When it comes to debates over health care policy, there are a number of terms that make veteran reporter Joanne Kenen roll her eyes.
There’s “access,” for example. “Saying you have access doesn’t mean you can really tap into that ‘access,’” says Kenen, executive editor for health at Politico and health reform topic leader for AHCJ. “If I have access to something that costs $25,000, that’s not really access. Who is this protecting and what does this really mean?” In other words, Kenen says, “access means whatever you want it to mean.”
And don’t get Joseph Burns, a Cape Cod-based freelancer and AHCJ health insurance topic leader, started. “The health insurance system is in perhaps the worst shape from a consumer’s point of view that I can ever recall and I’ve covered health care since 1991,” says Burns.
Welcome to debates over health care in 2020.
As our members gear up for coverage of this year’s election, which will no doubt include candidates sparring over health care policy, I thought it would be a good idea to pick the brains of Kenen and Burns, AHCJ’s in-house experts. Here are 10 issues to keep in mind that I took away from those conversations.
It’s really about attitudes on government. “Reporters need to understand that health care is a proxy for how people feel about the role of government – state, federal, local – and the market,” Kenen says. “Because it has been so hyperpoliticized, it has made it extremely difficult, even more than other ideological topics, to move ahead on solving the large problems without constant warfare and litigation.” At the same time, Kenen notes, “we’ve seen bipartisan progress on issues like FDA, drug pricing, public health, and the opioid crisis.”
Affordability is being ignored. “What people really care about is not the politics but whether they can get affordable care,” says Kenen. “Affordability keeps getting punted. Democrats are fighting over what the next step in coverage should look like, but all Democrats envision a larger role for government. Even the moderate Democrat proposals involve more tax dollars. Short-term plans from Republicans are shifting costs to older and sicker people. Neither one is really getting at the underlying costs of health care because it’s really, really hard.”
Surprise bill legislation is good – but don’t let it distract you. The bills “take away an egregious thing but don’t change the fact that health care is 18% of GDP,” Kenen notes. “We don’t know how far they’re going to go on drug prices.”
Who are health insurers, really? “When reporting on the health insurance system, it may be best not to characterize health insurers as private insurance companies,” says Burns. “This issue comes up when critics of Medicare for All or any plan that would harm publicly traded insurance companies is proposed because opponents of such plans characterize health insurance companies as private insurance or private insurers. That makes them sound great when in fact the biggest insurers are publicly traded companies which means that by law they need to serve their shareholders first. Patients are not their primary concern; shareholders are.” Publicly traded insurers “have reported record profits in the past few years,” notes Burns, “while many Americans have found health insurance and health care costs to be unaffordable while those costs have been rising sharply. Some health insurers are nonprofits but that doesn’t mean they don’t make a profit. They are still big companies that pay their executives whopping salaries and charge their members hundreds of dollars each month in premiums.” For those reasons, “it may be more accurate to refer to government-run versus corporate- run insurance,” says Burns.
Watch the non-Medicaid expansion states – and their paradoxical politics. “In states that have not expanded Medicaid, for the haves and have nots, in an era where inequality is part of our political conversation, some have left people without any ability to get coverage,” Kenen says. “And this is also having repercussions on rural providers including but not limited to rural hospitals and safety nets.” Kenen notes that “if you’re in a non-Medicaid expansion state, not only are people in your state not getting insurance coverage, you’re sending dollars to Washington so that people in other states can get covered. Mississippi is a great example, but it’s not just Mississippi. If states say it’s too expensive, there’s a lot of data saying that the federal government picks up 90% of the costs and that there are additional spillover effects.”
The Affordable Care Act is here to stay. “The fight about the ACA, while never over, has tamped down because when the Republican-led Congress got rid of the individual mandate; they got rid of something that among the public, Republicans hated and Democrats, disliked – and removing the mandate reduced some of the intensity about repeal,” Kenen says. “The things that Republican voters like, including coverage of pre-existing conditions and subsidies for the working poor, have been kept. Chances are that unless the court throws the ACA out, which leads to chaos, it is here to stay.” But that doesn’t mean the fights haven’t come at a cost, Burns says: “Since 2019, some 7 million Americans lost their health insurance due to efforts to repeal the Affordable Care Act and other efforts by those who oppose the health insurance reforms of the Obama administration. And [attorneys general] in a number of red states have a lawsuit pending that could further undermine the law and remove the protections Americans have for pre-existing conditions.”
Look beyond blue and red. “There are states, both red and blue that have taken steps to stabilize their markets and prices,” says Kenen. “States as red as Alaska and Oklahoma have tried. Despite all the rhetoric, they have looked at the tools available, ways of strengthening and protecting insurers against highest-cost patients. There is a bit of pragmatism. Is your state looking at the ways of stabilizing the market? If so, why? If not, why not?”
What does “less expensive” mean in terms of insurance plans? “If someone says they’re in favor of a less expensive insurance plan, what does it really cover?” Kenen suggests asking. “What happens if I get sick?”
Campaigning isn’t about details. “Every campaign is going to have a plan,” Kenen says. “They’re going to evolve over the course of the campaign, and they’ll be specific enough to show that they have a plan, but not specific enough to get dinged on details. That doesn’t mean you shouldn’t as a reporter push as best as you can. Just realize you’re not going to succeed.”
Figure out how to localize stories. Kenen tries to end many of her AHCJ blog posts with three or four questions to ask local representatives. When it comes to stories about financial toxicity – a story that came up more than once at the recent AHCJ annual conference in Baltimore – Burns recommends finding consumers “through Facebook, Twitter or through health system PR departments or through doctors’ offices. The PR folks and docs would need to clear your request with each patient, and they may be willing to help because doctors see the effects of financial toxicity, which results from inadequate insurance coverage and high health care costs.” Another way: “Find patients through patient advocacy groups or through nonprofits that promote improvements to the health care system. Patient advocacy organizations may operate in most state or journalists can reach out to members of the Alliance of Professional Health Advocates. The alliance has an electronic discussion list in which journalists can post questions about specific kinds of patients in certain locations. To do so, you’ll need to go through the PR department. Also, try the National Association of Healthcare Advocacy or search for patient advocates in each state.”
There are, of course, lots of great resources on healthjournalism.org, from the topic pages on health reform and insurance edited by Kenen and Burns, respectively, to those on aging, edited by Liz Seegert, and social determinants of health/disparities, edited by Pia Christensen. Find them all on the “Core Topics” menu at healthjournalism.org/core-topics.
Happy reporting. And let us know about stories and broadcasts you’re particularly proud of – we’d love to consider them for a “How I Did It” piece.