By Trudy Lieberman, AHCJ president
From the Winter 2008 issue of HealthBeat
Recently a Nevada nurse told The New York Times that she thought Hillary Clinton was "trying to bring in a socialistic health care system which would probably bankrupt the country." She was wrong, of course. Clinton's proposed health care plan calls for an individual mandate that would require people to buy their own coverage from the nation's private insurers. Her plan is hardly social insurance like Medicare where everyone pays into a national system through a combination of taxes and premiums, everyone is entitled to benefits, and costs and risks are spread over a huge pool of people.
The nurse's comment was striking not only because it was incorrect and misleading but also because it raises a significant issue for our members: the use and misuse of the language about health care. "Socialized medicine" is the granddaddy of such of terms. It has such a deep, negative connotation that even 20-year-olds believe it's a bad thing, even though the term surfaced in 1948 when the Truman administration tried to enact a national health insurance plan – long before they were born.
But the health care vocabulary of this campaign extends beyond the term "socialized medicine." Candidates throw around words like "universal," "comprehensive," "guaranteed," "mandate," "coverage," "care" and "choice." Journalists pick up these terms, weave them in their stories, and telegraph a meaning that politicians want, although it may not be the same as the one in the dictionary.
Take the word "universal," for example, which means all or the whole without limitations or exclusions. In other countries, universal means that all citizens are entitled to health care as a matter of right. They pay into their national systems and have a right to receive care. In the vernacular of the U.S. campaign, "universal" has come to mean a plan that will force people to buy insurance. The more people who buy, under threat of penalty if they don't, the more universal is the plan. Presidential contenders are trying to make the meaning of universal fit their brand of reform even though it's unlikely that any of their approaches will provide everyone with health insurance. As in Massachusetts, where politicos have been touting the universality of the state's plan, some percentage of the uninsured will always be excluded.
"Guaranteed" is another of those terms that has a different meaning in other countries. Citizens are guaranteed access to health care. No matter who they are or how much money they have, citizens can always get care with a standard set of benefits. In campaign speeches, "guaranteed" does not appear to mean automatic access. Candidates seem to say it means that private insurance companies must take everyone on as a customer regardless of any health problems they may have.The question we need to ask is how are candidates going to make them do that?
Any reporter who has written about health insurance knows that companies, especially in the individual market, are choosy about whom they will insure. Even companies that say they support proposals requiring them to be less picky tell me that there are ways to cover sick people, but policies will give them less coverage or make them pay more. The meaning of "guarantee" becomes slippery.
The word "guaranteed" is also related to the terms "care" and "coverage," and candidates use them interchangeably. Early in the campaign, Clinton said that a goal of her proposal would be "health insurance for every child and universal health care for every American." Now ponder that one. In the United States, insurance coverage is the ticket to care. But even having insurance doesn't necessarily guarantee care. Increasingly, doctors are refusing to treat people who have certain kinds of insurance or insurance from particular carriers.
"Choice" is a term almost as popular as choice itself, a focus-group-tested concept that is often invoked because it plays well in Peoria. But what exactly does it mean other than to convey to voters that a candidate is on their side? Choice of health insurance plans, choice of doctors, choice of treatments, choice of hospitals? Usually that's unclear. Choice may be what people want, but does it mean that Medicare beneficiaries want or need 56 Medicare Advantage plans from which to choose?
Bottom line for us: Let's pin down the candidates and explain what the words mean before we let them get away with a smorgasbord of empty terms. We will better serve our audiences if we do.
Trudy Lieberman is president of the AHCJ board of directors. She is director of the Health and Medicine Reporting Program for the Graduate School of Journalism at City University of New York.
