Jan 1 1994

When ‘Both Sides’ Aren’t Enough

The Restricted Debate Over Healthcare Reform

InsuranceCompaniesJournalists pride themselves on presenting “both sides” of a story. But if establishment media can decide which positions get to take part in debate, then telling “both sides” may be a way of keeping news consumers on the outside.

Coverage of the health care reform debate provides a wealth of examples. Major news outlets go out of their way to avoid mentioning the progressive alternative to the Clinton health care program: a Canadian-style single-payer reform, which would replace private insurance with tax-financed comprehensive universal coverage.

Hillary vs. Insurers

In November, major media focused on the White House-promoted story of “Hillary Rodham Clinton vs. the Insurance Industry.” “The First Lady came out swinging, visibly angry as she took on the health insurance industry,” said ABC‘s John McWethy (11/1/93). “Hillary Clinton Accuses Insurers of Lying About Health Proposal,” blared a front-page New York Times headline (11/2/93); the Washington Post‘s followed suit (11/2/93) with “First Lady Lambastes Health Insurers.” CNN‘s Bob Cain (11/3/93) declared that the Clinton administration was “engaged in something close to an all-out war with the health insurance industry.”

These stories referred to Rodham Clinton’s attack on a $6 million advertising campaign by the Health Insurance Association of America challenging the Clinton plan. What the news outlets didn’t mention is that the “Big Five” insurance companies–Aetna, Cigna, Prudential, Metropolitan Life and Traveler’s–have withdrawn from HIAA and are generally supportive of the Clintons’ health policies. These companies have invested aggressively in Health Maintenance Organizations and other managed care networks, which stand to expand dramatically under the Clinton “managed competition” plan. The “managed competition” theory, in fact, was cooked up by executives of the Big Five and other medical industry leaders in annual meetings held in Jackson Hole, Wyoming.

The Times‘ Adam Clymer equated HIAA with the “insurance industry” throughout his piece–a particularly egregious error, given that the Times had earlier (2/28/93) run a detailed report on the Jackson Hole Group. The Post‘s Dana Priest hinted at reality, describing HIAA as a “trade group of mainly medium-sized firms,” and later saying that the group “represents 270 medium-and small-sized insurers, many of whom could be put out of business by reform.” Insiders will recognize this as a reference to the fact that big insurers stand to profit greatly from the Clinton plan; other readers will remain in the dark.

Viewers of the Nov. 2 MacNeil/Lehrer NewsHour, however, got a more realistic view of the dispute. Along with advocates for the Clinton plan and for HIAA, the show’s discussion of the ads featured Dr. David Himmelstein, co-director of the Center for National Health Program Studies at Harvard. Himmelstein, a single-payer advocate, agreed with the first lady that the insurance industry is the problem, but also noted that the HIAA represents the “small sharks” which will be eaten by the big sharks under the Clinton plan.

Conservatives vs. Clinton

Although a bill for a single-payer health care system currently has 95 co-sponsors, most press accounts did not acknowledge that the Clinton plan had serious competition until more conservative alternatives were unveiled.

The introduction by Rep. Jim McDermott (D.-Wash.) of a single-payer bill in March 1993 was largely ignored. ABC World News Tonight, in fact, has run only one story (6/23/93) that even mentioned single-payer since the beginning of 1993–a political report pointing out that Hillary Rodham Clinton had already dismissed single-payer, but needed to shore up her support among single-payer advocates.

But in September, when Republican Senator John Chafee (R.I.) introduced his “plan”–actually a 14-page outline–it was greeted with media fanfare. The Boston Globe (9/16/93) called it “the first serious response to the president’s proposal.” ABC News‘ Bill Greenwood (9/15/93) concluded optimistically: “Thirty-seven million Americans are now without health insurance. Between the President’s plan and today’s Republican alternative, they’re certain to finally get some coverage.”

Actually, Chafee’s proposal closely resembles the Managed Competition Act introduced by Jim Cooper, which differs from the White House plan in not requiring employers to offer coverage, and by making insurance purchasing cooperatives voluntary, not mandatory. A Congressional Budget Office analysis of 1992 health plans (7/93) conservatively estimated that Cooper’s bill would leave 25 million Americans uninsured.

But reporters rarely challenge the assumption that conservative “alternatives”–even that offered by hard-right Republicans like Sen. Phil Gramm (Texas) and Rep. Dick Armey (Texas)–actually guarantee universal coverage. “Growing Consensus on Covering All, but How?” was the New York Times‘ headline on a summary of the debate (11/14/93).

MacNeil/Lehrer helped puncture the consensus–in large part because instead of presenting “both sides,” the debate featured members of four congressional factions: single-payer advocate Rep. George Miller (D.-Calif.), Clinton supporter Sen. Jay Rockefeller (D.-W.V.), Chafee supporter Sen. Nancy Kassebaum (R.-Kansas) and conservative Rep. Armey.

In contrast to discussions which start with the question of cost control, host Jim Lehrer began by pressing all participants on their commitment to universal coverage. Kassebaum said she supported “the premise of access for everyone.” Armey replied that “we can achieve universal affordability.” Rockefeller attacked the Republicans and conservative Democrats head on: “There are only two groups that support [universal coverage], and that is George Miller with the single-payer approach and President Clinton with his job-based approach.”

Bureaucracy vs. Market Forces

The New York Times‘ Clymer (10/17/93) also divided the debate between the Clintons and single-payer on one side, and Cooper and the Republicans on the other. Clymer admitted vaguely that the conservative alternatives were “less generous,” but also insisted they were “less complicated”–the Republicans and Cooper “all see a virtue in less bureaucracy.”

In fact, the U.S. market-based health insurance system is by far the most costly, bureaucratic and complicated healthcare system in the world. Peer-reviewed research published by Himmelstein and Harvard Center co-director Dr. Steffie Woolhandler (New England Journal of Medicine, 5/2/91, 8/5/93) found that private U.S. insurers spend 13 percent of every dollar for overhead, while Medicare and Medicaid combined average 3.5 percent overhead. Canada’s single-payer system has insured overhead of less than 1 percent.

False ideological assumptions about bureaucracy and competition dominate op-ed and editorial pages. According to Washington Post columnist Robert Samuelson (10/20/93), “We need to admit that reform’s twin goals–comprehensive universal insurance and cost control–are at odds.”

The General Accounting Office (6/91) and the Congressional Budget Office (7/93), however, both concluded that the savings on bureaucracy from switching to a single-payer system would almost immediately offset the increased cost of extending coverage to the uninsured and underinsured. Although single-payer achieves universal coverage and the conservative plans don’t, the CBO concluded that by the year 2000, annual national health expenditures under a 1992 single-payer proposal would total $169 billion less than projected under Cooper’s proposal.

Despite the fact that single-payer is the cheapest proposal on the table, journalists use the false equation of “cost” with federal expenditures to dismiss the Canadian-style plan. The Times‘ Clymer (10/17/93), wrote that single-payer requires “unpopular taxes,” causing some sympathetic Democrats to dismiss it as “politically impossible.” Clymer noted that these taxes would “replace” health care premiums, but didn’t note that within a few years they would likely total substantially less than the combined premiums and taxes paid under either the Clinton or Cooper plans.

When asked by a reader why the administration had not given serious consideration to the single-payer plan, USA Today (9/27/93) replied that a single-payer system would have “caused great disruption to the economy, resulted in higher taxes and given the federal government vast new powers.”

Beyond ‘Both Sides’


Some mainstream outlets avoid these pitfalls. MacNeil/Lehrer has made an effort to include single-payer supporters on its health reform panels. Last year, the Chicago Tribune‘s Sunday magazine section (5/31/92) carried a long article that examined the problems facing the Canadian system without obscuring the broader successful context. The Minneapolis Star-Tribune‘s special section on health reform (10/25/93) compared the U.S. system to those in other countries, and gave advocates of four reform approaches ample room to present their views. (Only single-payer, however, had a “counterpoint” placed in the middle of its argument–a distorted attack on the Canadian plan from HIAA spokesperson Ed Neuschler).

The medical press, including the New England Journal of Medicine and the Journal of the American Medical Association, has sustained a lively reform debate among medical professionals for years. Independent press highlights include special issues of Dollars and Sense (5/93) and the Washington Monthly (9/93), an In These Times piece by Woolhandler and Himmelstein (1/25/93) laying out the economic arguments for single-payer, and David Corn’s insightful reporting on the politics of the single-payer movement for The Nation (e.g., 10/18/93).