Michael Joyce produces multimedia for HealthNewsReview.org. He tweets as @mlmjoyce
Attempts at health care reform in the United States go back over a century. If you wanted to find just one politician and one journalist who are well versed in both the history of those reform efforts, as well as what might be needed moving forward, you would be hard pressed to do better than Dave Durenberger and Trudy Lieberman.
Durenberger was a progressive Republican senator for Minnesota from 1978 to 1995. He was a chairman of the Select Committee on Intelligence as well as the Health Subcommittee of the Senate Finance Committee. He’s also a former chair of the National Institute on Health Policy at the University of St. Thomas in St. Paul, Minnesota.
In this interview recorded in his living room in January, 2017 — just one week after the inauguration of PresidentDonald Trump — we cover a lot of ground, but mostly focus on why reforming health care in this country is such an intractable problem.
After speaking with Durenberger it struck us that it would be interesting to have a veteran health care journalist listen to the interview and share her memories and reflections on the exact same issues over the same period of time.
Trudy Lieberman has been a reporter for nearly 50 years. She started as a consumer reporter for the Detroit Free Press in 1968. Health care was just one of many topics she covered as a consumer reporter but, as the issue became increasingly important to the public, it became a passion for the Nebraska native. Lieberman has been published in Consumer Reports, The Nation, Harper’s, and the Columbia Journalism Review (the “CJR” to journalists, where she has been a contributing editor for 20 years). She is considered one of the most knowledgeable health care reporters in the country and that is why we feel fortunate that she writes for us as well.
Two things struck me about interviewing her. First, she clearly combines wisdom and diligent preparation as she opines effortlessly on healthcare policy, ethics, finance, media, advocacy, etc. … but always with an empathic awareness of consumers (aka “the reader” or “the patient”.) Secondly, she is proof that you can be assertive and humble at the same time, and I think that comes through in this Q&A.
MJ: How did you get into health care reporting?
TL: I came to it by doing a lot of insurance ratings and Medicare ratings for Consumer Reports where I worked for nearly 30 years. The last 20 or 30 years I’ve focused a lot more on health care and health policy.
MJ: Your memories of Dave Durenberger?
TL: I remember a friend of mine was a congressional intern for him but I never met him in person or interviewed him. But I do remember him being very active in health care.
MJ: What are your impressions of how Congress handled health care reform back when you started versus now?
TL: In terms of where Congress is at with health care reform – what’s possible and the stumbling blocks that exist — they are the same ones that have been there since the beginning of the 20th century. I’ve been covering health care since the early nineties and when I look back at what I wrote for CJR in the early nineties (Clinton’s first term), what struck me is how similar those stories were to what I’m writing about now with the Affordable Care Act (ACA, or Obamacare). What is different is that Congress seems less polite. There’s not a lot of tolerance for other people’s ideas and thoughts as there used to be.
MJ: Makes me wonder if not much has changed, why are we so stuck when it comes to health care reform?
TL: Let me answer that by giving examples of my coverage of health care reform efforts in the nineties and compare that to what I’ve written lately about Obamacare. During the Clinton years there was an alternative reform plan by a Tennessee Congressman named Jim Cooper (Democrat; 1983-1995) that people called “Clinton Lite”. The plan got a lot of coverage because it was a middle-of-the-road-centrist plan, versus the Clinton plan which was considered both far-out and not even close to a national health plan. My criticisms of Cooper’s alternate plan were almost the same as my criticisms of Obamacare. First, the American people knew very little about either plan. Secondly, there was a lack of skepticism by the press when it came to investigating the claims made by Cooper. The reporting was serving as a bulletin board for the Washington policy wonks. It didn’t help ordinary people understand how health care reform would change their lives. I could have used the exact same words when Obamacare passed as I did writing about Cooper’s “Clinton Lite”. Same issue. Same results. Same stories.
MJ: Can you give me some specific examples?
TL: Sure. The Cooper plan called for subsidies just like the Obama plan. Cooper didn’t explain what would happen to those people who were too rich to qualify for subsidies, but too poor to buy coverage on their own. So, back in 1994, I raised the question: “How would a family in this situation get insurance?” …well, I raised the exact same question during the debates on Obamacare. And this is now one of the big crisis points with the Affordable Care Act. And even though we have more media now the coverage hasn’t changed much either.
MJ: Yet other countries have tackled health care for their people fairly well. Is there something unique to America which might account for our struggles?
TL: Part of it is we don’t have a parliamentary system. I harken back to Theodore Marmor, a Yale Professor Emeritus of Public Policy and Political Science, who’s written extensively on Medicare. His point was that if we had a Westminster parliamentary system, it’s likely America would have gotten a national health insurance system long ago. I think it also has to do with the fact that American political institutions are really fragmented. It disperses power across many different people and institutions.There are a lot of veto points. There is no assurance a sitting president, even with a majority, can get something as controversial as health care reform passed. Finally, and this is very germane, is the representation of special interests. You have physicians, hospitals, drug companies, insurance carriers and even high-tech companies which are all very well funded and well represented. They can be very persuasive and often carry the day. That was true in the Clinton years and it’s true now. These special interests have pretty much controlled the debate in the end.
MJ: I asked Dave Durenberger this too: Is it that Americans don’t VALUE health care reform … or … we don’t UNDERSTAND it?
TL: I think Americans, on some level, don’t understand it. We do value health care when we need it. There’s an analogy with our financial system. When we get into really complex financial interactions how many of us really understand them? Do we really grasp our banking system? It’s so complex, like health care. Even something as simple as understanding our benefits is something most of us can’t understand because the language is so oblique. So many people don’t even know the basic difference between Medicare and Medicaid. Like Durenberger said in your interview: “if we don’t even understand the basics, how are we supposed to have an intelligent discussion about how our system should change?” We have to find a way for people to learn, otherwise we concede to the special interests. And that’s where the media come in.
MJ: Do you think most reporters understand health care reform?
TL: No. I don’t think they understand the system either. I once asked a journalism professor how much health policy he was teaching and he said ‘as little as I can get away with!” This gave me pause, because you’re basically telling journalism students it’s boring. Yet they can’t be good journalists without understanding it.
MJ: So what would be your advice to journalists who want to improve their health care reporting?
TL: Anybody who wants to be a good health care journalist has to start by reading widely. Not just science but they must learn how the health care system works. There are a lot of good books out there. At the very least learn how Medicare works. Secondly, find people you trust who understand health care and sit down with them and have them explain the basics to you. I did that and those lessons come back to me in nearly everything I write. It takes time, but that’s what it takes. Finally, do the same thing with science. Nobody is born knowing the difference between absolute and relative risk. But once you know such those things you’ll be in a position to do good reporting.
MJ: What about consumers? Where can they turn to get reliable information?
TL: I just published a story last week in CJR on health care reporting. I mention a number of outlets including StatNews, Vox for health policy, HealthNewsReview.org, and the New York Times and Washington Post for general topics.
MJ: How would you grade Obamacare?
TL: I agree with Durenberger that it gets an “F” for getting the message out. It did some things that were very good but in a way that is coming back to haunt. What it tried to do was bring more insurance to more people. It was never intended to be a national health insurance program like in Britain, Canada or France. They tried to craft a more universal type of arrangement on to a private system and it’s hard to make that work. Without an individual mandate to make people buy coverage, only the sickest people would likely sign up and that leaves insurance companies with a lot of high claims, costs and eventually higher premiums for everyone. This is sort of what we are experiencing now. The way it was sold was with the slogan: “Affordable, Quality Health Care for All!” But that was an over-promise, and the framers knew that it wasn’t achievable, as the public has found out over the last few years with escalating premiums. Some people now feel lied to and that’s why there’s backlash. Even Obama, in one of his exit interviews, said “I guess I could have sold it better.”
MJ: What about the Republicans?
TL: I think the Republicans were strangely silent at first, especially about the individual mandates, but later became very vocal and forced the discourse further to the right. That precludes us from ever moving toward a truly national health care system in the foreseeable future. That also means we won’t have the cost controls that are necessary to contain those high prices we see in almost all health care services. In your interview with Durenberger he said “Republicans are for cost containment” and I thought “really?”
MJ: Speaking of Durenberger, anything in our interview with him either resonate with you or push some buttons?
TL: He said that Democrats should have written a more liberal bill – he probably meant either a Medicare-for-all or public option. And I’m guessing why they didn’t is that they were beholden to the same special interests who have never wanted it … the doctors, hospitals, drug companies, and insurance carriers. They would all object because both Medicare-for-all and a public option would be a foot in the door toward national health insurance. And that is the last thing they want. Because if there were such a thing, that would bring cost controls and their incomes would be affected. So — aside from the politics and veto points — we have special interest groups that are NEVER going to let that happen. And that is the long and short of why we don’t have a national health insurance plan in this country. But I’d like to add something else that never gets talked about but I think is worth mentioning. Is that OK?
MJ: Sure. Go ahead.
TL: There is no social solidarity in this country. About half of us believe health care should be available to everybody, and we should pool our risks — like Germany and Britain do — across the rich-and-poor, young-and-old, and the sick-and-well. But we don’t have that kind of solidarity in this country. The other half says they don’t want to pay for somebody else’s healthcare. In other countries with national health insurance systems you would never hear anybody say that. It’s unthinkable.
MJ: One last question Trudy. And thanks so much for your time and insights. Why do you do what you do?
TL: I’ve never wanted to do anything else but be a reporter. It’s the thrill of the chase. Finding something new. Having a window on how government and business operate. Going after those who prey on the little guy. But … it’s always about helping the public. Explaining something to help them, like understanding our economic system and our Byzantine healthcare arrangement. That is what journalism is all about. Too often we journalists forget that. We are not writing for our sources, or our editors, or to get that next job. We write for the public.
The Durenberger interview for the podcast was recorded on Thursday, January 26, 2017 in St. Paul, Minnesota. Video clips from the interview are available here.
I spoke with Trudy Lieberman by phone on Tuesday, February 7, 2017