hill and most recently, the 2008 presidential election. Levey was a panelist on the Talking Health webcast about insurance on May 1, 2009.

Relevant stories

Here are some stories you want to consider on a local level:

Insurance premiums aren't likely to come down any time soon. Tracking what local insurers are doing, especially before a new regulatory regime is put in place would be worthwhile. Look for the kind of gaming that drug companies are accused of doing this year to boost prices. Tracking premiums in the individual market is very difficult, but it is worth checking with your state insurance commissioner, as many at least require insurance companies to report premium increases. Kaiser Family Foundation maintains good data on what is happening in the large group market. And many larger states have consumer advocacy groups that can be helpful.

The bill would create a high-risk pool to help people before exchanges start up in 2014. But these have a checkered history in states nationwide in terms of expanding access in an affordable way. Could be interesting to look at what has happened with local plans and who will be signing up for them immediately. A good source on what has happened with these is Eliza Navarro Bangit at Georgetown. The consumer group Families USA, which maintains an excellent story bank of individuals who have struggled with the healthcare system, could be a good resource to find people who have used high risk pools or been forced to drop them because they are so expensive.

The red state rebellion against health reform in states like Idaho and Virginia has more life. Some Republican state officials are already talking about suing to challenge the insurance mandate in the bill. This will get the bulk of the attention. But it is also worth looking at the capacity and the willingness of state/local government leaders to take on the new responsibilities under the health legislation. A lot depends on what states rather than federal government will do. The Kaiser Family Foundation summary of the legislation contains good information on the responsibilities of state governments. The National Conference of State Legislatures, the National Governors Association and the National Association of Insurance Commissioners have information on what individual states are doing now to regulate healthcare, which may provide a good guide about their capacity to do more.

House reconciliation package promises aid to boost pay for primary care docs treating Medicaid patients, but will this be enough in states where doctors have already fled the Medicaid system?

Doctor shortages in Massachusetts have complicated that state's attempt to move toward universal coverage. Healthcare legislation seeks to address this with new incentives, but will that happen fast enough, especially in parts of the country that don't have nearly the number of doctors that Massachusetts had?

What's next for covering health reform? – Trudy Lieberman

Trudy LiebermanTrudy Lieberman is the director of the health and medicine reporting program at the CUNY Graduate School of Journalism. She is a contributing editor for Columbia Journalism Review where she writes about health care and the media for the "Campaign Desk blog." She is a contributor to The Nation and the author of several books. Lieberman has won numerous awards for her reporting including two National Magazine Awards. She also was a Fulbright Scholar to Japan and a John J. McCloy fellow to Germany to study health care in those countries. She is immediate past president of the AHCJ board of directors.

Relevant work for CJR.org

March 25, 2010
The affordability issues tucked into the health reform law cry out for exploration. Through this whole debate, people have been told that they would get subsidies to help them buy coverage, but all the nuances of those subsidies available through the state exchanges, or shopping services, and the amounts people will actually pay out of pocket have barely been discussed. Some readers, viewers and listeners will be in for a big surprise. They may have to decide between buying subsidized insurance with a hefty out-of-pocket outlay for premiums along with high deductibles – perhaps as high as $4,000 – or taking a tax penalty that will be a smaller hit on the family purse.

Subsidies are based on family income; those at the low end of the income spectrum will get more help than those with an income of $88,000, the upper limit for government help. Families with middling incomes will find themselves paying nearly 10 percent of their income on a policy with the government paying the rest. So a family making $66,000 would spend $6,257 for a policy that may cover only 70 percent of their medical expenses, on top of the deductible.

These insurance-buying dilemmas will make interesting and readable stories. Plus they will also get at the question of how well the law is working and whether people are really getting coverage. That, after all, was the central goal of the law. How are families going to make choices? Where will insurance actually fit in?

Reporters could begin this story by looking at what's happening in Massachusetts. Many people there have dropped their coverage because of affordability problems and have taken the penalty. Since the Massachusetts reform law is the model for the national legislation, it's worth looking at what people are actually buying through the state's Connector; if they are buying at all. Almost half are choosing the lowest cost, bronze policy with its smaller benefit package. We need to keep tabs on whether consumers in other states will also flock to the low-cost bronze policy mandated by the law, which will cover only 60 percent of the benefits.

For help understanding how all the elements of a policy fit together, including the out-of-pocket limits specified in the law, I recommend working with health insurance actuaries such as those who work for the actuarial firm Milliman. Through the years I have found actuaries indispensable in helping me understand the ins and outs of insurance. Many can translate complex concepts into plain English for reporters and their audiences and can help untangle your prose when you get stuck.

Reporters may want to keep an eye on how insurance companies will try to get around the ban on pre-existing conditions. If they must cover sick people with all their expensive ailments, they will somehow have to bring money in the door to pay all those claims and make a profit on the side. What proxies for medical underwriting will they use? The new law sanctions age rating; in other words, looking at age in determining how much someone pays. While checking out Massachusetts, find out how older people, especially older women, are faring. In that state, insurers can charge an older person twice as much as a younger one for the same coverage in the same geographic area. Sometimes they must pay several hundred dollars more, making insurance unaffordable. Under the new law, insurers can charge three times more. While gender rating; that is, charging women more than men, will not be permitted, women who work for large companies with a predominantly female workforce can be charged higher rates until 2017.

Another story on the affordability beat will be employer wellness programs. HIPAA regulations allow employers to create wellness programs based on health factors. Workers who hit targets like having blood pressure readings below a certain number might get a discount on their premiums. But the value of the rewards can be no greater than 20 percent of the combined premium paid by the employer and employee. Workers who don't meet the targets could pay higher premiums. The new law allows employers to offer a higher reward to "good" workers, up to 30 percent of the combined premiums. The secretary of the Department of Health and Human Services can increase it to 50 percent. Employers argued for flexibility.

There are lots of stories here – equity and fairness issues, whether it's impossible for some workers to hit their employers' targets because of medical reasons, employment discrimination, backdoor underwriting by insurance companies. This story can be done in any community.

Check with business associations like the Chamber of Commerce, local business coalitions like the New York Business Group on Health and the National Business Group on Health for leads. Or you might try old-fashioned shoe leather reporting. Start calling businesses in your community and ask whether they are starting wellness program and then find out how they work. Follow-up stories and monitoring are important here.

For background on whether wellness programs work at all and what kinds might be more effective than others, do a literature search and scour journals like Health Affairs (AHCJ members get free access). This story needs a lot of context and the jury is still out.

What's next for covering health reform? – Laura Meckler

Laura MecklerLaura Meckler is a staff reporter for The Wall Street Journal, based in Washington, D.C., where she covers the White House with a focus on domestic policy. She came to the Journal from The Associated Press Washington bureau, where she covered health care, social policy and politics. Before that, she covered state government in Columbus, Ohio. She was a Nieman fellow at Harvard University in 2003-04, and in 1999, she won the Livingston Award for National Reporting, a prize given to journalists under age 35, for her coverage of organ donation and transplantation issues.

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March 25, 2010
Implementing the program:
States will be responsible for setting up exchanges where people can buy coverage starting in 2014. What does your state need to do to get ready for this?

Enrollment: Medicaid, the health program for the poor, generally has a very poor track record of getting all the people who are eligible for coverage enrolled. This will also be a challenge with the expanded program that kicks in 2014. How well has your state done in reaching out to eligible families in past years? If the state has a poor track record, what - if anything - are officials and activists considering to do a better job with this next, much bigger and more complicated, round?

Community health centers: One of the underpublicized provisions of the new law would give a lot more money to nonprofit community health centers. Look at one of these centers to show how they are providing front-line care, and investigate whether they are likely to see more funding.

Small business: Many small businesses have opposed the bill, but they are eligible for tax credits if they offer insurance this year. Look at a small business that is eligible and see if they plan to offer coverage.

Medicare cuts: The health bill cuts Medicare reimbursement rates for many health care providers. One worth looking at is Medicare Advantage, the private managed care program that is offered in some parts of the country. Experts say these plans are, on average, overpaid by about 14 percent, and their rates will be cut by the new law starting next year. Insurers predict this will prompt companies to pull out of certain communities where it is more expensive to provide care. Is yours one of them?

20-somethings: Find some 20-somethings who will be newly subject to the individual mandate (starting in 2014) and see what they think. Are they resentful that they will have to buy insurance, or excited that they may get help paying premiums?

Legal challenges: More than a dozen states are challenging the new law, saying it's unconstitutional to require people to buy insurance. If your state is one of them, look at the political dynamics that prompted such a suit, as well as perhaps local views about whether it might succeed. National experts are generally skeptical that these suits will succeed in the courtroom, but they may succeed in getting a lot of press for the people who file them.