Challenges: Comprehensive Healthcare

Understanding the Healthcare Issue

The New York Times Video

The subject of health care, and more specifically the need to make quality health care available to all Americans at a reasonable price, has been under discussion since the end of World War II, and the conversation has become increasingly heated, and increasingly divided on ideological – although not necessarily partisan -- lines, since the turn of the century.
On one side of the issue is the view that health care is a right, and that the central government has an obligation to make it available, in the same way that public safety, education and economic stability are national responsibilities. This view has as its ultimate goal the same kind of single-payer universal, comprehensive national health insurance program available in every other industrialized nation, paid for through some form of taxation, such as Social Security. Some have described this objective as a form of “Medicare for all.”
On the other side of the issue is an extreme that health care is not a “right,” and that people with serious medical or health issues should expect to pay more for care than healthy people. While that perception may have been rational in the immediate post-World War II years of growth of the middle class in America, economic realities since then have resulted in income inequality that has worsened steadily since the 1970s, to reach levels not seen since 1928.
The first positive steps toward the single-payer approach, called the Affordable Care Act, also known as Obamacare, was grudgingly enacted by Congress in October 2009, Subsequently, while the administration of President Barack Obama made several significant adjustments to the regulation, administration, and enforcement of the law, Republicans in the House of Representatives led more than 50 specific attempts to undo, update, or replace the legislation, before succeeding by a narrow 217-213 margin on May 4.
A few years before his death in 2006, Dr. Milton Friedman, who was awarded the Nobel Prize in Economic Sciences in 1976 for his research on consumption analysis, monetary history and theory, and the complexity of stabilization policy, outlined the changes in society that gradually moved the nation away from a two-party approach to health care (meaning patient-doctor), to the present inefficient three-party approach (patient-doctor-insurer), which is by far the most expensive, while having the lowest performance in the world.
Friedman wrote that three key factors contributed to the changing attitudes, in the United States and in other industrialized nations. First, he said, were “rapid advances in the science of medicine; second, large increases in spending, both in terms of inflation-adjusted dollars per person and the fraction of national income spent on medical care; and third, rising dissatisfaction with the delivery of medical care, on the part of both consumers of medical care and physicians and other suppliers of medical care.”
While other countries moved to nationalize health care and centralize the means to pay for it, the United States did not. Friedman noted that American health care coverage continued to increasingly be a “benefit” provided by employers, supplanting the traditional approach of patients going to a doctor for treatment and paying for it directly. Introduction of the middleman of insurers to handle the financial transaction led to the growth of not only a new form of personal health insurance, but one of the fastest-growing U.S. service industries.
“We have become so accustomed to employer-provided medical care that we regard it as part of the natural order,” Friedman wrote. “Yet it is thoroughly illogical. Why single out medical care? Food is more essential to life than medical care. Why not exempt the cost of food from taxes if provided by the employer? Why not return to the much-reviled company store when workers were in effect paid in kind rather than in cash?”
At the same time, costs, not only for treatment and medications, have skyrocketed, and insurance premiums have soared accordingly. Specifically, premiums for health insurance have generally continued to rise despite improvements in insurance to help cover health care costs for more Americans with the advent of the Affordable Care Act. The U.S. insurance industry’s net premiums written totaled $1.2 trillion in 2015, with premiums recorded by life and health insurers accounting for 55 percent, according to S&P Global Market Intelligence.
At the same time, a Commonwealth Fund study, drawing upon three years of research on comparative health care programs in 11 industrialized nations (The full report, in PDF format, is available here.) found United States lags in these key elements:
• Healthy lives: The U.S. ranks last in infant mortality, (averaging 5.8 deaths of babies less than one year old per 1,000 live births) and on deaths (based on an average life expectancy of 79.8 years) that were potentially preventable with timely access to effective health care, and next-to-last on healthy life expectancy at age 60. (Idaho’s infant mortality rate, at 5.6, is somewhat better than the nationwide average. Average statewide life expectancy, at 79.5 years, is slightly below the nationwide average.)

• Access to care: People in the U.S. have the hardest time affording the health care they need. The U.S. ranks last on every measure of cost-related access. More than one-third (37 percent) of U.S. adults reported doing without a recommended test, treatment, or follow-up care because of cost.

• Health care quality: The U.S ranks in the middle. On two of four measures of quality—effective care and patient-centered care—the U.S. ranks near the top (third and fourth, respectively, among the 11 countries studied), but it does not perform as well in providing safe or coordinated care.

• Efficiency: The U.S ranks last, due to low marks for the time and money spent dealing with insurance administration, lack of communication among health care providers, and duplicative medical testing. Forty percent of U.S. adults who had visited an emergency room reported they could have been treated by a regular doctor, had one been available. This is more than double the rate of patients in the United Kingdom (16 percent).

• Equity: The U.S. ranks last. About four of 10 (39 percent) adults with below-average incomes in the U.S. reported a medical problem but did not visit a doctor in the past year because of costs, compared with less than one of 10 in the U.K., Sweden, Canada, and Norway. There were also large discrepancies between the length of time U.S. adults waited for specialist, emergency, and after-hours care compared with higher-income adults. The average per person cost of medical care in the United States passed $10,000 a year in 2016 for the first time.

Brought to you by MHA@GW:masters in healthcare administration

To help visualize the distinctions in health care delivery in the United States in relation to that in other countries, here is an infographic based on 2016 data as prepared by George Washington University’s Masters in Health Administration program.

“Now that millions more Americans have good coverage, we have to invest in our health care delivery system to be sure all patients—and especially those with the greatest need and whose care is the most costly—can get the high-quality, well-coordinated health care they need,” said Commonwealth Fund President David Blumenthal, M.D. “Those kinds of improvements will go a long way toward improving peoples’ health while making efficient use of our precious health care dollars.”
States have their own unique concerns and problems relating to healthcare affordability and delivery. While California, for example, could muster enough support in the state Senate for legislation to create a statewide single-payer health coverage program, that wouldn't even be considered in many states.
Needs also vary. The concerns over health care delivery, especially for elderly people, in states with large proportions of the population in rural areas, often with little or no medical treatment available, the cuts envisioned in the Republican "replacement" for the affordable care act would be untenable. That is true in Idaho, where, despite a gradual population shift from rural to urban, about 45 percent of the Gem State's 1.65 million people live in rural areas. The state has made some progress toward making medical care more available to those people.
The United Health Foundation, a research unit of United Healthcare Group, reports in detail where Idaho stands in comparison with other states in its most recent report on measures of healthy living for seniors. Thanks to partisan politics, however, most of that is once again in jeopardy. Spedifically in Idaho, according to information compiled by Close the Gap, the Idaho nonprofit that has led the Idaho drive for responsible health care legislation, the risk is high that 24 million Americans, including 134,600 Idaho residents, would lose their health insurance.
• Others would be denied Medicaid coverage as a result of a shift of $1 billion in federal funds to Idaho over 10 years, meaning coverage would no longer be available to many of the most vulnerable poor people with disabilities, children, and the elderly.
• Health insurance premiums copays would increase by thousands of dollars annually for millions more people.
• $38 million would be cut from insurance subsidies for low-income families.
• Annual out-of-pocket health costs would increase an average of $2,932 for people with coverage on the Your Health Idaho exchange.
• Although purporting to maintain coverage for people with pre-existing conditions, such protection is removed by giving individual states discretion on raising premiums, limiting or eliminating coverage.

The Affordable Care Act, (As Amended, 2011) Full Text (all 974 pages), is here.
A Washington Post analysis of the history and circumstances of Republican efforts to dismantle the Affordable Care Act is here.
The New York Times analysis of the healthcare deliberations expected in the Senate is here.

The PBS Newshour report on Senate GOP discussions on healthcare legislation is here.
A Washington Post review of significant changes in the enforcement and administration of the Affordable Care Act is here.
The New York Times report of the May 4 House of Representatives vote, by a narrow 217-213 margin, to repeal and replace the Affordable Care Act is here. Pew Research Fact Tank data, “U.S. income inequality, on rise for decades, is now highest since 1928,” is here. Dr. Milton Friedman, in “How to Cure Health Care,” from The Public Interest, Winter 2001 Issue, addressed the change in attitudes toward health care for all here.
A 2016 report on the U.S. insurance industry’s growth, from the Insurance Information Institute, is here.
A 2014 Ranking of health care quality by nation, from The Commonwealth Fund: “US Health System Ranks Last Among Eleven Countries on Measures of Access, Equity, Quality, Efficiency, and Healthy Lives,” is here.
The companion report, Comparative Health Care Rankings Among 11 Industrialized Nations, from “Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally,” is here.
Infant Mortality Global Rankings from the CIA World Factbook (2016) are here.
Life Expectancy Global Rankings from the CIA World Factbook (2016) are here.
World Health Organization Infant Mortality Data (2016) are here: Additional WHO Comparative Health Care Data (2013) are here. The very helpful George Washington University Masters in Health Administration Infographic “U.S. Health Care vs. The World (2016) is here.Mbr/> The World Health Organization Report, in PDF format, on “Measuring Overall Health System Performance of 191 Countries,” is here.
Idaho Health Care Standings Among U.S. States (2016), from the United Health Foundation (UHF is a nonprofit healthcare organization whose members include the United Healthcare insurance companies and numerous charitable healthcare nonprofits.) are reported here.
Per capita Health Care Cost in U.S. Passes $10,000, as reported by PBS Newshour via The Associated Press is detailed here.
“National Health Expenditure Projections, 2015–25: Economy, Prices, And Aging Expected To Shape Spending And Enrollment, “ as reported in the journal Health Affairs, are here.
The Kaiser Family Foundation’s April report “The Role of Medicaid in Rural America” outlines the importance of Medicaid and Affordable Care Act benefits for the elderly who live outside urban population centers.
The Los Angeles Times reported early in June on obstacles anticipated for a California Senate bill to provide universal healthcare.
The United Health Foundation's report on where Idaho stands among states in a range of health-related measures is here. The Close the Gap report “Undersanding the Coverage Gap in Idaho, in PDF format, is here.

How to Fact-Check 'Fake News' Web sites

A century ago, American journalist Elbert Hubbard, author of “A Message to Garcia,” wrote the definition of an editor as: “A person employed by a newspaper, whose business it is to separate the wheat from the chaff, and to see that the chaff is printed.” How times have changed: Now it is not only more difficult to distinguish wheat from chaff, but we are being confounded by a president who calls any published statement he disagrees with “fake news,” even as his own fact-checked statements are found to be falsehoods 73 percent of the time. During the election campaign, PolitiFact found only 15 percent of Trump’s statements were even partly true.
We know democracy is best served by informed voters. One of the key objectives of United Vision for Idaho is to help provide clear, accurate information on important issues, and to help voters distinguish fact from opinion so they may respond appropriately to key legislative issues at all levels, and to make their own best choices when they go to the polls. As President John F. Kennedy said, “The ignorance of one voter in a democracy impairs the security of all.”

Even before the Trump “fake news” onslaught, the American media landscape was undergoing a shift, particularly as the advent of cable, satellite, and Internet and social media outlets were making it more difficult to distinguish factual reporting from opinion and commentary, or even from outright lies. The blurred line between information and opinion was the focus of a March 2013 Pew Center report on “The State of the News Media 2013: An Annual Report on American Journalism.” To be sure, opinion has always been part of the American media landscape. In 1721, when Benjamin Franklin’s older brother James started the New England Courant, arguably the first American newspaper, he used it as a platform from which he launched countless attacks on the ruling powers in New England, assuring himself both editorial independence and commercial success. He railed against pirates and the undue influences of Cotton and Increase Mather, two Puritan minister brothers who instigated the Salem Witchcraft Trials, and published literary essays by Richard Steele and Joseph Addison from The Spectator to flesh out the straightforward reports of more mundane and less controversial ship schedules and cargo.

Audience Dwindles; Credibility Shrinks
Part of the change has been brought on by the increased emphasis on profit at the expense of content. In 1983, 90 percent of American print and broadcast media were owned and controlled by 50 different companies. Today, at least 90 percent of what we read, watch, or listen is dominated by these six media conglomerates:
- Comcast
- News Corporation
- The Walt Disney Company
- Viacom
- Time Warner
- CBS Corporation

At the same time, the advance of Internet delivery of news, and wider availability of cable and satellite TV, get more of their news online than from radio and newspapers combined. While this may be good news for trees, the shift has had its own downside. Last year, Pew, in its biennial study of news consumption habits, found 23 percent of people living in the United States said they’d read a print newspaper the day before. That’s half the number who did so in 2000, when nearly 50 percent read a paper the day before. Twenty-nine percent reported reading a newspaper in any format.
This decline or demise of many once-famous, well-respected and highly credible newspapers, among them the Hartford Times, the Chicago Daily News and the Rocky Mountain News, and news magazines such as Time, Newsweek, and U.S. News and World Report. As the print media have disappeared or fallen upon hard times, the survivors that have not adapted to electronic delivery have become practically irrelevant as primary sources of information, especially information at the local level. That is obvious in Idaho, which, in its relatively short history as a state, has never been a particularly rich media environment. As Pew Center research consistently confirms, local TV outlets are also beginning to show the effects of economic reality and popular demand. Rather than devote the time and reporting resources required to research and cover social and government issues, local television increases presentation of the staples – traffic, sports and weather – which make up about 40 percent of local news content. Complex issues, such as science and technology, education, and politics, are hardly addressed at all.
At the same time, cable news outlets devote more than 60 percent of their airtime to commentary and less than 40 percent to reporting (reflecting both audience demand and the need to spend less). And more of what reporting remains is coverage of what is sometimes described as “popular culture,” rather than on events or activities that actually affect and involve us. CNN now devotes less than half its programming to news. At Fox, it’s less than 45 percent. MSNBC, which is cast as a competitor to both, in fact brands itself as the liberal “place for politics,” and devotes a mere 15 percent of its programming to “hard news” reporting.

Cable News Falters Too
The rush to irrelevancy has not been lost on the audience. Nearly one-third—31 percent—of people say they have deserted a particular news outlet because it no longer provides the news and information they had grown accustomed to, according to the Pew survey of more than 2,000 U.S. adults early this year. The primary concern for people who gave up on an outlet seems to be quality. When asked which they noticed more, fewer stories or less complete stories, far more people (61 percent) said the latter. And those most likely to have walked away are better educated, wealthier and older than those who did not—in other words, they are people who tend to be most prone to consume and pay for news.
Turning away from the diligent coverage of real news comes at a cost, as CNN is learning. There, viewership has declined since 2008. Four years ago, nearly a quarter of Americans (24 percent in the Poynter study) said they regularly watched CNN. In the most recent survey, the CNN audience had fallen to 16 percent (21 percent watch Fox and 15 percent watch MSNBC). While there is obviously a market for those who tend to follow sources that agree with or reinforce their own beliefs, 64 percent said they “prefer getting political news from sources that don’t have a particular point of view, compared with 26 percent who said they would rather get news from sources that share their political perspective. This is on par with opinions since 2006.”
Making matters worse, another Pew study found more people who now get their news online, rather than in print or broadcast, admit they have shared “fake news” via social media, whether knowingly or not. The “instant” spread of information, especially false information, simply confirms a notion often attributed (perhaps falsely) to Mark Twain, that “A lie can travel halfway around the world before the truth can get its boots on.”
Nevertheless, and countering the Trump assertion that American media are “fake news,” those media are still widely trusted, according to a survey by Morning Consult, a media consulting firm. The study, in PDF format, is available here.

The UVIdaho Blog is part of our mission to serve Idaho voters by filling in the information gaps, shun blather, and clarify what is often a gap between information and speculation. In our Blog posts, we do not publish unsourced information. When possible, we back-check published reports and seek confirmation from a variety of resources, which we identify, to help our readers weigh the quality and credibility of not only what we publish, but what you may read or see or hear elsewhere. We hope you will tell others about our effort and guide them to the UVIdaho Blog. We also hope you will consider these guidelines in your quest for news.
You’re probably familiar with the Journalist’s Questions, the “Five Ws” of journalism: Who, what, when, where, and why. And, to the extent possible: What does this mean to me? In addition, thanks to Mike Bugeja, a former United Press International reporter and now director of the Greenlee School of Journalism and Communication at Iowa State University we should also apply the “Four Ds of journalism:”
• Doubt (healthy skepticism that questions everything),
• Detect (the nose for news” in relentless pursuit of the truth),
• Discern (priority in applying fairness, balance, and objectivity in reporting), and
• Demand (free access to information and freedom of speech). A truly balanced news report takes into account the limits of what is known at the time of reporting, and identifies what is known (and how it is known) as distinct from what is not known.

Speculation is not information, and thus is not news. Opinion, while separate from a straightforward account of events, is based upon the information obtained in pursuit of the news. To be considered valid, opinion should also be constrained by those “Four Ds,” and not wander off into the thicket of rumor, conjecture, or, worst of all, conspiracy theories. The information used to bolster opinion should be confined to the facts relevant to the argument being presented. In this way, opinion can justifiably be weighted to a liberal, or “progressive” set of values, or to a “conservative” set of values. The facts, however, should stand on their own.
The Best of What’s Left
So where do Americans get their news? Here is the list gleaned from results of the Pew Research studies and from News Trust, an affiliate of The Poynter Institute, the Florida-based nonprofit journalism training institute. News Trust regularly reviews content from a broad selection of American news resources to determine the most credible, trustworthy sources, peer-ranked on the basis of such criteria as immediacy, accuracy, clarity, identification of sources, and perspective.
The New York Times
The Guardian
Washington Post
Los Angeles Times
Wall Street Journal
Atlantic Monthly
Mother Jones
Rolling Stone
Huffington Post
Informed Comment
Daily Kos
Robert Reich
Think Progress
BBC News
ABC News
CBS News
NPR: All Things Considered
Wire Services
Bloomberg News
The Associated Press

Fox News Deemed Worse Than No News At All
As good as good can be in news coverage, the opposite is much worse. About one-quarter of Americans who responded to media surveys in the past three years (21 to 28 percent, depending upon the poll, with a 3-point margin of error in most reporting) put themselves at a serious knowledge disadvantage by relying upon sources that are not on the list above. The worst, in terms of credibility, verification of information sources, reliability, and trustworthiness, is Fox News Channel, ironically a subsidiary of the Fox Entertainment Group, which is part of the media and entertainment conglomerate controlled by Rupert Murdoch. Fox News was established in 1996, conceived to compete with CNN. Its founding chairman and longtime chief executive officer was Roger Ailes, who was President Richard M. Nixon’s primary media consultant in the 1970s. Ailes was ousted in 2016 after a series of allegations of sexual impropriety with members of the Fox on-air staff.
The origins of Fox are outlined in a 318-page memo titled “A Plan for Putting the GOP on TV News, archived in the Nixon Presidential Library, Ailes was almost prescient about what would become the current media landscape. He wrote: “Today television news is watched more often than people read newspapers, than people listen to the radio, than people read or gather any other form of communication. The reason: People are lazy. With television you just sit—watch—listen. The thinking is done for you.”
Ailes’s take on what is now the Fox News audience is supported by the findings of a 2011 Fairleigh Dickinson University Public Mind Poll that found Fox News viewers were less informed about current events than people who didn't follow the news at all. The survey had asked current events questions like "Which party has the most seats in the House of Representatives?" and also asked what source of news people followed. The Fox viewers' current events scores were in the basement. This finding was immediately trumpeted by rival media—by Fox, not so much—and has since become known as the Fox News effect. It conjures the image of Fox News as a black hole that sucks facts out of viewers' heads. Contrary to its logo claim of “fair and balanced,” Fox credibility, never very high, has actually fallen a further 9 percent in the past three years. A Public Policy Polling annual survey on media credibility reported in February this year that, just like Fox News ratings, credibility was at a record low, with 46 percent of viewers saying they do not trust it.
Part of Fox’s problem is in featuring commentators – people with a definite point of view – and presenting their comments as news, often with serious factual errors, editing video to delete content that does not comport with the Fox point of view, and outright lies, often taken verbatim from far-right personalities such as Mike Huckabee, Sarah Palin, Glen Beck, and Anne Coulter, without verification. Examples of these abuses of the most basic tenets of journalism and fair play were abundant during the 2012 presidential election campaign, and, although all media make mistakes, Fox has been notoriously poor about providing corrections.
To be fair, no media outlet enjoys a very high level of trust. And there is some built-in distrust of sources depending upon the political perspective of viewers. For example, none of those polled who associated themselves with the Democratic Party said they trust Fox News. The self-identified Republicans trusted Fox the most. “We continue to find that Democrats trust most TV news sources other than Fox, while Republicans don’t trust anything except Fox,” said Dean Debnam, president of Public Policy Polling. “News preferences are very polarizing along party lines.” In the first PPP poll, Fox was deemed credible by 49 percent of those surveyed. (Conversely, the most trusted TV news source, PBS, was rated as credible by 52 percent.) The most recent survey had a margin of error of plus/minus 3.5 percent.

PolitiFact’s running file of Donald Trump lies is here.
Politico’s report on the effect of lies from the Oval Office is here.
The Poynter Institute’s Media Trust report on the impact of the Trump Administration’s assault on media credibility is here.
A Huffington Post report on the post-election media revival is here.
The Pew Center’s 2013 report on where Americans get their news is here.
The Pew Center’s 2016 report on how the media has responded to the changes is here.
The 10 best resources for fact-checking are here.
The Pew Center’s 2014 report on political polarization and media trust is here.
The Pew Center report on how people are turning away from television as a news source is here.
The Farleigh Dickinson University/PublicMind poll and analysis of how some media actually make people less informed is here.
The Huffington Post report on steep declines in Fox News credibility is here.
The Pew study showing increased sharing of “fake news” through social media, specifically Facebook and Twitter, is here.

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