What the death of health reform teaches us about the press.

On a November day in 1991, the nascent Clinton presidential campaign summoned Ted Marmor, one of the authors of this article, to a private meeting with the Arkansas governor at the Washington Court Hotel on Capitol Hill. At the time, the politics of health care reform were gathering force. Harris Wofford had just championed the issue in his landmark Senate victory in Pennsylvania, and Clinton was in search of a health care policy. Debating Marmor--an advocate of Canada's single-payer system--was Ron Pollack, the head of FamiliesUSA, which was then supporting a plan called "play-or-pay."

For about two hours, Clinton and a collection of his advisors listened as Marmor and Pollack squared off. Single payer, Marmor argued, could save billions by cutting out redundant insurance bureaucracies, would achieve universal coverage, better control costs, and guarantee doctor choice. Pollack, once an advocate of single payer himself, made the case that play-or-pay, not single payer, was politically feasible. It built on the existing system by requiring all employers to provide insurance for their workers (play) or contribute to a pool that would cover them (pay). By doing so, play-or-pay avoided direct taxation and the political hazards of calling for the government to become the nation's insurer.

After the two advocates finished, Clinton looked thoughtful, pointed to Marmor and said, "Ted, you win the argument." But gesturing to Pollack, Marmor recalls, the governor quickly added, "But we're going to do what he says." Even considering the Canadian system, everyone in the room agreed, would prompt GOP cries of "socialized medicine"--cries that the press would faithfully report.

But the price of this pre-emptive concession was large. In all the recent obituaries of health care reform, no one has yet noted this first, fateful Clinton concession. On that November day, Clinton decided not to pursue reforms that had been proven in practice. This retreat from considering the pros and cons of foreign experience, combined with a press that also largely failed to explain how those lessons could be applied here, doomed constructive debate on the most important social issue of our time.

Once Clinton's political strategy was set, he became open to proposals celebrating market competition--a clear way, this New Democrat hoped, to avoid the Old Democrat label. So by early February 1992, around the time of the New Hampshire primary, Clinton was privately talking about California Insurance Commissioner John Garamendi's proposal for managed competition. By Labor Day, the seduction was complete, and Clinton had made his second fateful concession to what appeared politically feasible. He committed himself to a plan that advertised market competition as a cost-control device and used employment-based premiums instead of national taxes--things the press said might pass while more straightforward reform could not. What Canada, Germany, Australia, and France had learned in achieving universal coverage with cost control--while still spending less, with higher levels of public satisfaction--was thus off the table.

Clinton did not need to endorse a foreign system outright. But the lessons they provide could have been used to develop a coherent reform plan. And the president could have cited American experience with military medicine, especially during World War II and Vietnam, when very good doctors were drafted and worked under the broad authority of a democratic government. (In fact, the Vietnam work was so good it revolutionized civilian emergency medicine.) Clinton could have marshalled all of this evidence to pre-empt the insurance industry's line (made famous in the $16 million "Harry and Louise" ads) that "government-controlled" health care doesn't work. He is, after all, a president with enormous potential to educate. Remember his splendid Little Rock economic summit? The first budget address? The warmly received initial health care speech to Congress? The fight to pass NAFTA? Clinton knows how to run big teach-ins.

To cover the uninsured (whose expensive emergency care helps drive up costs for everyone), Clinton could have argued, we could target the most obvious source of waste in our system: private-sector bureaucratic overhead from 1,500 private insurers. This way, Clinton could have told the American people that despite what they hear about "big government" from Phil Gramm and Newt Gingrich, administrative costs in Canada's government-centered system are less than half the U.S.'s. Then the Clintons could have made the point that the real tangle in American health care has less to do with governmental than with private bureaucracies. But by sticking with the existing insurance system, and constructing a Rube Goldberg-like plan, the Clintons could not make that anti-bureaucratic case and were hobbled in fighting back when charges of government bureaucracy were thrown at them.

Whatever the Clintons did, they were sure to encounter opposition from interests like the House Republican Conference and the Health Insurance Association of America--opposition whose commercials could distort debate and whose soundbites would be automatically passed along by the media.

That's why the blame for the death of health reform this year does not lie completely with the Clintons. It wasn't tht they crafted a flawed plan and made crucial concessions because they didn't know any better. Instead, they did it because they understood that the American press, by and large, is culturally incapable of confronting an issue, explaining it, exploring possible solutions, and sorting fact from fiction.

To understand how the press' failure to explain the implications of health reform affected what the Clintons did, consider the example of costs. The Clintons were very reluctant to acknowledge that health insurance is something society has to pay for somehow, whether by taxes or premiums or contributions. They never came clean and said, "To pay for the reform we all agree we want, we are going to have to pay a tax of some kind. So let's be honest and debate which kind of tax is best. Employer-based? Value-added? Higher taxes on the rich?"

Instead, because the administration did so many rhetorical pirouettes (Mrs. Clinton insisted to The New York Times in 1993 that their employer mandate was "a premium, not a payroll tax"), voters got the sinking suspicion they were being conned. For their part, journalists rarely reported the significance of costs, explaining how they have to be confronted and then holding the Clintons to account for dodging the issue. If the press had turned its spotlight on how to pay for reform, for instance, it could have detailed how an employment-based tax (or "premium") might cost workers jobs by burdening the employer-employee relationship. But instead of simply knocking the Clintons, the press could then have gone on to do what the administration did not: lay out the options for paying for reform so that people could figure out what the best way might be. Sadly, however, reporters focused on the legislative game, not on explaining the differences in employment-based taxes or broad national ones.

There is no better example of the impulse to hype the political over the explanatory than the late September day George Mitchell declared health reform dead for the year. The Washington Post's page-one headline announced: "Democrats Pull the Plug on Health Care Reform." But a little story buried inside raised the real point: "Health Care Costs Continue to Rise Faster Than the National Income." They consumed 14.2 percent of our 1993 GDP, and medical plan costs during that year for American workers and their families rose an average of 7 percent--twice the rate of general inflation. Suddenly, the press rediscovered the health care crisis. Robin Toner, in The New York Times' "Week in Review" Sunday section, argued on October 2 that--get this--health care reform is still critical. She went on to detail, with sharp analysis, the liberal, conservative, and moderate positions, calling them all on where they were off base. But during the debate, such pieces were few and far between.

Why weren't such points made when they could have mattered? Do you, like most Americans, feel that you actually understand less about health care than you did a year ago? "For the most part, the media followed this as a who-was-up and who-was-down story; who was stalling and who wasn't; who's to blame and who isn't," says Senator Jay Rockefeller. "As a result, I don't think the people got to learn very much during the debate."

The numbers help prove the point: According to the Times Mirror Center, fewer than 1 percent of health care stories in 1993 and halfway through 1994 carried foreign datelines. And damnably few pieces explained, point by point, whether Clinton or Cooper or Mitchell or Gephardt or Chafee made sense in light of what has worked elsewhere. When reform was at center stage in Washington in 1994, CNN's lead health reporter, Jeff Levine, wanted to go back to Hawaii to do another story (the network had done a superb report in late 1992) on the state's successful implementation of universal coverage. But Levine knew better than to ask his editors if he could do the piece.

"If I had suggested that we revisit the Hawaii story, they would have insisted that my temperature be taken," Levine says. In short, newsroom culture in Washington--get it first, get it fast, keep it fresh, and keep it focused on the big players--forces reporters to follow the pack and keep their eyes on a limited number of established politicians and their disagreements, not on explanation.

What the country desperately needs is something we don't have now. With the poisonous adversarialism and interest-group thinking that now dominate our political culture, the only institution that can objectively explain to the public the pros and cons of possible solutions is the press. This has to be done not just once, in spot series, but again and again, as often as journalists now turn to politics, polls, and predictions.

If reporters continue to insist that they are here only to "report" what politicians say and "balance" their stories with voices from the other side, without determining the plausibility of what is said, then the country will get the same unsatisfying results it got with health reform. It is not as though the press is giving the people what they want; an October Times Mirror Center study found that 71 percent believe journalists get in the way of solving the country's problems. The press has to turn that figure around. If it doesn't, instead of illumination, we will get more fragmentation and confusion; the voices of fear and self-interest will always get a hearing and sidetrack us from making informed choices.

That, indeed, is what happened during the health care debate. To see how the habits of Washington journalism controlled and ultimately distorted the discussion, come with us to a party in suburban Washington last winter.

A group of reporters were drinking beer and lamenting what had already become apparent: The coverage of health care resembled nothing so much as the hasty horserace stories of a political campaign. What could we do?

"Shoot Robert Pear," said one network television reporter, referring to his enterprising colleague at The New York Times who was breaking story after story on the health beat. The comment produced a roar of laughter from the table; everyone there had had an angry editor demanding a follow-up on a Pear piece. The laughter masked, as it often does, fundamental frustration.

The laughter also underscored the fact that reporters assigned to the health care debate were operating under rules as old as the ones governing Hildy Johnson in The Front Page, the thirties Broadway play about hard-bitten newsmen.

Press Pass

The first rule then, as now: Don't get scooped. There may be no better reporter at scooping the competition than Robert Pear. But get-it-first journalism was not what America needed during debate over the most ambitious social legislation since the New Deal. Yet that was what the nation got, as the beery lamentations over the Pear-driven agenda show. Go back to May 1993. One morning, the Times published a page-one Pear story suggesting that Medicare might be dismantled and incorporated into the Clinton health plan. The Washington press corps' response to the story? Get Magaziner and follow up on the Pear story. That afternoon found CNN's Levine, USA Today's Judi Hasson, ABC's George Strait, the Associated Press' Christopher Connell, and others clustered outside a downtown Washington office building in which Magaziner was rumored to be attending a meeting. "We were determined to gang-tackle Magaziner if we had to," Levine recalls. "We waited and waited and said to each other, 'What are we doing here?' It was absurd, but there is competitive pressure. You have to have what the other guy has."

Other Beltway journalistic imperatives pulled coverage away from explanation of what the options really were--always for the worse:

* Conflict, not explanation, is news.

If reporters don't spend their time taking proposals apart to figure out what's good and what's bad about them, they have to spend their time doing something. And in health care, that something was to report on any special interest or group that had a beef with the president's plan. Because reporters are attracted by conflict (after all, it provides an easy dramatic narrative), the people who want to sink major reform--those with stakes in the status quo--have a ready-made ally in any reporter.

Consider these New York Times headlines from the period leading up to the submission of the Clinton plan to Congress: INFLUENTIAL GROUP SAYS HEALTH PLAN SLIGHTS THE AGED; BUSINESS GROUP ASSAILS THE SCOPE AND COST OF THE CLINTON PLAN; LOCAL GOVERNMENTS MAY PAY MORE IN HEALTH PLAN; HEADS OF HMOS HAVE CONCERNS ON HEALTH PLAN; CLINTON HEALTH CARE PLAN MAY CUT BENEFITS TO CHILDREN.

What conclusion could you draw from this kind of coverage but that health care reform was a chaotic jumble, full of sharp conflicts that would take someone with the combined talents of Jesus Christ, John F. Kennedy, and Tip O'Neill to resolve?

Newspapers are hardly the only sinners. The most influential television players in Washington--the talk shows and "The MacNeil/Lehrer NewsHour"--also showcase absolutely opposing points of view, leaving it to the viewer to figure out who's right and who's wrong. One example from ABC's "This Week with David Brinkley": Soon after the president's bill was introduced, in 1993, Jay Rockefeller, the Clinton's biggest booster in the Senate, had a heated debate with Bernadine Healy, the conservative former director of the National Institutes of Health who was then running for the GOP nomination to the Senate from Ohio. There were frequent interruptions and seemingly incompatible assertions of fact. What was dramatically missing from the show was an effort by Brinkley or his colleagues to assess the upsides and downsides of Rockefeller and Healy's points. This happens over and over again on the supposedly objective television shows.

* Cover issues by covering what politicians say about them.

News in Washington centers around "newsmakers," and much of what passes for reporting in the capital amounts to transcribing the words and thoughts of highly placed sources. One Sunday this summer, for example, found Daniel Patrick Moynihan holding forth on CBS' "Face the Nation." On the show, Moynihan declared that there simply wasn't money to fund universal coverage; yet, virtually in the same breath, he made the case for increased funding ($126 billion in the next 10 years) for academic health centers--many of which happen to be located in New York, where Moynihan happens to be from.

Now, here was a priceless opportunity for Bob Schieffer and his panel to question Moynihan on a major contradiction. Anyone who understands the current problems in the U.S. system knows that without more primary-care practitioners and fewer pricey specialists, the pressure on health costs will remain enormous. An important reform, scuttled this year by Moynihan, would have required medical educators, in exchange for their generous federal funding, to train 55 primary-care docs for every 45 specialists. Losing this was a quiet blow for long-term reform. Yet none of the reporters on the show asked Moynihan how he could reconcile claiming there was not enough money for universal coverage at the same time he was plumping for more spending on a part of the medical world that drives up costs.

There was a lot of this kind of passive reporting on congressional characters in the last two years. According to Lee Ann Brady, of the Times Mirror Center, news organizations in 1993 and 1994 moved in packs "to put one or another member of Congress into the spotlight every two weeks." During the last 10 days of January 1994, for example, after Clinton's State of the Union speech, Bob Dole received 9 percent of all health care coverage, then faded. In February, when he proposed a "Clinton Lite" plan, Rep. Jim Cooper took the spotlight. Then the limelight moved to successive chairmen as different committees took up reform: first Pete Stark, then Dan Rostenkowski, then Ted Kennedy.

* Don't report what's already known.

Like CNN, USA Today tried to tell its six million daily readers in the last two years what has worked and what hasn't, sending reporters to Germany, Canada, Oregon, Minnesota, and Hawaii. "But," says reporter Judi Hasson, "most of those trips were in 1992 and 1993, when the public was not really focused on the issues. We should have done it later. But we didn't."

In the late eighties and early nineties, there was a burst of media interest in how other nations, especially Canada, had successfully reformed their health care systems. After Lee lacocca wrote a widely noted 1989 New York Times op-ed in favor of Canada's health program, the major networks and Consumer Reports examined Canada's experience with universal health insurance. The Philadelphia Inquirer, among other publications, explored the national health systems in Germany and other nations as well.

The problem was that few organizations in 1993 and 1994 returned to these examples to produce clear, frequent explanations of international lessons, how to see through the rhetoric, and how to judge the arguments presented. Editors, ever in search of something new, were bored by intelligent, sometimes repetitive assessments of what had already been reported. Even those who ultimately allowed follow-ups were at first skeptical of revisiting international experience. This year at the Minneapolis Star Tribune, for instance, editors questioned a proposal to look again at Canada because the paper had done the story in 1989. "You already did that," reporters were told. "Let's do something new."

Of course, journalists can always cite the occasional explanatory story. The point, however, is that such stories are vastly outnumbered by those that fail to explain what reform could mean to individuals and to the country--not to politicians or the parties. The New York Times and The Washington Post, for example, waited until the issue was officially dead for the year before reporting how managed care bureaucracies--which are growing in importance under the status quo--can inflate costs. Had this come--and had the point been repeated--during the drafting and debate over reform, the president might well have decided to reconsider depending on managed care as his central cost control device.

The after-the-fact Times and Post stories show that there is drama in exposing the wastefulness of private corporations or the efficacy of government, if only because they fly in the face of the conventional wisdom. But once the piece on an institution like a health care system is done, there is little way to go back and make it fresh again, as you can endlessly do with congressional or White House personalities.

In the make-it-or-break-it final weeks of the session, for example, the public needed to know not only what Moynihan was thinking or what Chafee could sell to Kerrey but what was the cost of no reform? More Americans have lost coverage since 1992; more employers are dropping insurance or not hiring permanent workers they might have to cover; and medical costs are estimated to be rising at twice the rate of inflation, adding up to nearly a trillion dollars a year we can't spend on anything else. Towers Perrin, a major accounting firm, estimates that without reform, health costs as a percentage of income for typical workers will double by the end of the century. But few news organizations reported this. Why? Projections of cost increases had been reported already.

Pressing Debate

There is little room in our press culture for what journalism critic Jay Rosen calls "constructive advocacy." But we must make room, beginning now. Can newspapers break their worst habits and actually educate the public? Can television stop letting partisan voices lie in the service of their own ends and use dispassionate expertise to separate truth from distortion?

The media can do this, because they already have.

Think back to the third week of June. Traditional health reform coverage dominated, with stories about what the five congressional committees would do and whether "universal coverage" was dead or alive. But real murder won out as news.

The coverage of the murders of O.J. Simpson's wife, Nicole, and her friend Ronald Goldman, ranged from the grotesque to the engrossing, from tabloid speculations about whether O.J.'s father was a "drag queen" to legal experts explaining the Fourth Amendment. As the drama unfolded, something remarkable happened: Millions of Americans who tuned in to the preliminary hearing were treated to an extraordinary public education about the most complicated corners of the law. Hour after hour, the country watched how an American courtroom operates--how it separates fact from fiction, opinion from evidence, speculation from documentation. Television covered the event with teams of expert legal analysts, explaining what was going on and what it all meant. With that coverage came a surprising illumination.

E.J. Dionne, in The Washington Post, spoke for millions when he noted that the hearing dominated conversation at his rented beach house. "Our household was apparently rather typical in thrashing out such constitutional fundamentals, and it is a mark of television's power that a whole country would find itself chatting about rules of evidence, personal liberties, and the duties of the forces of order."

The O.J. coverage was our national teach-in on the law and a television seminar on the Fourth Amendment. In an odd way, we have it--and the institutions in which it will be conducted--as a reminder of how careful coverage, argument, and analysis can make sense of complexity, whether the issue is search-and-seizure or the control of health costs.

Some of this did happen with health care. In October, PBS' "The Great Health Care Debate with Bill Moyers" vivisected the misleading ads that had dominated the year, proving that the forces arrayed against the Clintons were formidable, well-financed, and fundamentally misleading. In June, NBC News aired a special "To Your Health," which cast the issue in personal, pocketbook terms. This kind of reporting was the exception: An analysis of health coverage during the first half of 1994 found that only 8 percent of stories focused on the potential impact of health care reform on individuals and their families. This must change.

Gavel-to-gavel coverage of congressional hearings with expert commentary, televised town meetings and frequent Little Rock Economic Summit-events won't do the trick entirely, however. The print press, which drives much of television coverage (remember the chase for Magaziner last April), must reform itself, too. Pie in the sky? Hardly. Why can't the mainstream papers and magazines do for public policy what Consumer Reports does for cars and refrigerators? Journalists would gather detail on competing options, assess the features of each in light of the results it promises, and present the information clearly and comprehensibly. Of course, journalists could then take all of this one step further and, after the reporting is done, fearlessly name one policy or another the "best buy." (In fact, Consumer Reports did just this, producing excellent reporting on health care this year, using foreign lessons as benchmarks and coming down, in the end, for single payer.) But if journalists would just get the first part of this down, for the second round of health care and for welfare reform and education reform and the rest of our national business, the shift would be nothing less than revolutionary.

WHAT THE PRESS GOT WRONG

If you really want to understand the press' culpability in the public's enduring confusion about health reform, consider the following interest-group claims that were allowed to become fixed in people's minds. You can argue that the press has to be objective or you can argue that it's not the press' role to help the Clintons pass legislation. But you cannot argue that the press is doing its job when distortions are held as truth. Because the Clintons relied on the existing insurance system, they would have preserved much of the status quo. Yet even this plan drew virulent attacks against government-led reform. Despite the caricatures, plans like those in place in Canada and Western Europe would give Americans more of what they say they want: choice of doctor and an understandable system.

* Fear of loss of choice.

In one Empower America (a GOP group) TV ad, the camera is focused on a hospital heart monitor. "Bill Clinton wants to socialize our health care," the deep-voiced announcer intones as the monitor beeps. "Your doctor won't decide what health care you receive. The bureaucracy will decide. The bureaucracy will never examine you ... yet it will severely limit your choice of doctor." As the pulse goes flat and an insistent alarm rings, the announcer says: "The bureaucracy will decide when and if you can see a doctor. Under this plan you will lose choice and control."

Sure, Americans should be deeply concerned about being able to choose their own doctor. But it is harder in the United States today to do that than it is in Canada, Europe, and Japan. Try choosing your doctor or hospital today in this country, where private managed-care bureaucracies are preventing patients from doing what most people in these other countries can do. According to a Harvard survey of 10 nations, Canadians were the most satisfied with their health system; Americans were the least. And Canadian and European doctors are less hassled and more satisfied in their jobs than their American counterparts.

* Fear of bureaucracy.

"It's going to harm your freedom. You'll have to ask for permission from the government before you can do anything about your health care." So said Rush Limbaugh to his vast daily radio and TV audience. As with choice, however, effective reporting could have stood this soundbite on its head. What doctors and patients object to and fear most in the United States right now is the interference of insurance company bureaucrats in the delivery of care. Meanwhile, the practice of medicine in Canada and Germany is relatively unfetered. Although sophisticated journalists who have studied the issue know this, they rarely reported it, while the Rush Limbaughs repeated their distoritions daily.

* Quality.

"The United States now has the best health care system in the world," Senator Phil Gramm warned time and again, implying that any government-led attempt to reform it would result in disaster. But the evidence suggests that countries with national health systems offer superb care. The General Accounting Office, for example, issued a report in early 1994 showing that U.S. treatment of bone marrow cancer lags behind Western Europe's in efficacy and availability. (To the understandable dismay of the study's authors, the report made little news in the U.S.) And Canada and Germany outstrip the U.S. when it comes to basic measures of health such as infant mortality rates.

* Cost.

The National Restaurant Association and some of its powerful allies in the Business Roundtable used fear of the loss of jobs from the supposed high cost of reform to turn their workers against plans guaranteeing universal coverage through an employer mandate. While the mandate might indeed have raised employer costs, the commercials left the impression that any reform would be too costly. In one TV spot, food service employees were shown at work while the restaurant association's president intoned: "They want a plan that doesn't eliminate jobs because cost and bureaucracy are too high."

In fact, reform of any sensible kind would save most people money over the status quo. But reporters let the impression grow in the country that reform was a money-eating monster waiting to pounce. Few noticed when the Minneapolis Star Tribune compared four major plans--Clinton, Cooper, Nickles, and single payer--and found that against current expenditures for health care, all of them saved working class and poor families money.