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.”
What is the most important thing that reporters digging into rural health should know?
Rural spaces are as varied as urban areas. We wouldn't think to cluster New York City and Des Moines say, in the same category of city because we instinctively understand that these are distinct places with their own culture.
It's the same with rural areas – you have rural agricultural places, manufacturing spaces and places where tourism is the biggest industry.
It's important to understand that rural areas aren't a monolith and treat reporting there with the same curiosity, courtesy and respect that we extend to other stories.
Liora Engel-Smith, currently at North Carolina Health News, has reported on rural health in several states, in very different parts of the country.
You are a radio journalist and now a podcaster. How do you get people to open up in intimate and revealing ways, especially if you’ve just met that person and have a microphone inches from their face?
This question is especially important for radio and podcast reporters where “great tape” (strong soundbites) can sometimes be the difference between a good and great story. Here’s my quick and dirty recipe to build trust quickly:
1) Explain and contextualize your story.
The more intimate the question (end-of-life, poverty, addiction, mental illness) the more important it is to explain why sharing painful details will strengthen your story.
2) Embrace the discomfort
After your source has said something emotionally powerful, there can be a temptation to move to the next topic. Especially if it was hard to ask! Resist. Push. Ask for a few more details. This is particularly important if your journalistic Spidey-sense tells you there’s a richer answer.
3) Watch your source closely.
Is your source fidgeting? Getting angry? Are their answers clipped? If the person you are talking to is upset and fast losing interest in talking, hit the pause button. Check in. Reiterate why your story matters and their involvement is critical.
4) Make yourself vulnerable.
In my experience, it can be much easier for a person to *keep* talking about a painful moment if I share a story about myself at some point in the interview.
Caveat - this is not a moment to stop talking about your source and start talking about yourself. Just an invitation to share a bit, letting your source know you are giving them a piece of you.
What I’ve learned over 20 years is that building trust with your source can first and foremost lead to great tape. It can be cathartic for the person you interview and leave you satisfied that you connected with this person in a unique way. Best of all, when your source hears your piece, they recognize themselves in your work.
Dan Gorenstein is the founder and executive producer of Tradeoffs: A Heath Policy Podcast.
You narrowed your records requests by using key words after looking at the “deliverables” – the goods and services promised in the managed care contracts. How did that work?
We found a lot of our stories in looking at the stuff [reports] that the state received from companies that it had not itself analyzed…Every contract outlines the stuff that has to be delivered back to the state and the intervals that it has to be delivered on… it was easy for us to go in there and see not just what was supposed to be in the various reports, but what the volume was going to be like on them. And that allowed us to find documents that we wouldn’t have otherwise known existed.
Andrew Chavez, along with J. David McSwane, did a prize-winning investigation of Medicaid managed care in Texas for the Dallas Morning News. (Thanks to the Shorenstein Center at the Harvard Kennedy School for letting us reprint and excerpt their interview with the AHCJ and Goldsmith award winners.)
How do you find what’s really important when you have voluminous public records?
Being here in Austin, I’m able to form some connections with state government, and eventually people would guide me toward stuff that made our lives a little bit easier…For instance, we were told to request all email that contained sort of ‘trigger words’ that are really only used in bureaucracy — for instance, ‘member harm’ — and that request ultimately pulled thousands of emails that were directly related to people being hurt as a result of managed care failures or policies or denials.
J. David McSwane, along with Andrew Chavez, did a prize-winning investigation of Medicaid managed care in Texas for the Dallas Morning News. (Thanks to the Shorenstein Center at the Harvard Kennedy School for letting us reprint and excerpt their interview with the AHCJ and Goldsmith award winners.)
After you identify a patient with a story – or that patient comes to you – what’s your first step after the initial interview to verify and understand their complaint or grievance?
Get the paperwork. Some consumers have a lot of documentation, meticulous notes, email. But if they don’t you need that crucial information. I ask the consumer to ask for the records - it’s usually faster than if the reporter makes the request. Start with the bill itself – an itemized bill with a listing of each charge and the medical coding. Then turn to the insurance, starting with the EOB (explanation of benefits).
Chad Terhune (@chadterhune) is a health care investigative reporter with Reuters. As a senior correspondent at Kaiser Health News, he reported on an insured high school teacher hit with a $108,951 bill after a heart attack at age 44. He spent four years covering the business of health care for the Los Angeles Times. Before the Times, he was an award-winning reporter for The Wall Street Journal and Businessweek.
What are some good tools for reporting on rural hospitals, and understanding their financial stresses?
You can pull years of a hospital’s 990 forms – a task that is much easier now with AHCJ’s new website hospitalfinances.org.
In addition many rural hospitals are still county– or locally–owned, with a board of directors made up of local community members and often physicians with local roots. I’ve found they are often very approachable and open – even sometimes letting a reporter visit the facility.
Bram Sable-Smith, until recently the health & wealth reporter at KBIA-Columbia, Mo., and Side Effects Public Media, is starting a freelance career in Madison, Wis.
What’s one thing you learned about covering rural hospitals that reporters might not always think of?
If your local hospital is publicly owned, you can FOIA their management contracts and bank statements. That gives you lots of information about the hospital - and will let you see if anything seems out of the ordinary.
And if your hospital is in a small community, don’t be afraid to reach out to the administrators directly. You might be surprised how willing they’ll be to work with you.
Bram Sable-Smith, until recently the health & wealth reporter at KBIA-Columbia, Mo., and Side Effects Public Media, is starting a freelance career in Madison, Wis.
You invited your radio audience to call in and leave voicemails with their experiences related to your reporting, a series on a local shortage of physicians. How did it work, and how did you engage with those callers and turn their voicemails into usable material?
The first thing we did was to set up a dedicated phone number and run an on-air promo inviting listeners to call in. The response was overwhelming: After running the promo for about three weeks, I ended up with close to 35 voicemails.
What I was less clear on was how to engage with them. So I experimented, initially trying to economize my time and not calling all of them back. For a time, I even considered simply excerpting their voicemails in my pieces, without speaking with them first, and thanking them afterwards. But even though I had made clear this was a possibility in the message I recorded on the tip line, it felt sneaky and insincere.
These listeners had gone out of their way to call and share deeply personal stories – a woman who had difficulty finding an oncologist for her husband who ultimately passed away from lymphoma; another who spent weeks in agony without mood stabilizers for bipolar disorder – and I owed it to them to call them back and listen. It took time, but getting on the phone with each caller was gratifying for me, and seemed to be cathartic for them.
In the end, those calls gave me two main characters,10 voices that I shared in a map of audio stories, and a handful of new story ideas – not to mention a clearer picture of the face of my story.
Kerry Klein, from Valley Public Radio, won first place for Health Policy (small outlet) in AHCJ's Awards for Excellence in Health Care Journalism for her series “Struggling for care,” looking at the physician shortage in California's San Joaquin Valley.
What’s the most important thing you’ve learned about how to localize a national health policy story for your community?
Speak to local experts. For me that includes lawyers who are handling cases in national health care policy for local clientele.
These people are incredibly knowledgeable about national health matters and, for my publication at least, are always willing to localize many national stories.
Tyler Patchen is a reporter who covers health care for the Birmingham Business Journal.
You’ve been covering health policy in Tallahassee for a few months. What’s the one thing about your beat that you know now that you wished you knew earlier?
Read the actual bills!
You can't always trust the lawmakers to get it right when you talk to them about their legislation, and sometimes staff analyses have errors. You have to check the text for yourself.
Elizabeth Koh (@elizabethrkoh) is a state government reporter for the Miami Herald/Tampa Bay Times’ Tallahassee bureau, a merged operation between the two papers. Naturally, covering the legislature means covering health care.
You've been writing about wealthy hospitals and their relationship to poor neighborhoods around them, with high disease burdens. A recent piece looked at asthma. Why did you choose this condition to illustrate this point?
Asthma is ubiquitous in low-income neighborhoods. It’s relatively easy to track in the data and the case for prevention is so compelling.
Asthma flares are very costly. ER treatment is $800 or so. Typical admission is $8,000. That doesn’t count the very high cost of kids missing school, parents missing work to take care of sick kids etc.
Contrast that with the low cost of prevention – meds training from a community health worker, a few hundred dollars for filters and mattress covers or a few thousand dollars to fix a leaky roof.
Hospitals don’t need to invent new technology or hire expensive experts to lower asthma admissions. They know what to do.
The gap between the high cost of illness and the low cost of prevention sort of screamed out as a telling example of health system failure.
Rachel Bluth (@RachelHBluth) is a reporter and the Peggy Girshman Fellow at Kaiser Health News. She recently earned her master’s from the Philip Merrill College of Journalism at the University of Maryland where she reported on health disparities in Baltimore, and her work was published on NPR.org and PBS.org. She was previously the lead political correspondent for the Annapolis Bureau of Capital News Service.
Jay Hancock (@JayHancock1) joined Kaiser Health News in 2012 from the Baltimore Sun, where he wrote a column on business and finance. Previously he covered the State Department and the economics beat for the Sun and health care for The Virginian-Pilot of Norfolk and the Daily Press of Newport News.
You recently traveled to Tennessee to report on the Tennessee Farm Bureau, which doesn't comply with Affordable Care Act rules. What source did you find unexpectedly helpful?
We sometimes forget how well they know their state's market – and what people needing insurance are looking for in a plan. And they are often willing to talk.
Erin Mershon is a Washington, D.C., correspondent for Stat News. She has covered health policy for Politico and Congressional Quarterly. During her yearlong Health Care Performance fellowship from the Association of Health Care Journalists, she reported several feature stories on the impact of the Affordable Care Act in rural areas, including this story on Tennessee Farm Bureau Insurance – an established health plan that is exempt from Affordable Care Act rules and standards. It gives some hints about what health insurance could look like under President Donald Trump’s executive order – a system that could lead to two parallel insurance markets – one where plans follow ACA rules and accept everyone, and one where the plans may be more affordable for people who are healthy but may not be available to those who are not.
How did you move from writing up a short story about an academic study to a deep dive into surprise bills for patients getting emergency care at in-network hospitals?
In February, I heard about a biennial study on hospitals with out-of-network ER doctors. I almost didn’t write it because I was busy. But it was 300 hospitals and that number seemed huge so I did a quick bottom-of-the-business page story. By noon the next day I had at least 50 emails and calls from readers who said it happened to them. I decided to dig deeper than the usual doctor vs. insurance company excuse, figuring there must be some financial reason. I looked for a pattern of hospital or insurer and found none. It was happening most everywhere. The only thread was it happening to patients who, despite being diligent about going to in-network hospitals, were still getting balance billed. It became clear that it was because they were not able to check doctor status. The turning point was when I was slipped the investor analysis which suggested it could be a business model – with more profit by intentionally staying out of network.
Elisabeth Rosenthal, M.D., was for 22 years a reporter, correspondent, and senior writer at The New York Times before becoming the editor in chief of Kaiser Health News. Her recently released book, "An American Sickness," is a New York Times bestseller. She trained in internal medicine and has worked as an emergency room physician. She lives in New York City and Washington, D.C.
How do you learn the nitty gritty of health care as it plays out in your community – especially if you aren’t in a big city?
Ask! Don’t be afraid to ask the providers for their time. They are passionate about what they do, and they want to share. They’ll be happy to talk to you, especially if you are willing to work around their schedules.
Michaela Morris is the health reporter for the Northeast Mississippi Daily Journal.
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?
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?
It 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?
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?
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.
Where can a reporter find current financial information about not-for-profit hospitals’ community benefits?
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?
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?
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?
Yes. 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?
What's a good starting point when you are looking for sources on a new topic or aspect of the beat?
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?
We asked people to share what their insurance paid and what they paid. That got us around the deductible and co-pay conundrum.
If you were doing a small project on price comparison in your area, what procedures, treatments or tests would you focus on?
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.
What's the first step in understanding the impact of Medicaid expansion on your local hospitals?
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?
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.
What are the journalistic red flags with epidemiology statistics?
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
"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?
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?
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?
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.
What antenna go up when you see a press release about a study with remarkable findings?
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?
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.
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.”
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?
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.
What's one of the big things our readers/viewers need to be reminded of?
I’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.
How do you get context in covering health law implementation in your state?
It'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.
When you started the health beat at the Victoria (Texas) Advocate, what was the first call you made?
The 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)?
A 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?
I 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?
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?
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.
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?
Sept. 2011 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?
March 2010 The 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.
Noam 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.
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 Liebermanis 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.
March 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 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.
March 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.