Health care reform under Trump: A guide to “universal access” and other slippery slogans 

Trudy Lieberman is a veteran health care journalist and regular contributor to She tweets as @Trudy_Lieberman.

The next health care reform messaging war has begun, and when the slogans start flying, some reporters start following.

We’ve been through this before. In 2009 during debate on the Affordable Care Act, hardly a day went by without some news organization passing along the shop-worn phrase, “affordable quality health care for all.” It worked like magic for the Democrats even if the public wasn’t sure what that meant. The public found out once the law went into effect as some families, especially those who got no government help to buy insurance, learned about the high premiums, high deductibles and high coinsurance they’d have to pay.

These costs were anticipated and Oregon Sen. Ron Wyden predicted that affordability and underinsurance would continue to bedevil American families. Why weren’t more news outlets reporting on that? I asked him during debate on the law. “It doesn’t fit their idea of news,” Wyden told me. After some prodding from Vox’s Sarah Kliff, House Minority Leader Nancy Pelosi acknowledged, “I think we missed a beat in messaging all along.” Slogans and clever messages can backfire.

Now lawmakers are engaged in a second war over Obamacare and new slogans are making the media rounds. Deep explanations of what the words mean still don’t seem to fit some new organizations’ idea of news.  Democrats have no control over the legislative process, Vox reported, and their only hope is to stir up public opposition until the GOP gives up. Slippery slogans stir up the pot all right, but the public needs more than the watery broth they offer.

In the spirit of helping those who cover the war, I offer here a brief primer on the new messaging vocabulary and how to think about what the slogans really mean – especially when it comes to variants of “universal” care.

Universal coverage vs. universal healthcare vs. universal access

It’s a sure bet those words will be tossed around, but the distinction among them can be vague – or worse, deceptive — and misunderstandings can muddy political discourse quickly. Journalists need to cut through the jargon to make sure readers understand what it is we’re really talking about.

Universal coverage means that everyone in the country is covered by insurance, such as that provided by the national health insurance plans of nearly all European countries and Canada. Citizens are entitled to coverage as a matter of right, and the health system pays for their care. The Affordable Care Act was never meant to provide universal insurance coverage. It was expected only to be “more universal,” as if the term universal could be modified by the word “more.” Supporters simply wanted private insurance and Medicaid to cover more people, and the law provided subsidies to individuals and state Medicaid programs to make that happen. About 30 million people would remain without insurance largely because there weren’t enough federal dollars allocated for subsidies to help buy it. And without subsidies, most of them could not afford it.

Universal healthcare means everyone can get treatment when they need it, at least theoretically. Having insurance, though, doesn’t automatically translate into care. High deductibles, high copays, and high coinsurance increasingly mean insured people skip care, even care they need. Those high out-of-pocket costs, part of America’s skin-in-the-game approach to cost containment, are not barriers to care in other countries that have true universal systems and other ways to control medical costs. In addition, individual doctors and physician practices don’t accept health insurance from all insurance providers. That’s a problem for Medicaid patients, and it’s becoming one for Medicare beneficiaries, and also for commercially insured patients who find themselves with a narrow choice of providers. The latest Commonwealth Fund survey found that “although the U.S. has made significant progress expanding insurance coverage, it remains an outlier among high-income countries in ensuring access to healthcare.”

Universal access is a back- to-the-future solution that some politicians are already talking about to address the conundrum of the law’s central features – the individual mandate and preexisting conditions. In order to cover sick people, commercial insurers must have a big pool of customers that includes lots of healthy people. Requiring everyone to carry coverage was supposed to make that happen, but it didn’t quite work out that way when enough healthy people didn’t sign up. Premiums exploded through the proverbial roof, and many carriers pulled out of the market claiming they couldn’t make enough money (although their profits don’t seem to be suffering).

Universal access can mean many things to watch for and explain. Over the weekend talking to Washington Post reporters, Donald Trump announced “we’re going to have insurance for everybody,” which without specifics could mean anything. A replacement plan could provide universal access allowing all sick people (who presumably would no longer be able to buy coverage in the private market) to get coverage through a high-risk pool. That remedy has been tried before — unsuccessfully. High premiums and skimpy coverage made these plans unattractive.

Universal access might also mean that everyone with a preexisting condition could get a policy but with waiting periods before their conditions were covered. That used to happen in the old days. It could also mean insurers would still have to take on sick people, but if policyholders let their coverage lapse, they wouldn’t be able to get a new insurance policy unless they paid much higher premiums.

Another version could require people to have continuous coverage for 12 or 18 months before being allowed to buy a new policy. The idea is to deter sick people from signing up only when they need insurance. Variations of this twist are used in other insurance arrangements. Seniors wanting to buy Medigap policies must do so during the first six months they’re eligible for the program without having an insurer question their health.

Other slogans to watch out for

Make America Sick Again.  The Democrats’ riff on Donald Trump’s Make America Great Again is a cutesy, ambiguous description that obviously needs lots of scrutiny in any news story. Does it mean the subsidies granted by the ACA will disappear and everyone who loses them risks getting sick without insurance? Remember, millions of struggling American families already don’t qualify for subsidies — like a family I’ve been covering for the last eight years that already has had major health problems.

Then again, what happens if the subsidies that do exist are replaced by tax credits favored by Republicans? They probably won’t be as generous as subsidies. A credit of $3,000 would hardly make a dent in premium costing $13,000 a year. Skimpy tax credits could make it harder for people to buy good policies that pay for sufficient care.

Chaos. That’s the word that Senate Majority Leader Chuck Schumer repeatedly used in an interview with Politico to convey the idea that scrapping Obamacare will cause major upheaval in the country. “It’s chaos rather than affordable care,” said Schumer. Really? What does chaos look like? Collapsing companies and markets? It’s hard to see such giants as WellPoint and UnitedHealthcare going out of business since they make oodles of money from other kinds of insurance. Phrases like “insurance markets will collapse” need a lot of explanation. If people lost their subsidies and insurance, there could be fewer people in each insurer’s individual market and that could become a problem especially for those who remain – the people who buy in the market but don’t get subsidies because their incomes are too high. Lawmakers aren’t talking about them, but journalists should be.

Thoughtful, explanatory journalism can help shape the debate

Despite bluster from both sides, in the end there will be compromise, and the slogans will disappear.  But what will we be left with? The New York Times  reported, “Some lobbyists have tacitly accepted the likelihood that major provisions of the health law will be repealed, setting their sights instead on shaping its replacement.” One insurance executive said his industry would have more to say when Congress turned to the task of devising a replacement for the law. You bet they will, along with the rest of the healthcare industry.

The challenge for reporters is to leave the slogans in the dirt and get on with the task of good explanatory journalism. Says former insurance executive and blogger Robert Laszewski, “The press is still fighting the last war over whether Obamacare is good or bad. That war is over. Where do we go from here?”

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Comments (2)

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Sarah Christopherson

January 24, 2017 at 5:41 pm

What an odd, odd piece, particularly if the goal really is to foster a careful discussion about and more enlightened news coverage of the health care reform debate. Did “premiums explode through the proverbial roof”? I suppose, if by “explode through the roof” Ms. Lieberman really means, “But even if premiums increase by the 10 or 15 percent overall that some are predicting for 2017, they will still be far lower than premiums otherwise would have been in the absence of the law.” (via Health Affairs, “Obamacare Premiums Are Lower Than You Think”).

But sloppy, slogan-ish ways to describe premiums and the individual mandate aside, it seems strange to mention “affordable quality health care for all” but not “death panels,” perhaps the most memorable phrase of the entire health care debate. Or to caution against “chaos” but not against “freedom,” the literal description given by Rand Paul for his proposal to allow skimpier plans with higher deductibles.

Wading through the spin (for example, both sides promise coverage for pre-existing conditions but they mean very different things) is helpful. I’m not sure this piece accomplishes that.

    Cathy S

    February 13, 2017 at 5:18 am

    I scrolled down to find that Sarah had captured my thoughts to a T. This piece doesn’t rise to Healthnewsreview’s usual standards!