In the 2009 debate over health care reform, it can be argued that there was one particular factor that contributed to the current situation. It was not conservative opposition to liberal legislation or complex health-policy questions. In any substantive debate those problems would have existed, no matter which way the sides or issues were rotated. Rather, what failed in one of the first significant policy debates of the 21st century was the news media. Between the weblogs, television and newspapers, the amount of disinformation and gossip that was produced swallowed any substantive discussion that could have taken place.
Cable television and the Internet have increasingly led to the segregation of individuals toward media sources that espouse their own political, social or cultural viewpoints. This is dangerous for a democratic society that requires engagement with opposing perspectives. During the health care debate this trend was exacerbated, in part, by a lack of journalistic rigor by the media and the decline of serious media, like newspapers. While reading or watching the news, the majority of the public could expect to find stories about backroom deals and the spectacle of the legislative process. When stories covered the debate in depth, as some newspapers did, readers were more likely to learn what a legislator's political point or a policy suggestion was, rather than what the purpose of that policy was or how it would affect the public. Readers and viewers learned about politics, not health care reform.
This failure of media coverage was certainly no different from the 1994 reports on the Clinton health care reform effort, which was practically more difficult than reporting today's health care reform efforts. The current legislation was by that standard simpler to understand, but received worse coverage. The 24-hour news cycle that was still developing in the 1990s had come into full bloom by 2009. It is now easier to report on the minute events rather than provide actual substance. So there was a great deal of coverage in 2009 on health care reform, except nothing was actually said during most of it.
Yet a great deal of the current opposition to the legislation was based upon the premise that the American public categorically rejected the legislation. This is premised on the concept that Americans knew what was in the legislation. But a January 2010 Kaiser Family Foundation poll run prior to the Massachusetts election demonstrated that not only did individuals polled have a poor idea of what was in the legislation, but that when told about 27 separate provisions of the bills, 17 provisions made a majority of individuals more likely to support the legislation and only two provisions less likely.
Some of the provisions that made the legislation more palatable to opponents of the bill included provisions in the legislation to provide tax credits for businesses to buy insurance, protect current insurance policies, prevent federal funding for abortion services and health care for illegal immigrants, create health insurance exchanges and close the Medicare doughnut hole. Seniors found this last provision especially appealing — except many did not know that it existed in the bills. Interestingly, one of the least known effects of the legislation was the Congressional Budget Office's (CBO) prediction that the bills would reduce the federal deficit. Only 15 percent of those polled believed that the legislation would achieve this goal, but 56 percent upon learning that it would, based on CBO estimates, became more supportive of the legislation.
The poll revealed expected discrepancies between Republicans, Democrats and Independents in terms of support for the legislation. Both Republicans and Democrats knew about the same amount of information regarding the bills. There were some differences in that more Republicans than Democrats knew about the individual mandate provisions, and more Democrats than Republicans knew about the doughnut-hole provisions. Independents were three times more likely than Republicans to support the bill because it covered the uninsured, while Independents worried more about the costs of the legislation than Democrats. There were, however, two key questions at stake in the legislation that individuals had a difficult time reconciling: cost in the form of the approximately $870 billion 10-year price tag, and access to coverage through the individual mandate. These are invariably two of the most difficult issues to resolve.
Cost in the legislation is tied to the premise that in order to cover the insurance expansion for most of the uninsured there must be subsidies to pay for the expansion. Here there are no easy answers because the issue is one of ethics and a social contract, rather than the correction of insurance industry abuses or technical issues. What this brings up are social questions: Does American society share the belief that it is a necessity for everyone to have access to health care coverage and insurance? Or, is our society is willing to accept the current, tiered health care system? These are the questions that should have been debated and explored, not the circus of death panels or the by-the-second accounts of the latest outrageous statement. But the news media chose the path of least resistance and did not discuss these issues, or evidently most of the actual provisions of the legislation.
Some specialized resources dedicated to covering the health care debate and policy did emerge during the debate, including Kaiser Health News and the New England Journal of Medicine's (NEJM) Health Care Reform Center. Among the standard general media, The New York Times, National Public Radio and The Washington Post did a good job of covering both sides of the debate and what the legislation meant for the public. But the question remains — with fewer journalists, more polarized media and the decline of print media, what can be done to prevent a repeat of the 2009 debacle?
One potential solution would be for more academic journals to step in like NEJM did to fill in the gap created by a lack of discourse. During the debate, journals from the Journal of the American Medical Association (JAMA) to Health Affairs largely ignored coverage of the issues. Even NEJM's coverage was not necessarily accessible to the general public. But if NEJM, JAMA or Health Affairs were to partner with organizations like Kaiser Health News to distribute perspectives and commentaries, the distribution range of their content would be greatly increased. This model could be extended to topics beyond health care reform, including swine flu or cancer screenings. Having access to commentaries published in JAMA on the breast cancer screenings is more valuable than a dozen aggregated news stories. Yet the information remains locked behind the academic firewall.
In the end, though it may be pessimistic to consider the possibility, it seems that if current trends continue we can continue to see more of what happened with health-care reform in future policy debates. Opinion will continue to be shaped by distorted messages, the public will remain woefully misinformed, and the democratic process will suffer. In 2009, both the traditional and new media failed the public in the health care debate. Alternative strategies are necessary to disseminate information, but what these would be is currently unclear.
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Michael Shusterman is a senior majoring in biology and history. He is editor-in-chief of TuftScope Journal of Health, Ethics, and Policy.
