If you’re a local journalist in a conservative place, how should you cover the ACA?

As part of its “You Asked, We Answered” series, the Center for Health Journalism has been fielding journalists’ queries about health reporting. This week's question: “As the U.S. Supreme Court decides the future of the Affordable Care Act, how can local health journalists in predominantly conservative areas effectively report on the law?”

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When Bram Sable-Smith reports on the most consequential health care law of the past few decades, he doesn’t refer to it by name. The terms Affordable Care Act or Obamacare have become so politically toxic in many corners of the United States that Sable-Smith, an investigative reporting fellow with Wisconsin Watch, avoids them at all costs.

Instead, he concentrates on parts of the legislation — like protections for preexisting conditions — that tend to be way more popular than the law in its entirety. Sable-Smith, who reported on health in Missouri for five years, has found that when he does that, sources turn out to be very receptive and well-informed about the intricacies of the, ahem, Affordable Care Act.

“The more that you can focus on those specific issues the better,” he said. “Because that’s the real tangible stuff and that takes the coverage to a level that I find more interesting and that serves the public better because you’re helping people understand what’s in the law and how it can impact their lives. Politics has this way of derailing so much conversation in the public health sphere that, if you’re able to get around it, that’s a good thing to do.”

Show your work

As the U.S. Supreme Court once again readies its decision on the fate of the Affordable Care Act, health reporters around the nation have been trying to explain to their audiences exactly how this would affect them. For local journalists in more conservative parts of the country, where skepticism or hostility toward the legislation and the news media in general are common, that can often be a challenge.

“Even though it's local coverage, because it's a national issue, it can come with that distrust that is associated with national news organizations,” said Lynn Walsh, assistant director of Trusting News, a group that helps journalists gain trust with their audiences. “In any coverage where you have an issue like this or other very nationally politicized issues that you're trying to look at locally, it's a good idea to explain what you're trying to accomplish.”

For instance, she suggests news outlets be transparent about their goals, perhaps even appending editor’s notes explaining why they’re doing the story, and to outline the reporting process, like describing the general opinions of the sources who were left out. Also, if it’s a wire story, make that clear, so consumers can better learn the difference between local and national news.

Walsh said reporters and editors should emphasize that their objective is to inform local communities, not carry out a political agenda, which can “break down (readers’) initial reaction, and they're like, ‘Oh wait, they're mentioning our town. OK, this is about more than just what's happening in D.C.’” To that end, she suggests finding trusted sources from local rather than national organizations, and avoiding talking to politicians — even if they are local — if the resulting interview is likely to just create more confusion.

She also recommends answering — rather than ignoring — disapproving social media comments and even doing follow-up stories based on some of those reader critiques.

What audiences stand to lose

I have firsthand experience dealing with public confusion about the Affordable Care Act as a local health reporter. When I wrote for an Indiana newspaper during the Republican efforts to repeal Obamacare in 2017, I visited some community health centers to talk to patients who’d gained coverage through either the law’s tax credits or its Medicaid expansion, which in that state was known as the Healthy Indiana Plan (or HIP).

In one memorable interaction, a 22-year-old woman told me: “I don’t have Obamacare. I have HIP.” When I informed her that her plan was part of Obamacare, she said: “I didn’t know that.” (Even so, she was unfazed by the prospect that her insurance might go away.)

Most of the folks I interviewed hadn’t voted for Hillary Clinton. Several of them opposed the Affordable Care Act even though it was the reason they were insured. But, even though we were discussing a politically charged topic, they were for the most part extremely cordial.

Caity Coyne, health reporter for the Charleston Gazette-Mail in West Virginia, can relate.

“The most effective reporting I've done is the type that points out to people what they would lose that they weren't even necessarily aware they would lose — showing them what's at stake,” she said. “A lot of the time you'll find out they didn't even know that that was something at risk, which is always interesting.”

Reasons for that lack of awareness include a dearth of insurance outreach in West Virginia and the broader problem of disinformation being spread by public officials, social media and partisan news outlets.

Coyne said that it can be even harder to report on these issues in more remote sections of the state, where she’s often looked at as the “big city reporter.” Her newspaper no longer regularly covers or distributes in those rural areas because of the decline in local news revenue. To that point, Coyne started at the Gazette-Mail as a corps member for Report for America, which funds local news jobs in underserved areas, before she was hired as a staffer.

“It's an automatic barrier to gaining their trust,” she said. “There needs to be a lot of work done in a lot of different places in the U.S. to confront that and rebuild those relationships. That will end up being better for everyone: You trust the news that you're reading, and you put more trust into the people that are actually doing good for your state instead of an automatic distrust and a they're-out-to-get-me mindset.”

‘You cannot argue with improved outcomes’

Erica Hensley, a freelance public health reporter in Mississippi, said she tries to avoid controversy in her reporting on the Affordable Care Act by sticking to the data.

“The facts on the ground are that we have the highest infant mortality rate in the country, one of the highest maternal mortality rates in the country,” she said. “Research is finally starting to catch up with Medicaid expansion and shows that states that expanded it have benefited by reducing those maternal health outcomes. You cannot argue with improved outcomes.”

While Mississippi hasn’t expanded Medicaid, and it remains a heated topic of debate there, Hensley chooses to focus on the public health impacts of Obamacare. In her previous job, at Mississippi Today, she would always report on the annual open enrollment period and discuss lesser-known benefits, like the gains for women’s health care and how many full-time workers obtained coverage thanks to the law’s tax credits.

“What really tends to reach people is understanding the emotional side of it,” she said. “So I try and lead with that emotional connection, like, ‘Hey, here's a couple of folks who have preexisting conditions but could now get insurance for the first time.’”

Hensley inevitably gets nasty emails from the law’s opponents, though she acknowledges that most come from a place of misunderstanding. She pointed out that many Mississippians have fallen victim to robocalls with bogus information about the Affordable Care Act.

“Most of the state does qualify as a news desert, as far as having one or fewer news sources in the county,” she said. “If all you see on your one newspaper or your one TV station headline is Trump saying, ‘We're going to repeal and replace Obamacare,’ that really did seep into the collective understanding down here. Almost everyone I interviewed back in 2017 and 2018 about the ACA who had actively got plans had told their navigator: ‘I did not think we had Obamacare anymore so I did not actively seek y'all out to help get insurance.’”

Hensley said it just speaks to the lack of full-time health journalists who have the knowledge to explain intricate health care issues.

“I think the silver lining of the pandemic is that it has forced the hand of newsrooms to think of all reporters as health reporters,” she said. “More than ever we realize right now that every story is a health story.”

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