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Reporter discusses what fueled her Medicaid reporting Date: 10/03/16

Maggie Clark

By Mary Otto

Reporters can find it daunting to cover Medicaid, the huge state-administered federal program charged with providing health care benefits to more than 70 million Americans.

Maggie Clark embraced the challenge. In recent months, her Two Million Kids series for the Sarasota Herald-Tribune has delved into many aspects of Florida’s troubled Medicaid system. Stories have explored the shortage of preventive and specialty care (particularly the formidable barriers faced by poor patients in accessing dental services), the struggles faced by health care providers who work with the program and the long history of efforts to reform the state’s system.

Clark’s multi-faceted project also has featured interactive graphics, unique outreach efforts and partnerships with a range of community, media and health care organizations.

A tip sheet she created for AHCJ members last month provides a good template for investigating Medicaid dental care for children in your state. Now, in this new Q and A, Clark explains how a fellowship helped to get the project off the ground and how she and her editors worked together to plan and structure the series. She also discusses lessons learned, including tips on how she sold her bosses on taking on this major project.

Q: Your “Two Million Kids” series was reported with support from the Dennis A. Hunt Fund for Health Journalism and the National Health Journalism Fellowship program, which is based at the University of Southern California’s Annenberg Center for Health Journalism. How did this assistance help you launch this project?

A: Applying for the fellowship required me to do enough pre-reporting to pitch a compelling story, including identifying the data and starting some of the analysis I would need to prove my findings. This meant I also had enough information to sell my newsroom on investing in the project – whether I was accepted into the program or not.

Once I was accepted, the fellowship connected me with a projects editor, Diana Sugg, and a community engagement editor, Cole Goins, who were invaluable resources throughout the reporting and writing process. They offered insights that helped both me and my editors in Sarasota elevate the project to have statewide impact.

Q: With so much to say about Medicaid, how did you choose your angles and manage to keep the Two Million Kids project under control?

A: Among the first things my editors and I did when planning this project was identify our goals, which were to 1) raise awareness of the Medicaid program; 2) expose the system and the politics behind it; 3) identify solutions; and 4) develop tools to help parents and the public navigate the Medicaid maze. Every story or tool we developed had to meet one of these goals.

Jennifer tries to pay bills and go through some paperwork while her son, David, 2, competes for her attention. (Photo: Rachel S. O'Hara/Sarasota Herald-Tribune)

We also decided to make parents of Medicaid-enrolled children a key audience for the series. That decision came after lots of time spent listening to parent stories, and hearing the same themes over and over again – no doctors willing to accept Medicaid insurance, discriminatory treatment, confusing instructions from the health plans and state regulators and their general feeling of helplessness.

We realized that if the parents did not understand how to navigate the system and advocate for their children, no amount of systemic reforms would make a difference. Looking at the system this way we saw how, in many cases, the system had been designed to thwart access and confuse parents, rather than create a user-friendly experience. Ultimately, that meant that kids were going without care. Those findings inspired the first two stories in the series, which focused on parents trying to navigate the system.

For our general audience, we first needed to educate them that this system was out there, how big it is and all the ways it affects their lives. For instance, Medicaid covers nearly half of all Florida children, so if those children are missing school because their health needs aren’t being met, they’re falling behind in school and may not graduate, making it more likely they’ll need to rely on public assistance in the future.

We also wanted to expose the privatization of the Medicaid system, which happened slowly over the last decade. It has been enriching private insurance companies at the expense of children’s health.

In addition to sharing parents’ stories, we wanted stories that the paper’s largely retired and wealthy readership could relate to. That included an in-depth look at a Sarasota pediatric office that was struggling to keep its doors open as Medicaid reimbursements continue to decline. In it, we introduced readers to Dr. Carola Fleener, a 67-year-old pediatrician.

Through her practice, we explored the business of Medicaid and the difficult choices physicians face when forced to decide between treating a sick child and keeping their practices profitable. This story struck a chord with our wealthier retired readers, who could sympathize with a small business owner watching her retirement savings slip away.

To keep these project from being too overwhelming, we used multiple story formats and kept each story as narrow as possible. I used sidebars, timelines, profiles, interactive graphics and data visualizations to give readers different points of entry to the story. We tried to keep my larger stories focused on a particular issue.

Q: Your work on the series has reached beyond the pages of your newspaper. You collaborated with a local radio program and nonprofits and also appeared at a Children’s Week health fair. How did these activities fit in with your more traditional reporting work?

A: As I mentioned before, we started out with slightly unconventional goals for this project, including a high priority on community engagement in both the reporting and rollout of the project. The idea to take the stories on the road came from my community engagement editor, Cole Goins.

Our first stories published in January 2016, just after the start of the legislative session. We had learned about a children’s policy week during at the state capitol that was open to any group concerned about child health and wellbeing. During one of the days, there was an opportunity to set up a booth to share information with about 1,000 children and their parents or caregivers at the event.

We had two goals for attending the event: collect contact information from parents and advocates who wanted to receive updates on our series, and offer an engaging activity for the kids related to our work.

The children’s activity was an art project in which kids wrote and drew pictures of what they needed when they are sick, which brought more humanity into our reporting and reminded readers what was at stake in discussions about children's health. It was a non-traditional role for a journalist but added more opportunities to share our work with a new audience and hear directly from parents and advocates at the fair.

Our work with a statewide health-focused NPR program, Health News Florida, met a requirement of the fellowship program to collaborate with other media outlets. Since children's Medicaid is a statewide story, the reporters and editors at Health News Florida were interested in working with me and came down to Sarasota several times to work out the details of how best to work together.

The nonprofit collaborations came after the first series published, and a local coalition focusing on school readiness recognized the overlaps in my reporting and their advocacy work. They had not considered that barriers to health care might threaten early school success. Because of my reporting, they’ve made health access a key part of their strategy to make sure children are reading at grade level by third grade. They also connected me with their national partner, the Campaign for Grade Level Reading, which invited me to speak at their national conference this past April and used my work as inspiration for a national meeting on the health indicators of early school success, which scheduled for later this year.

I also engaged in a research partnership with the Georgetown University Center for Children and Families. In my initial reporting, I noticed that there was no information about the effects of the statewide transition to privatized managed care in pediatric offices. I’d developed a relationship with the Georgetown center and asked whether they’d be interested in designing a survey where Florida pediatricians could report how the managed care system was working in their practices. The survey resulted in a report issued in June that inspired several meetings, a public forum in Sarasota and a statewide conference for health experts on ways to improve the Medicaid managed care system. I’ve blogged about this partnership.

Q: In your exploration of the Medicaid system in Florida, what discovery has surprised you most?

A: I am consistently surprised at the scale of the Medicaid program. It’s responsible for the health care for nearly half of all children age 0-17, or about 2.2 million kids as of August 2016. Depending on how you look at it, that’s either a huge problem or a huge opportunity.

Q: One of your pieces, Shattered Smiles, zeroed in on the problems with access to dental care under Medicaid in Florida. How are the problems with dental care different from the other problems you investigated?

A: In dental care, the disparities and barriers to access were even more drastic than in medical care. Only 18 percent of dentists accept Medicaid, and even among the ones that technically accept the insurance, many are not taking new patients. With medical care, about half of children see a pediatrician every year. But with dental care, it’s only one-third of children.

The consequences of going without dental care can also be more pronounced than missing a medical checkup. Dental pain is the leading cause of school absence, and dental caries, the disease that causes dental pain and cavities, is more prevalent among low-income children. These kids are much more likely to fall behind in school and put extra strain on the education and, as they age, the social services system. Dental problems also weigh heavily on a person’s self-esteem. Job candidates with rotted or missing teeth are much less likely to be hired than people with healthy-looking smiles.

Politically, dental care also had been subcontracted to medical health plans, meaning that the state does not know how much is spent annually on children’s dental care. Dental insurance companies have no medical loss ratio requirement, meaning there’s no requirement that the plans spend a certain amount of money on care versus administrative expenses. While medical insurers don’t always follow the rules, they are held to a strict 85/15 medical loss ratio, requiring them to spend 85 percent of the taxpayer money they’re given on direct patient care and only 15 percent on administrative expenses. There’s no such requirement for dental care.

Q: This project represents a major commitment of space and resources for your newspaper. What advice can you give reporters on how to sell their editors on a major project like this?

A: It was a lot easier to convince my editors to invest in this project after securing the endorsement of the fellowship. I encourage other reporters interested in project reporting to explore fellowship programs that can provide outside funding and support. That can help convince your editors that your project is worth the time.

That said, the Sarasota Herald-Tribune has a long history of working on projects well beyond what most papers our size are willing to undertake. We have a terrific team of editors, including projects editor Scott Carroll and deputy managing editor Tony Elkins, who have shepherded dozens of projects in the last five years or so, and won national recognition for their work.

We decided that, to meet the six-month timeline set by the fellowship program, we would have weekly meetings with the project team, which included myself, my part-time reporting assistant, a photographer, graphic designer, web designer, project editor and innovation editor. We kept each other posted on our status and set goals for the coming week. The meetings kept everyone on track and the resulting website and storytelling overall were cohesive in tone and intention. It created an immersive user experience that was warm, inviting and informative.

I’d advise reporters contemplating a significant project to corral your team early and have regular meetings with clear goals. That way you can better keep tabs on the tasks completed and bounce ideas off talented experts in your newsroom. Our regular meetings and updates also helped make everyone feel part of the team rather than just performing a task for any other story.