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Health Care Policy Is Always a Human Interest Story

It does your readers no good to keep them at a remove from the partisan politics that built this calamitous system.

Joe Raedle/Getty Images

Eli Saslow is a Washington Post reporter whose award-winning work on rural hospitals tells stories that a well-to-do Beltway reader could never even imagine. Hospital staff working without pay; patients living hundreds of miles from specialists they need; doctors coping with the lonely and emotional burden of serving an isolated, older population that depends on their care—everywhere there is a bleak picture. But Saslow’s stories fail to mention one major factor that drives the decline of rural hospitals: The decision made by 14 states not to expand Medicaid under the Affordable Care Act, leaving millions uninsured.

An investigation by the Pittsburg Morning Sun found that 72 percent of rural hospital closures since 2010 occurred in states that didn’t expand Medicaid. The state with the worst rate of hospital closures, Kansas, did not expand Medicaid; 64 percent of its hospitals lost money in the last decade. Rural hospitals suffer when states don’t expand Medicaid because the populations they serve are sicker, older, and less likely to be insured, but hospitals still have to treat these patients when they get sick enough to need emergency care (which is more likely when you can’t afford to get cheaper primary care). When they’re covered by Medicaid, the government picks up the tab. When they’re not, the hospital can send the patient the bill—something else Saslow has reported on—but they’re likely to end up eating the cost.

Politico reporter Dan Diamond spoke to Saslow about his series in August, and asked him why he never mentions Medicaid expansion. His answer was lacking. Diamond wrote that Saslow told him he aimed to “bring readers into the scene, people and moments rather than focusing on partisan fights, like the debate over Medicaid.” Saslow went on to tell Diamond that he’s “not a policy reporter,” adding, “I hope in my best moments, my stories reflect the shortcomings of policy.”

This is simply not enough. Readers are not experts; they rely on reporters to fill gaps in knowledge as fully as possible. How can you be so sure that a reader will be able to connect the dots between lack of Medicaid expansion and the decline of rural hospitals? Unless this key detail is included, you can’t. If you don’t tell a reader why this is happening, you haven’t advanced their knowledge of the “shortcomings of policy” at all—you’ve just told them some sad stories.

Saslow’s work paints a horrifying picture of the bigger problems with American healthcare, only one of which is the lack of Medicaid, but it’s precisely this problem—that American health care is a nightmare from almost any angle—that makes it impossible for the reader to draw any particular conclusion about what can be done without more guidance. More broadly, a reporter cannot truly tell these stories, however powerfully they do it, in isolation from the policies that led there. Politics is about who gets hurt, and when you are telling the stories of those who got hurt, it’s dishonest not to point out who’s hurting them, and how.

In this way, omitting mention of the way Republicans have road-blocked Medicaid expansion is a kind of malpractice, because it denies those readers the concrete means to demand change. The idea that readers are somehow better off for setting the petty politics of health care policy aside is a classic example of a solution in search of a problem. There’s value in a story that generates sympathy for our fellow citizens, caught in this predicament. But this value is magnified when you can give the readers something concrete about what—and who—is causing it in the first place.

Yes, in Washington, there are two bickering sides over Medicaid, in that one party wants it and the other does not. One side wants to expand Medicaid in the dreadfully limited way that the Affordable Care Act allowed, to cover everyone who makes less than 138 percent of the absurdly low poverty line, instead of keeping it limited to certain categories of unfortunate person deemed more deserving. The other side does not want to expand Medicaid at all, even though the federal government would cover the majority of the cost, and is okay with more people dying if that’s the consequence, which it is.

But among the public, Medicaid is broadly loved: 74 percent of voters have a favorable view of Medicaid overall. And when you shift the scene to states in which Republicans dominate politics, this affection holds: 60 percent of voters in deep-red Idaho voted to expand Medicaid with no work requirements; 53 percent of voters in Nebraska and Utah did the same. Medicaid expansion is only a “partisan fight” when it’s viewed through a Beltway lens. There’s no reason in the world why Saslow has to ruthlessly maintain this point of view in the course of his storytelling. The only thing he’s ensuring by doing so is that his readers will emerge from those stories ill-equipped to fight back.

And lawmakers could use all the help they can get. In order to save the lives of those in these underserved rural communities under Trump, some state Democrats have had to contend with Republicans holding Medicaid hostage to the establishment of vicious work requirements, which exist to punish the poor. In states like Virginia and New Hampshire, Democrats compromised with Republicans to allow the state to impose work requirements in exchange for expanding Medicaid—though in Virginia, those requirements won’t kick in for years, and a judge blocked New Hampshire’s requirements, weeks after the governor delayed their implementation because it became clear they were likely to kick off 68 percent of those subject to it.

It’s not entirely clear how the public feels about work requirements; as Vox noted last year, polls that ask about the same policy framed in different ways produce starkly different results (which is true of a lot of issue polling). If you ask people if they support denying Medicaid to people who don’t work, the public says no; if you ask them if they support work requirements in order to get Medicaid, they say yes. Naturally, these two things amount to the same thing, but it speaks to the political difficulty that Democrats might feel they face in fighting work requirements. Like so many terrible Republican policies, work requirement policies have the advantage of appealing to a basic American value—Work Is Good—that Republicans cherish and Democrats either agree with or are too afraid to really challenge. (Work, in fact, is bad.)

There is no reason to think that voters are demanding work requirements for Medicaid recipients, or that they would punish Democrats for fighting them, and the experience of disastrous rollouts in states like Arkansas should warn even the cruelest Republican politicians that they’re playing with fire. Sadly, on the state level, Democrats just don’t have a lot to fight with; Republicans have invested in state politics at rates that vastly outstrip Democrats for decades.

Which doesn’t mean they’ve given up. In Missouri and Oklahoma, progressive groups are aiming to get Medicaid expansion on the ballot, following the ballot box successes in other states in 2018. Other states, like Texas and Georgia, don’t have that option, leaving their citizens to struggle until Democrats make inroads; Texas has the highest uninsured rate in the country, and currently only allows parents making less than 15 percent of the poverty level to apply. (That’s $196 a month for a single mother of one child.) This situation leads to the absurd reality where someone unlucky enough to live on the wrong side of the Missouri-Illinois border can make the difference between catching breast cancer early and letting it grow to the size of a walnut; where you have news articles talking about doctors in a “border city” seeing “how the coverage differences affect people,” as if we’re talking about Juárez, not St. Louis.

Medicaid should not have to exist, because there should not have to be a separate safety net program for the poor that will always be vulnerable to right-wing attacks, always have to shoulder higher costs, always be seen as second-class. There should be one plan that covers everyone, because no one deserves better care than anyone else; Jeff Bezos should have to go to the same hospital as a laid-off Amazon warehouse worker. Until we have single-payer, however, it is willful ignorance and borderline maliciousness to refuse to acknowledge what Republicans are doing in refusing to expand Medicaid: They are killing people. Not every story has a bad guy, but this one does. You have to tell your readers the truth.