Health-Care Nation

Trudy Lieberman, who monitors media coverage of the presidential candidates' health-care proposals, recently gave a gold star to the Associated Press. The A.P. filed an accurate description of Barack Obama's general approach. The Democratic candidate is not for socialized or nationalized medicine, nor is he for universal coverage. He's for "universal access to medical coverage" for America's 47 million uninsured and the 25 million regarded as underinsured.

To Lieberman, who runs the graduate journalism program in health and medical reporting at the City University of New York, this coverage is a rare bright spot in a year marked by outdated terminology and simplistic "stenographic" accounts of the nation's No. 1 domestic problem. "The truth," she concluded after examining coverage of John McCain's health-care proposals, is that the media has been "M.I.A. on this one."

She's not alone in taking this dim view. On his website, Health Business Blog, MedPharma Partners co-founder David Williams summarized Lieberman's work, noting that the press "stuck to making dry comparisons of the candidates' wonkish proposals without delving into the implications for everyday people." For Harvard Business School professor Regina Herzlinger, an unpaid health-care adviser to John McCain, the reporting on McCain's plan to radically alter the group insurance system that covers 177 million Americans has been "factually presented, but without any amount of analysis."

In sum, overall expert opinion is that media coverage of the $2.7 trillion industry that touches-or neglects-every American life has been sparse, shallow, and timid. It's worth noting that Lieberman, whose columns appear in the moderately liberal Columbia Journalism Review, assigns her students writings by Herzlinger, a free-market conservative she's never met. To me, that symbolizes the degree to which the intellectual debate over health-care reform has left both the press and the politicians in the dust. The general public, relying on newspapers and television, is being led to think that two huge unanswered questions loom over this campaign: (1) Will the government regulate and control health care? and (2) How much tax money will be doled out to low-income families?

In fact, the answers are already in. They are yes and a hell of a lot. Although the public seems largely unaware, policy wonks on both the left and the right have been moving for a long time toward a realists' consensus on those issues. The candidates know this too-or at least they're being told by their staffs what it will take to produce anything approaching decent coverage for all Americans, regardless of income. But Obama has been cautious about admitting how strong the government's role will have to be, and McCain can't speak plainly about the radical nature of his plan to eliminate employer-funded health insurance as the mainstay of financing health care.

Before we pursue those points, let's take a look at the information gap that afflicts the public and much of the press. In talking to Lieberman and Herzlinger, I found that they had different but complementary explanations. As Lieberman has written, Herzlinger is "no ordinary B-school prof." In 2007, Modern Healthcare listed her as one of the nation's 100 "most powerful people" in the health-care debate. Her new take-no-prisoners book Who Killed Health Care? is a scathing denunciation of the big insurers and hospitals. Herzlinger contends that these institutions would oppose the transparency of a nationwide computerized registry of patient medical records. The lack of such a database, Herzlinger notes, leaves consumers and journalists in the dark about which doctors, hospitals, and treatments are the best. No other industry in the country could get away with this lack of accountability, Herzlinger says.

Her observation triggered a memory from my days as a mainstream journalist mixing with the elite of Washington and Manhattan. When rich and famous people get diagnosed with cancer, their friends usually start pulling strings at Sloan-Kettering, Massachusetts General, or M.D. Anderson to make sure they see the best doctors. To cite one well-reported instance from the rarefied reaches of the Upper East Side, it's generally conceded that socialite fundraiser Nancy Kissinger prolonged the life of designer Bill Blass by interceding in the routine treatment he was receiving for oral cancer. "Even the wealthy don't have good information," Herzlinger says. "How do you know your doctors are the best? Do you know how many patients die who see them in your risk category? I know more about the safety and reliability of my car and my automobile dealer."

Most city magazines publish annual lists of the best local doctors and hospitals, but consumers can no longer count on a steady diet of in-depth explanatory journalism in newspapers. Reporters who are given time to dig into complex subjects are indeed missing in action-that is, no longer employed in adequate numbers, except at a few big papers. The New York Times has been good on the costs of medical technology, and the Wall Street Journal on the damage from "risk pooling" by insurance companies. But with cutbacks in the newsrooms of midsize and large-circulation papers, the main engines of explanatory or investigative journalism in this country are being shut down in city after city. You've read a lot about financial losses in a declining newspaper industry. In this campaign year, we're also feeling the loss of reliable information. In years past, consumer reporters at papers in places like Austin and Wichita, Kansas, would have been all over how much McCain's proposal will hurt people whose employers currently provide their health insurance. "There has been hardly any explanation of these kinds of problems outside the health-wonk community," Lieberman says.

McCain proposes a tax credit of $2,500 for individuals and $5,000 for every family not covered by an employer-based insurance plan. In some markets, this amount would enable a typical family to get decent coverage, but the millions who live in cities where annual costs run much higher would be losing money from day one. But, as Herzlinger points out, companies could reach new levels of global competitiveness once they dump their health plans. General Motors currently pays, by varying estimates, $600 to $1,600 per vehicle in health benefits, while Toyota pays about $110, creating a competitive advantage too large for G.M. to close simply by instituting greater efficiencies. To speed the decline of employee programs, McCain also wants to tax company health benefits as income for every worker receiving them, adding $160 billion to the individual income-tax bill of working Americans. Herzlinger, ever candid, says some on the McCain team would like to eliminate this "health-insurance tax exclusion" entirely. But, she adds, "I don't think they see it as politically possible" to go all the way this year. One reason may be McCain's reluctance to explain why he wants a heavier tax burden on middle-income workers while keeping the Bush tax cuts for oil companies and the wealthy. Lieberman says news stories haven't made it clear enough that McCain has chosen the eventual elimination of workplace insurance-"the bedrock of American health care'-as the centerpiece of his health plan. It's a massive bedrock too.