After the Election, Some Fresh Ideas for Reporting on Health Reform

The Affordable Care Act squeaked through the election along with the president last night. The law will go forward. It was not, however, the deciding factor some thought it might be, and exit polls showed voters remain divided on the law and still don’t know much about it. In thinking about how we should cover health reform going forward, it’s helpful to focus on who you're writing for.

That sounds easy, but in the coverage of Obamacare as it moved through Congress, the press forgot about ordinary Americans, focusing instead on the political horse race. How would the law affect them?

Our task going forward is to answer that question.

A useful way to tackle your coverage is to consider big themes in the law and break them into small bites. It’s also helpful to put Americans in two buckets—the 160 million or so who will continue to have coverage through their employers and the 30 million now uninsured who will get coverage in the state insurance exchanges or through expanded Medicaid in some states.

You might try framing stories around the following topics:

Premiums: For both groups, health insurance premiums will continue to rise. How much depends on whether medical cost inflation slows down. The cost control measures in the ACA are weak, and some experts believe in the end, they will do little to lower costs. Market consolidation occurring in the hospital and insurance industries may mean a few companies will be able to dictate prices for care and coverage which could continue to go up.

For those shopping in the exchanges, premiums will also depend on how many of the uninsured sign up for coverage. According to George Halvorson, the retiring CEO of Kaiser Permanente, "if you only have 10 percent join the exchange, your premium needs to be really high. If you get 100 percent or 90 percent of the risk pool, then your premium can be quite low."  The number signing up will also depend on government enforcement of the mandate. Some people may find it cheaper to take the penalty and skip the insurance.

Out-of-pocket costs: These, too, could increase for both groups. Employers are already requiring higher deductibles, coinsurance, and copayments, and remember people buying in the exchanges will also find policies with lots of cost sharing. The bronze policy, the cheapest of four plans, will be designed to cover only 60 percent of someone’s medical costs, leaving them to pay the rest. It’s likely to be popular, though, because of its price tag. In the Massachusetts shopping exchange, the bronze policy is the best seller.

Coverage: Obamacare calls for states to determine what’s called an essential benefit package, but they have a lot of flexibility in determining what that means. Look for a ton of politics in the states over what gets covered and what doesn’t. A related issue is your state’s mandated benefits, which may require coverage for everything from wigs to nutritional supplements. The business community has never liked these mandates arguing they increase the cost of insurance. Expect employers and insurers to try to repeal state mandates as state officials craft the benefits package.

Financial help for the uninsured, aka subsidies:  At the heart of the ACA are the subsidies the government will make available to individuals and families whose incomes are less than 400 percent of the federal poverty level, or $92,200 this year. For a while now, there has been back room talk about lowering the income threshold so fewer people qualify and the government will save money. How will those who might be cut off pay for health insurance, which now costs upwards of $15,000 for good family coverage?

While we’re in this territory, look at the adequacy of the subsidies for those who will qualify for them. During debate on the law, reporters paid little attention to how these subsidies would grow over time to keep pace with the growing cost of medical care. How are they indexed, and will they really hold their value if medical costs don’t moderate?

Defunding the subsidies: ACA opponents are likely to look for ways to defund the law, which, if successful, could ultimately affect the size of the subsidies people receive. Keep an eye on two initiatives – one by the medical device industry to get rid of a tax on their products like stents and defibrillators  and the other, a tax on insurers. The National Federation of Independent Business continues its "Stop the HIT" campaign to build grassroots support for repealing the tax intended to raise $87 billion over ten years. The group is employing a media strategy in towns all over the country to get reporters to write about their campaign. A warning: if you’re going to write about it, be sure to give all sides and some context too.

Quality of care: This one is a close cousin of cost containment. Provisions in the ACA like medical homes, accountable care organizations, and more health IT — electronic medical records and such — are intended to make medical care better and while they’re at it improve efficiency and reduce the cost of care. The jury is still out, but evidence is trickling in that they may have unintended consequences. In a major expose this fall, The Center for Public Integrity found that electronic medical records were actually making it easier for doctors to charge Medicare more for their services. Reporting on this stuff is badly needed but calls for a good dose of skepticism.

Insurance regulation Ah! The topic few reporters want to tackle—it’s wonky, complex, and sooo technical. But tackle it we must, because whether the insurance industry behaves itself and complies with rules for insurance payouts such will have much to do with whether the law succeeds or fails. There’s no easy route to this one except for sitting down with experts and having them explain things to you. It’s always good to have an actuary in your hip pocket. For that matter, it’s good to have an expert on all these topics in your pocket to help you out as the Affordable Care Act takes effect.

A big question in my mind is how will companies deal with risk selection—the technical phrase that means they don’t want to insure a bunch of unhealthy people. Since they can no longer deny cover for preexisting conditions, what will they do to compensate?

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