Finding the Holes in Obama’s Healthcare Speech

Allison Kilkenny Sep 11, 2009

“My job is to point out where the holes are,” Trudy Lieberman explains to me during our phone interview. I called Lieberman to get her opinion of President Obama’s health reform speech, and I also asked her to grade the media’s performance in explaining the issue of reform to the American people.

A veteran journalist, who has reported on health care and consumer issues for over thirty years, Lieberman is a contributing editor to the Columbia Journalism Review, has taught in the Science, Health and Environmental Reporting Program at New York University and the journalism program at Columbia University, received numerous honors and awards, and is the author of five books, including the Consumer Reports Guide to Health Services For Seniors, which was named one of the best consumer health books for 2000 by Library Journal.

With over three decades experience covering health care, Lieberman has amassed a wealth of knowledge with which she hopes to arm average citizens. Her job is to “point out where the holes are” when politicians talk about health reform, and Lieberman spotted several holes in Obama’s speech last night.

For months, CJR and Lieberman has been “hammering away at [Obama] to be a little more articulate about what this whole reform effort is about,” says Lieberman. Last night, in her opinion, Obama came closer to defining his message when he said his plan would meet three basic goals: provide more security and stability to those who have health insurance, provide insurance to those who don’t have it, and slow the growth of health care costs.

Public option (for less than 5 percent of Americans)
As usual, Lieberman has clearly defined the “what’s in it for me?” question many Americans may be asking themselves. An area of confusion involves Obama’s declaration that he would sign into law a bill that said no insurance company could deny people for preexisting conditions.

“He seemed to be saying that in relation to people who already have coverage, and he made it very clear to them that they won’t be forced to change coverage, change doctors, or any of those sorts of things. What he didn’t say was that employers often change coverage to get cheaper premiums, or to get a different carrier, and when they do that, people often have to find new doctors, so I don’t know how meaningful that promise was. He seemed to be talking to the individual market people,” says Lieberman.

Obama promised the American people that insurance companies would no longer be allowed to deny coverage if you’re sick.
“But that is not an issue in the employer market,” Lieberman says. “It’s a big issue in the individual market. So my take is that he was sort of mixing up apples and oranges here. It was not clear to people exactly what he was saying to them and what it would mean to them.”

According to Lieberman, the really big “take away” from the whole speech, and for people who have insurance, is that they’re not going to be able to use any kind of public option, no matter what form it takes. In the speech, Obama clearly stated that the public option would only be for those citizens who don’t have insurance. No one would be forced to choose it, and it would not impact those without insurance, and then he went on to say that the Congressional Budget Office has estimated that less than 5 percent of Americans would sign up for it.

“What they’re doing there is limiting its usefulness to only people who do not have insurance…which raises the question: what’s all the hullaballoo about the public plan in the first place [if] most Americans wouldn’t even be able to access it?” asks Lieberman.

Insurance Exchanges
While the concept of “triggers” has entered our lexicon, “insurance exchanges” may be a foreign term to anyone living outside of Massachusetts, a state that currently utilizes a healthcare system similar to an exchange. Lieberman has been blogging extensively about Massachusetts’s health care system (the entire archive can be read here).

“[Insurance exchanges] would work very much like the Connector up there,” says Lieberman. Massachusetts’s system of health care is called the Commonwealth Health Insurance Connector Authority, also known as the Health Connector (”Connector” for short). “It would be sort of a brokerage operation – a big, glorified brokerage operation where insurance companies – if they wanted to sell in this market – would make their policies available probably subject to some minimal standards of coverage.”

All the insurance companies that want to participate in this market would design a policy that they could sell. “They would be free – pretty much – to sell what they want, again subject to whatever minimum standards Congress comes up with. So people could go into the market and buy one of these so-called approved policies,” Lieberman explains.

The part that Lieberman says she finds “baffling” is the issue of leverage. Obama has proposed a system where people, who are going to be able to buy in this exchange, will somehow be able to exert leverage on providers and insurance companies in the same way big employers and the government do when they select insurance for their employees. “I don’t see how that is possible. I just don’t understand how these small people buying in this market are going to exert any kind of leverage over Aetna and WellPoint.”

Risk Selection
If the agreement is that every American must be covered, and they must buy insurance, Lieberman believes insurers won’t be able to give up “risk selection,” the process where an insurer tries to attract people with a lower-than-average expected risk of ill health and deter those with a higher-than-average expected risk in order to increase profits.

“Even though it sounds good, the rhetoric sounds great, they can’t give [risk selection] up if they want to stay in business, so they’re going to find a way around that…It’s the whole question of age-rating.”

Age-rating is when insurance companies use the age of someone as a proxy for medical underwriting. Insurers may agree to cover everyone, but they could also charge a lot of money to older people, who are more likely to get sick. “A 55-year-old woman, or a 58-year-old man — likely starting to have some kind of health problems show up — may get charged a lot more, and in the Baucus plan, which is being circulated, they could be charged as much as five times more than a younger person,” says Lieberman.

There may be increased coverage, but Lieberman is concerned about the quality of the expansion. “I think that everyone has to ask themselves, yes, they can get coverage, but at what cost? And is that the reform people want?”

Grading the Media
The horse race coverage of the healthcare reform debate does not impress Lieberman. The chatter of “Who’s up; who’s down? Who’s winning today? Does Pelosi have the votes? What’s going to be the game-changer? What should Baucus do because he can’t get the votes out of his committee?” doesn’t inform citizens, she says. “That kind of coverage certainly wouldn’t rate very high—probably C-, but I tend to be a very tough grader.”

Lieberman is concerned that people are being miseducated about healthcare reform. That’s part of the reason she’s been doing town hall meetings for CJR where she goes to different places and interviews people (the CJR town hall archives are here). Her experience at these meetings reveal how little the media teaches citizens. “People have no idea what any of this is, and what it means to them.”

For example, Lieberman asked shoppers in a Pennsylvania Wal-Mart about the issue of healthcare reform. In one particularly colorful interaction, she interviewed an eighty-one-year old man named Russell Fullem. Lieberman barely got the words “health care” out of her mouth before Fullem boomed: “I believe we should have the same insurance as Senator Kennedy had, and I will broadcast that everywhere.” Lieberman wrote that Fullem seemed to be saying he was in favor of health care equity when he added, “I want the same insurance to go to the biggest and best hospital in the world to take care of my cancer [if he gets it].”

Of course, Fullem doesn’t want socialism. Fullem said that Vladimir Putin had told Obama that his country had had enough socialism, so why should the U.S be getting it now? He believed that Obama himself had the best health care in the world, but “he’s trying to shove something down us that’s unrecognizable. It’s socialism,” he concluded.

Lieberman pressed him a little further and asked him what he thought was in Obama’s plan. His answer: it was going to cost too much. She pressed for a few specifics, and Fullem, who considers himself a “political independent leaning toward a constitutionalist,” brought up the death panels. “If people are going to die, he [Obama] is going to put them to sleep. It’s like Soylent Green. That’s his health plan.”

Death panels with a pinch of Socialism. Either the President has failed to get his message to average citizens, or the media has distorted the message. Lieberman seems to bestow a hefty share of the blame on the media. “When you take a look at the coverage in that sense, I would give them an F,” she says.

But she’s quick to add that there have been bright spots here and there. Sometimes, Lieberman says she finds a piece that begins to fill in the details. “The Kansas City Star and Kaiser News came out with a couple of really good pieces that began to explain the individual mandate.” The Kaiser piece shows the holes in the whole subsidy question, and how people are still going to have huge out-of-pocket expenses even with these subsidies.

And yet subsidies were not “explicitly discussed by Obama last night,” says Lieberman . “He talked about the aggregate cost—$900 billion over 10 years—but he didn’t say the taxpayers will be paying this, and more importantly, he didn’t say who’s going to get these [subsidies,] and under what circumstances. So that’s another big missing piece.”

Lieberman is worried that Joe Wilson’s tantrum (and his cry of “You lie!”) will distract from the real issues in the same way Joe the Plumber hogged the spotlight. She writes at her CJR blog, “This time, we hope leveler heads will prevail, and assignment editors will be more interested in having their reporters explain and answer for their audiences the ‘what’s in it for me’ question, using some of our observations as a guide.”

We shall see.

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