Wait and see

Two weeks after the U.S. Supreme Court’s decision on the Democratic health care plan came down, the public remains poorly informed about what the plan contains—and journalism has been very little help at solving that ignorance. Both CNN and Fox got the Supreme Court ruling wrong, both initially reporting that the individual mandate in the Democratic plan had been overturned by the court.

The problem of misinformation about the plan began long before that, of course. In March, a Kaiser Family Foundation survey reported that 14 percent of the public believed the plan had already been overturned by the U.S. Supreme Court.

Other Kaiser surveys found that many features of the law are popular, like tax credits for small businesses offering coverage and the right of patients to appeal decisions, but that the public did not know the Democratic plan contains them—and the number who did know it was declining. In April 2010, 75 percent of respondents to a Kaiser survey said they knew that the law would provide subsidies for some low-income people. By March of this year, that number had dropped to 56 percent.

Nevada School of Community Health Sciences dean Mary Guinan at the University of Nevada, Las Vegas, said this week that the law is so long and lobbying and advertising did so much to distort its provisions that the public has no real idea of its content.

“Even I don’t know, now, what the state of it is,” she said after the court protected some parts and overturned others.

A few days before the court ruling, health care writer Trudy Lieberman of the Columbia Journalism Review wrote that “the enemies of the Act are winning the communications war. And they seem to have the help of the media.”

Lieberman, who reported on health care and insurance for three decades at Consumer Reports, said in an RN&R interview that the public remains poorly informed after the court ruling.

“They didn’t understand it as the act was going through, the debate was going on three years ago,” she said. “They don’t understand it now. They didn’t understand it after Obama signed it into law in March of 2010. … And I don’t think anything has changed.”

She said there is plenty of blame to go around, including to President Obama.

“He didn’t do very much to tell people what it was all about and why he needed it. And that’s something we talked a lot about at CJR, and I think that’s a big problem. That opened the way for a lot of demagoguing by Republicans.”

Guinan said some parts of Nevada’s perpetually unhealthy health profile could be improved by the plan.

“We have a very poor [screening] rate in Nevada for cancer,” she said. “It’s clear that screening for cervical cancer can actually prevent the cancer, because pre-cancerous lesions can be found.”

She also said Nevada currently has a half-million people with poor or no insurance, about 300,000 of whom could now qualify for Medicaid under the law. The other 200,000 could use the state insurance exchange. Medicaid is a program of health care for low-income people.

But Nevada’s extent of participation in Medicaid is still uncertain. A peculiar line of argument being used in Nevada on whether state Medicaid programs will be opened to more Nevadans has emerged since the Supreme Court decision, which upheld making an additional 17 million people nationwide eligible for Medicaid in 2014—but further ruled that states cannot be penalized for not expanding its Medicaid programs for those people.

Under the Democratic plan, the new income threshold for Medicaid eligibility is $29,000 dollars a year for a family of four. In Nevada, Gov. Brian Sandoval has taken a wait-and-see position on whether Medicaid eligibility should be expanded.

Some of the debate on whether that should happen in Nevada has dealt not with whether more poor people should be served but on whether doing so would help the state’s economy by bringing more federal dollars into the state.

The Las Vegas Sun, for instance, quoted UNLV professor Robert Lang saying that Clark County lags in the size of the health care industry-share of the economy. Nationally, that share is 18 percent, and in Clark County, it is 14 percent. Beefing that up could provide 40,000 jobs in the state, Lang said.

That line of argument troubles Guinan. “I think that’s a rather unfortunate approach to health care, saying it should stimulate the economy,” she said

Democrats themselves may be surprised by some of the consequences of the new law, particularly in continuation of the trend—already under way in the private sector—of dumping more health costs on consumers and workers. Congressional Democrats closely tied the program to insurance companies. Lieberman said the continued primacy of insurance companies is likely to mean large, even shocking increases in insurance costs.

“So what you’re beginning to see now are policies with humongous deductibles like not just a $100 or $200,” she said. “We’re talking $5,000 or maybe $10,000 in some cases. And I’ve seen a few that go as high as $20,000 or $40,000. … In addition to the high deductible that people are facing, there is going to be other kinds of cost sharing. And I’m not talking about raising a co-pay from $40 to $60. I’m talking about the substitution of co-insurance for co-payment. And co-insurance is the percentage of the bill that the insurance company or the employer requires you to pay. And that number is going up as well. So then instead of, say, 10 percent co-insurance on some services, you might be paying 30 percent, or 40 or 50 or 60.”

She said many people will likely pay the fine for not having insurance instead.

Lieberman also said the patient’s experience in the doctor’s office will probably be unchanged. Nothing in the Democratic program simplifies things. The practice of having to deal with a mini-bureaucracy in every doctor’s office will, if anything, get worse.

Nevada was not a party to any of the lawsuits against the federal health plan. But two Nevada governors—Jim Gibbons and then Brian Sandoval—sued as private citizens. Sandoval must administer the plan. A recalcitrant governor could have an impact on how the plan is carried out. Guinan is hopeful that will not happen because Sandoval is more moderate than Gibbons was. By way of contrast, on Monday, Texas Gov. Rick Perry announced he would not expand Medicaid there and would try to obstruct other provisions of the law. Guinan said, “I believe he [Sandoval] is more understanding of the needs of the people of Nevada for health insurance. … Better heads will prevail.”

Lieberman said state governors can decide not to have the state insurance exchanges called for by the Democratic plan. Not, apparently, in Nevada, though. Nevada lawmakers created an exchange last year, and $75 million is in hand for its operation. It does not appear the governor has the authority to block its operation now. Even if he did, Lieberman said, the federal government would just come in and run it.

One way a governor could hurt the federal program is through the state insurance commissioner, who in Nevada is appointed by the governor. “A governor who is not keen on the act could certainly control what his state insurance commissioner was going to do, vis-à-vis regulation. And they may not regulate these policies very strongly.”