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President's corner: Look for opportunities to localize the debate on national health reform Date: 02/26/09

Trudy LiebermanA piece in early February published in the Florida Times-Union in Jacksonville told an interesting tale about WellCare, a managed-care provider dropping nearly 78,000 clients who were participating in a pilot program aimed at reforming the state's Medicaid program. The reason was unclear from the story.

The once high-flying company that made a specialty of Medicare Advantage plans and later got in trouble with the Centers for Medicare and Medicaid Services and other government agencies simply said that operating in the pilot program "is unsustainable."

The story talked about cuts in the state's Medicaid  reimbursement rate that the president of the Florida Association of Health Plans said were so low they made it difficult to continue participating in the program. It also noted that those dropped from coverage had to find a different health plan, and if they didn't, the state would automatically assign them to one.

That story had a lot to say about health care reform and how reporters can localize some the issues. Reform is now in the hands of Congress, and coverage of behind-the-scenes lobbying and dealmaking has inevitably shifted to political reporters. It always does. But that doesn't mean there aren't stories to write. There are plenty of them, and journalists who have covered the topic and attended our conferences and workshops are in a perfect position to tackle health reform from the grassroots.

The Florida story raised a number of topics that are linked to reform. We keep hearing about improving the quality of care and how people need medical homes and electronic records to improve continuity of care. Yet when a state allows providers to dump Medicaid recipients and force them to find another provider and possibly new doctors, that hardly fosters seamless care.

What about choice? During the campaign, we heard the candidates talk a lot about choice. But did they mean choice only for the middle and upper classes? What about poor people on Medicaid in Florida who could have their choices made by the state? And if WellCare dropped out because it wanted higher reimbursements, that raises the big question about cutting fees to doctors and hospitals and cost containment in general. Just how will reform deal with real cost controls that may squeeze the incomes of doctors and hospitals?

Good local reporting needs to dig beneath all this and reporters must be careful they are not used by providers in their campaign to get more money. Payments to doctors under the Medicare program will be on the agenda this year whether or not comprehensive reform occurs.

In localizing the story, Medicaid is a good place to start. It's key to the public/private model of reform that the health care cognoscenti apparently agree will be the American solution. Journalists need to examine who will really get coverage under any kind of expansion and who will be left out. The U.S. health system is good at not quite covering everyone and deferring until another day the time when all will have health insurance. What does the stimulus package do to let unemployed adults go on Medicaid, if anything? Will childless adults still go without coverage under the program? Take a look at kids still left out under the SCHIP expansion. Not every child eligible for Medicaid or SCHIP will be covered. Explore why they didn't make the cut and what they do to get care. That will help keep the spotlight on political promises that politicians, especially the president, made to cover everyone some day.

Pay attention to the rhetoric. Everyone seems to be for "affordable" coverage. Who wouldn't be? But affordable coverage does not mean affordable care. The new, high-deductible insurance policies that will undoubtedly be touted as an answer to getting more people covered may be affordable, but they often leave families with high out-of-pocket expenses they cannot afford. Dissecting this problem of lack of insurance from the point of view of people who actually have to buy the policies could make some great copy. Looking at the deductibles, coinsurance, limited number of visits, and services not covered can be a consumer story fit into the context of the debate.

And then there's the grassroots story. Various special-interest groups like the American Medical Association and America's Health Insurance Plans have already mobilized their own grassroots ambassadors who can be called on to write letters, phone members of Congress, send e-mails, and make themselves available for fly-ins to Washington to appear before congressional committees.

Reporters can help identify who really is representing the grassroots and who is representing the special interests with much to gain or lose from reform.

Health reform gives our profession a chance to show what good journalism is all about. Good reporting is also a lot of fun.

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.