Health care reporters used to be Medicare hounds. What happened?

In early October, President Trump signed a long-awaited executive order that has the potential to drastically change Medicare as we know it. In his column, Michael Hiltzik, a business columnist for the Los Angeles Times, excoriated Trump’s proposal. The headline: “Trump’s plan to ‘save’ Medicare would actually destroy it.” It was a harsh assessment.

Hiltzik pointed out the contradictions in the president’s public statements on Medicare. “As long as I’m president, no one will lay a hand on your Medicare benefits,” Trump has said, although for the last 25 years, a long-simmering goal of Trump’s right-wing allies has been to privatize Medicare. In the mid-1990s GOP House Speaker Newt Gingrich articulated that vision. If private alternatives were available, Medicare would “wither on the vine,” he said. 

Gingrich’s prophecy is belatedly coming to pass, with about one-third of all Medicare beneficiaries now getting their health care from those privately administered Medicare plans sold under the banner of Medicare Advantage. In his column Hiltzik reported that the Trump administration has been pushing Medicare Advantage assiduously in a way that may lure in seniors for whom these plans are  the wrong choice. “Trump’s executive order would turbocharge this trend, and we should ask: Why?” Hiltzik wrote, “Put simply,” the president is “proposing to privatize Medicare.”

My takeaway from this withering critique of Trump’s executive order is not just that Hiltzik wrote a good column, but that so few media stories reported on the ramifications of the move. There was scant analysis of what the order would do and how it will impact those now on Medicare and those yet to come. The press, for the most part, was AWOL. That’s despite the fact that the changes would affect the kind of coverage beneficiaries would get now and in the future.

That’s hardly surprising given Medicare’s low media profile these days and the fact the agency in charge of Medicare seems hostile to the program. Medicare reporting, once a staple of health care journalism, has disappeared from the health and political beats, leaving the public to get its Medicare news via advocacy group press releases and sponsored content or “submitted news,” once known as advertising. Consider this “sponsored feature” from Blue Cross and Blue Shield of Nebraska, which appeared in the Omaha World-Herald. The objective seemed to be to sell Medicare Advantage plans, and featured the director of the insurer’s Medicare Advantage business unit. 

I’ve previously raised the question of why there’s so little Medicare coverage. It seems now the stakes are even higher as Gingrich’s prophesy comes true. People approaching age 65 rarely know the full range of their options and the difference between Medicare and Medicare Advantage plans. To explore this knowledge deficit further, I rang up Julie Rovner, chief Washington correspondent for Kaiser Health News and host of its podcast, “What the Health?” In an August edition of the podcast, Rovner, who has covered Medicare for decades, noted the paucity of Medicare coverage. She observed that while the program “seems to have taken a backseat to sexier issues, a lot of those issues end up circling back to Medicare.”

Years ago, Rovner said, if you were a Washington reporter you covered Medicare “because it was the big kahuna and Congress did a lot of legislating on Medicare. You became a Medicare expert because that was pretty much all there was to cover.” That began to shift when Republicans took over Congress and brought with them different priorities and their own Medicare bill, which gave seniors the prescription drug benefit known as Part D. Then, in the run-up to the election of Barack Obama in 2008, momentum grew for new legislation that would bring health insurance to more Americans, further diverting reportorial attention from Medicare to expanding private health insurance.

“New reporters came on the beat and assumed they needed to cover the ACA, not Medicare,” Rovner said. But, she added, “We were having a gigantic fight over 5% of the population.” In other words, reporters were ignoring what was happening to a far bigger program that covers vastly more people and involves more money. In 2018, Medicare alone paid out $731 billion in payments, up from $462 billion in 2008.  The significant cuts the ACA made in hospital and other provider reimbursements, about $716 billion over 10 years, were almost never a major Obamacare storyline.

“It’s not just reporters,” Rovner said. “Policymakers have moved on from Medicare and reporters follow the policymakers.”

That means they’re not following Medicare advocacy organizations the way they used to either. Where once reporters who wrote frequently about Medicare cultivated such groups, which often tipped them off to good stories and patiently explained the many complexities in the program, today those groups are often viewed with the same suspicion as other organizations with explicit agendas. “Outside of open enrollment time, coverage is sporadic,” said David Lipschutz, associate director of the Center for Medicare Advocacy, a group that knows well the intricacies of Medicare and files lawsuits on behalf of beneficiaries. “We get a stream but not a torrent of folks contacting us about stories that need to be told,” he said.

When stories do appear, Lipschutz said, “There isn’t always a rigorous analysis of who’s the source of the information.” Sometimes consulting firms funded by the insurance industry form the basis of stories, but such relationships are not always disclosed, he added. If insurers pay a consulting firm for a study that finds Medicare Advantage plans are better, then the funding source needs to be disclosed, Lipschutz points out. There are happy exceptions though. He cited one good story last year by AP reporter Ricardo Alonso-Zaldivar, which linked the funding source to the insurance industry. Zaldivar dissected the workings of the Better Medicare Alliance, an industry front group dedicated to promoting Medicare Advantage plans. He showed how three of the biggest sellers of Medicare Advantage plans — UnitedHealthcare, Aetna, and Humana — primarily fund the group that pays Alliance president and CEO and former Congresswoman Allyson Schwartz over $600,000 a year. That’s information the public might need in judging any information or studies that Alliance disseminates.

Over the past seven years I’ve written a health care column distributed to community newspapers across the country, and Medicare is by far the topic I get the most emails about. 

After the president announced his executive order calling for potentially drastic changes to Medicare, Lipschutz’s center issued a news release. It noted that Trump’s order sought to ensure that the traditional Medicare program used by two-thirds of all beneficiaries did not have any special advantages over Medicare Advantage, the private alternative. The center’s analysis discussed finding how the administration may be trying to make it easier for beneficiaries to drop their hospital coverage, known as Part A, in favor of private insurance coverage. That in turn would undermine the universality of the program. The executive order also appears to make it easier for doctors and beneficiaries to privately contract for services. And it could erode rules that require Medicare Advantages plans to have adequate provider networks by substituting telehealth arrangements for live physicians.

Despite the far-reaching ramifications of such proposals, coverage was spotty. A few news outlets besides the Los Angeles Times did pick up bits and pieces of the order, such as Kaiser Health News, CNBC, NPR and Vox. But I’d wager most seniors on Medicare still have no clue about what could happen to the program as a result. I’d also bet they’d like to know.

Over the past seven years I’ve written a health care column distributed to community newspapers across the country, and Medicare is by far the topic I get the most emails about. As Mark Miller, an independent journalist specializing in aging and retirement issues, told me, “In my experience there are no topics that get stronger interest than Medicare and Social Security. I write about these two topics more than anything else.” Miller said, however, that mistakes made in stories about the program coming out of Washington are “kind of stunning,” a point reinforced by Lauren Young, his editor at Reuters, who said “the public is confused about where the money comes from. The general public does not understand how Medicare and Social Security are funded.”

As Rovner noted in her podcast: “Medicare is many things. Simple it is not.” 

That lack of basic knowledge among the media makes it easy for opponents to mislead people about Medicare. If journalists themselves don’t understand the programs and avoid reporting on them, how is the public supposed to separate fact from fiction in the ongoing debate about “entitlements,” or whether Medicare is the right model for achieving universal health insurance in this country? What exactly does “Medicare for All” mean? That’s fodder for a future discussion.

In September, six Democratic senators sent a scathing letter to Seema Verma, head of the Centers for Medicare and Medicaid Services (CMS), that laid out numerous problems with Medicare Advantage plans that are being heavily advertised this fall. The letter provides rich fodder for intrepid journos who want to find out what’s really happening with this program. Reporting out these problems would have been a great service to the public. Among the issues the six senators flagged: 

Overbilling: Taxpayers have overpaid MA plans more than $30 billion over the last three years, and CMS has taken little or no action to correct this. If you’re looking for background, Fred Schulte of Kaiser Health News has extensively reported on this problem.

Persistent performance problems: Audits done by CMS itself have found “widespread and persistent (Medicare Advantage) performance problems related to denials of care and payment,” and MA plans that “threaten the health and safety of their members.”

Misleading plan star ratings: Senators noted that that some “deficient” plans —“even those found to threaten people’s health and safety — receive four- and five-star ratings,” and called this finding “unacceptable.”

Missing information beneficiaries need: Senators called attention to missing information seniors need to made an informed choice. At a very minimum, the senators said, people should know “they cannot rely on star ratings or MA plan provider directories and that their out-of-pocket costs in a MA plan could be as high as $6,700 for in-network medical and hospital care alone and $10,000 if they use out-of-network providers. They should also know in some plans they may face inappropriate delays and denials of care.”

Nancy Altman, president of the advocacy group Social Security Works, says reporters have examined Medicare under the wrong lens. “They see it as a budget problem as opposed to a health care solution, she said. This perception didn’t happen by accident. Groups like the Committee for a Responsible Federal Budget and politicians like former House Speaker Paul Ryan, who is now back in Washington with a new group, the American Idea Foundation, have helped shift public perceptions of Medicare itself. “They changed the discourse on how Medicare was viewed — from a major provider of health insurance to a costly program the country couldn’t afford — beginning in the 1990s and continuing to this day,” said Altman.

Last week Health Affairs published a report of a Medicare study done last year by researchers at the T. H. Chan School of Public Health at Harvard, The Commonwealth Fund and The New York Times. The surprising conclusion: Slightly more than half of all Medicare beneficiaries had trouble paying a medical bill. Paying for prescription drugs caused the greatest hardship of all, and one quarter of the respondents reported that their hospital bills had burdened their families. The study noted that 90% of beneficiaries either had Medigap insurance, were in Medicare Advantage plans, or were also covered by Medicaid. It did not examine what type of supplemental coverage respondents had, but the study raises serious questions about how well that coverage is working for them. 

The findings offer an invitation to journalists to begin changing the discourse around Medicare from a federal budget story to one that focuses on health, and how well the various Medicare programs are serving Americans. Medicare is a huge health care story that cries out for honest journalism, especially if it’s being hailed by progressive politicians as a template for a new health system for everyone.

Veteran health care journalist Trudy Lieberman is a contributing editor at the Center for Health Journalism Digital and a regular contributor to the Remaking Health Care column.