Health-Care Nation

The coverage of the national health-care debate oversimplifies the feud. Now two authors are trying to set the media straight.

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and medical reporting at the City University of New York, this coverage is a rare bright spot in a year marked by outdated terminology and simplistic "stenographic" accounts of the nation's No. 1 domestic problem.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.

Continued

Like a growing number of congressional Republicans, Herzlinger sees long-term benefits in replacing company health plans with individual policies, but the way she'd get there would give free-market Republicans heartburn. She posits a model for "consumer-driven health care" that would put money and tax credits in the hands of patients and the physicians of their choice, instead of insurance-company gatekeepers and hospital billing departments. It's an ideologically driven plan with a sensible side. She points to the Swiss system of universal health care as a model: It makes frank use of government power and money to create a health marketplace that favors "health-insurance entrepreneurs" rather than giant insurance companies and hospitals. Health insurance is mandatory and purchased in the private sector, with the rates overseen by the government, and the government pays the premiums of those who can't afford it. In Switzerland, insurance companies who benefit by signing more healthy patients find their profits reassigned to companies that cover sick people. It's a self-correcting mechanism that blocks the risk-selection process by which American insurers deny coverage to the truly ill.

I suspect that neither the political press nor many G.O.P. voters have realized how completely the party's leaders have embraced the concept of medical markets being guided by an extremely strong governmental hand.

Herzlinger-who stresses that she speaks for herself, not the campaign-and Republican thinkers like Ross Douthat and Reihan Salam, co-authors of Grand New Party, think they see a politically sellable economic tradeoff: The idea is to use sweeping governmental rules to open health-care markets to more diverse and efficient private companies.
A built-in clientele is essential to such plans. Rising party leaders like Mitt Romney and Arnold Schwarzenegger have already decided that health insurance, like Social Security, must be mandatory. That way, the young and rich can't hobble a state or federal system by opting out. Also widely accepted is the pragmatism of the government's picking up some or all of the insurance tab for as much as 20 percent of the population. For example, former G.O.P. Senate Majority Leader Bill Frist wanted the government to, in effect, reinsure the sickest patients by taking over for private insurers when an individual's medical bill surpassed a figure in the range of $50,000. Others like progressive cost sharing, in which the poor are fully subsidized and wealthier families' subsidies kick in on a sliding scale when medical expenses start moving toward 10 percent of total family income.

To Douthat and Salam, embracing old bugaboos is the cost of strengthening the G.O.P. in national elections. They note that the traditional conservative answer to health care-less regulation, spending caps, tax-code adjustments-will drive up health-care costs for the poor and the old, just as Republicans are trying to erase the memory of what Bush has done to average wage earners: "No working-class political movement can succeed, though, unless it makes a push for reform in what may be the greatest source of anxiety for working families-the country's health-care system."

Lieberman's sharp critique of McCain's assault on employer-based insurance does not mean that she's promoting Obama, who has yet to be put under the microscope on this issue. She faults Obama for being vague about how he plans to reduce average premiums by $2,500 per family, while creating a public option plan similar to Medicare for those not covered by an employer. Many experts doubt that he can, as blogger Williams puts it, "square the circle of cost, quality, and access" so easily.

There are encouraging signs that Obama's turn to be scrutinized has come. In the kind of dissection that has been all too rare so far, Kevin Sack of the Times cast doubt on Obama's claim that he can cut the government's health-care spending by up to $273 billion by 2012. In a short, sharp item for the Wall Street Journal's website, reporter Amy Chozick wrote that she caught Obama second-guessing his own plan to achieve universal access through private insurance companies. "If I were designing a system from scratch," he told a town-hall audience in New Mexico, "I would probably go ahead with a single-payer system."

Despite such bright spots, my guess is that voters who follow the issue via daily newspapers and network-news broadcasts aren't going to be well-informed by Election Day. The best information is in newly published books, medical blogs, and professional journals, and in specialized outlets like Lieberman's columns on the C.J.R. website. She's done the most useful medical reporting I've seen this year, but her columns are designed as tip sheets for daily newspaper-assignment editors. Reading them, a layperson can see how a good newspaper editor's mind worked in the latter half of the 20th century: You'd look around the newsroom and find a reporter you could spare for a couple of weeks, whom you'd instruct to dig into a candidate's position and ask the most awkward questions possible. This still works, but I agree with Lieberman that too many of the desks where those reporters used to sit are now unoccupied. As with so many benefits of the old newspaper world we once took for granted, it's time to say R.I.P.

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