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The Ombudsman Column

Single-Minded About Single-Payer

PBS's venerable public affairs and investigative series Frontline is, I confess, a favorite of mine, and has been for as long as I can remember watching public television. For me, Frontline, along with CBS's "60 Minutes," is the best of what is in terribly short supply on American television: reliable, authoritative, in-depth reporting on the important issues of our time and on matters that we need to know more about.

That doesn't mean that at times it doesn't stumble, or produce something that draws questioning and substantive criticism from viewers. Indeed, Frontline has been the subject of several ombudsman columns over the years. Yet one of the distinguishing things about Frontline from where I sit is that many of those who write at times to express disagreement frequently do so by also saying, first, how much they respect the program. In other words, even when it is bad, in their view, it's still good.

At least some of that ambivalence was in evidence this week when our office was deluged with almost a thousand critical e-mails from people who said they were upset and angry that an hour-long look back at how the White House ultimately hammered out a historic agreement on health care, aptly titled "Obama's Deal," failed to deal with the single-payer system advocated by many of those who were not part of the deal.

Many of these e-mails appeared to have been generated in response to a handful of websites that criticized the program for what they saw as failures to deal fairly or adequately with this single-payer option and with one of its major proponents, Dr. Margaret Flowers. She is an activist member of Physicians for a National Health Program (PNHP), who also appeared in the film, and was interviewed briefly on camera.

The PNHP is a non-profit organization that claims 17,000 members — doctors, medical students and health-care workers — and is dedicated exclusively to a single-payer system of national health insurance, with the government as the single payer in what they say would be an expanded and improved version of the existing Medicare program that would cover all Americans.

Dr. Flowers' letter to me is posted below, followed by responses from Frontline's series editor, Ken Dornstein, and the program's producer, Michael Kirk.

Also, there is a critical statement from a spokesman for Sen. Ben Nelson (D-Neb.) about the portrayal of his boss on the program and the role of what was dubbed the "Cornhusker Kickback." This is followed by a Frontline response and an acknowledgment that it should have done better.

But first, some things that struck me as I watched the program, and some later thoughts about the single-payer criticism from Flowers and others.

A Target That Was Still Moving

On balance, I thought about three-fourths of this program was an excellent public service; that it pulled together in typical Frontline-style an intense look at a new president struggling to pull together a historic yet bitterly contested deal on health-care reform. It was much more about the inside deals and with whom, how and at what cost they were made than about the details of health care. Some of the deals clearly seem distasteful, and the picture of the freshman president who made them is fascinating but not altogether flattering. Whether or not you followed this tortuous process that consumed the first year of the Obama presidency, the program, in my view, succeeded in making sense of the endless daily sound bites we all experienced trying to follow this confrontation. It coherently piled up the crucial sequence of public and closed-door moments, the themes, compromises, political realities, self-interests, greed and general nastiness of politics and lobbying.

On the other hand, as a viewer who at least tried to follow the news coverage all year, I felt the program began to feel rushed and ended abruptly; that the producers were shooting at a big and historic target that was still moving through Congress and that they ran out of time without dealing with important changes in the final legislation. The program ended with the 219-212 victory for the Senate's bill in the House of Representatives on March 21.

Most importantly, there was no coverage or reference to the reconciliation process that followed soon after and to the numerous revisions, some of them quite costly, that were made. Some of the most publicly controversial deals — especially the so-called "Cornhusker Kickback" with Sen. Nelson that got a fair amount of coverage in the film — were removed from the legislation, but you wouldn't know that from watching the film.

There were no scenes of the racial and anti-gay ugliness reportedly experienced by some Democratic lawmakers outside the Capitol at the time of the final votes. And a fleeting snapshot of House Speaker Nancy Pelosi at a tense White House meeting, which may well have been accurate as far as it went, struck me as somehow unfairly diminishing her overall role in the final passage.

Not on, or Off, the Bandwagon

The specific absence of the single-payer theme, or even mention of it, did not strike me as I watched the film. I was aware of that approach to reform and the degree to which it had a large following. But it never really was on the table as something the administration wanted as its main health-care reform proposal and, as a viewer, I saw "Obama's Deal" as what journalists would call a tick-tock, an attempt to reconstruct how something important, for better or worse, actually happened.

Yet I believe the critics make a couple of important points that I agree with, and that I, too, find puzzling about Frontline's approach to this issue. The single-payer plan, as Producer Michael Kirk points out in his response printed below, was never considered by the White House or congressional leaders as a viable political option and therefore did not play a significant role in last year's political debate and deal making.

On the other hand, this is not a typical throw-away or easily cast aside idea. A public opinion poll by CBS News and the New York Times in February 2009 reported 59 percent of respondents said the government should provide health insurance, and a study published in the Annals of Internal Medicine concluded that the same percentage of doctors "supported legislation to establish national health insurance." A bill introduced years earlier in a House committee by Rep. John Conyers (D-Mich.) supporting the single-payer plan through an expansion of Medicare had 87 co-sponsors as of February 2010 (more than any other universal health-care bill) and lots of labor union support.

So, while the hard-nosed journalistic decision may be to focus on the real options and debate, it seems to me that to ignore something that was out there and popular with millions of people and thousands of health-care professionals but not really on the table, was a mistake. Although obviously tight on time, the producers should have found 30 seconds to take this into account because many Americans support it yet the deal makers never mention it nor is the politics of discarding it addressed.

What is also puzzling to me is that this is the second time that producers of major Frontline programs on health care have decided not even to mention the single-payer system with respect to would-be reform. The other program was a March 31, 2009, broadcast of "Sick Around America" which provoked a substantial amount of controversy and that I also wrote about at the time.

Here's Dr. Flowers' Letter:

It was with a sense of deja vu that I watched "Obama's Deal." As in "Sick Around America," the producers did a disservice by the failure to educate the public about the bigger picture of the health care situation in this nation and the range of possible solutions. Curiously, just as it was in the health "debate," single payer, improved Medicare for All, was also excluded from the film. The major point of the influence of health industry dollars on the reform process which should have been mentioned is that these dollars were spent in order to restrict the debate and protect industry profits. The lucrative status quo would have been threatened if single payer had been openly discussed because a publicly-financed national health program can provide high quality universal health care and control health care costs, something that a private insurance based system cannot accomplish.

After watching this film, viewers would have no idea that single payer exists or know that there is a strong movement for it. Considering that there have been attempts to push for a national health program for over 100 years in this nation and that, because of a strong grassroots movement, single payer legislation was nearly introduced on the floor of the House in November and was actually introduced on the floor of the Senate for the first time in this nation last December, the omission appears to be intentional.

Those of us in the single payer movement are accustomed to being censored by the corporate media. The reason for our exclusion is known: health insurance and pharmaceutical corporations advertise heavily on these airwaves and wield considerable power over the programming. This was described clearly by Fairness and Accuracy in Reporting's August 2009 piece titled "Single-Payer & Interlocking Directorates: The corporate ties between insurers and media companies" by Kate Murphy.

The producers at Frontline carefully cut single payer out of the film. When the host, Mr. Kirk, interviewed me for "Obama's Deal," we spoke extensively of the single payer movement and my arrest with other single payer advocates in the Senate Finance Committee last May. However, our action in Senate Finance was then misidentified as "those on the left" who led a "counterattack" because of "liberal outrage" at being excluded. This occurred despite an email exchange following the release of the preview in which I specifically requested that the producers identify that we are a nonpartisan group fighting for single payer: a health reform model based on evidence of what is effective here and abroad and on health policy principles. This mischaracterization unfortunately mirrors the way in which the health industry has portrayed the single payer movement (verified by Wendell Potter, a former Cigna executive).

When I wrote [Producer Jim] Gilmore with my concerns about the omission of single payer when I saw the preview, he responded that he hoped I would see that my role was treated fairly and that they correctly identified the role I played. I disagree that my role was treated fairly because I was misidentified as a leftist and there was no mention of what single payer is or why we advocate for it or why it was excluded from the debate. I hope you will address my concerns about this omission.

Here's Frontline's Ken Dornstein's Response:

We understand the frustration of Dr. Flowers and others in what she calls the "single payer movement" who felt excluded from the debate; and they are perhaps right in suggesting that the "debate" was narrowed from the start by the influence of various special interests and by political expediency or ideology. But we can assure Dr. Flowers that her interview with FRONTLINE was not left out of this broadcast to satisfy any similarly motivated agenda to narrow the debate; and we do not believe we abdicated our responsibility to educate the public about the various possible proposals to reform the health care system.

"Obama's Deal" was centered on the political process that led to the final reform bill, and on what that process revealed about the president and his style of governance during his critical first year in office. While there is much to say about the merits of the single payer idea — and about the politics of why it did not, in the end, figure significantly in this past year's debate — this issue ultimately fell outside the scope of this single hour of television. This is not "censorship," as Dr. Flowers argues, it's the work of journalism to report widely on a topic, then find the sharpest focus for his or her reporting, unfortunately leaving out much strong material along the way to shaping the clearest communication possible in the time or space allowed.

We understand that this will not satisfy many in the single payer movement — and many others may rightly complain about the lack of focus on a host of other issues that fell outside the scope of this broadcast. But we trust that the viewers can also see the merits of the film that was produced, and appreciate "Obama's Deal" for what it was: The most comprehensive telling of this year's historic health care reform process to be seen anywhere on television, and an important examination of the tough choices made during the president's first year in office.

'Obama's Deal' Producer Michael Kirk Adds This:

After talking to Dr. Flowers, administration officials, legislators, and other knowledgeable insiders, we concluded that a 'single payer' plan was never considered by the White House or Congressional leaders, and did not play a significant role in the last year's debate. Whether the 'single payer' option should have been considered is an issue which should be debated and discussed, but was outside of the scope of this particular film.

The section that included Dr. Flowers was focused on the power of the insurance lobby and showed how activists like Dr. Flowers were excluded from the debate over the bill. The protesters themselves said they were protesting the fact that they had been excluded from the debate, so we believe we presented the protests in the proper context.

Dr. Flowers alleges that her views may have been excluded because of the power of "health insurance and pharmaceutical corporations." We believe that any fair viewing of the film will show that the decisions on what to include and exclude from the film were based on our best journalistic judgment, and not the influence of corporate interest groups.

Kickback About the 'Kickback'

What follows is the main portion of a statement from Nebraska Sen. Ben Nelson's spokesman Jake Thompson issued on April 13, the day that "Obama's Deal" aired on PBS:

The program presents a flawed and irresponsible portrayal of the Nebraska Medicaid provision in the Senate health bill. No one associated with the program ever contacted Senator Nelson or his office requesting his explanation. This is an appalling disregard of the first rule of honest journalism — to seek all sides of a story.

Had anyone followed this basic journalistic duty, Senator Nelson would have provided documentation showing how he blew the whistle on a large unfunded federal mandate that would have socked states with a multi-billion dollar bill. He would have explained that he had asked Senate leaders for an opt-in provision for all states, so they could decide if they could afford its cost. With no Congressional Budget Office analysis available, he subsequently accepted Senate leaders' decision to insert the Nebraska provision in the Senate bill as a placeholder. He didn't ask for it, it did not win his vote, nor did he want help for only Nebraska. He always intended it as a placeholder to fight for eliminating the unfunded mandate, or providing federal funding for all states, in the final bill worked out with the House.

Frontline's Ken Dornstein Replies:

We understand that Senator Nelson has contacted [PBS President and CEO] Paula Kerger about last week's FRONTLINE broadcast, "Obama's Deal," and that his office has issued a press release critical of FRONTLINE's reporting. In light of this concern, we have carefully reviewed the film and consulted with the production team. At issue is our reporting on the widespread perception that Senator Nelson's vote for the Senate health care reform bill in December of last year was the result of a deal for $100 million in Medicaid funding for Nebraska.

While we stand by this reporting, we also want to acknowledge two of Senator Nelson's points: We should have contacted his office during the course of our reporting, and we should have made mention in the film of the fact that he publicly denied the widely-held view of a $100 million deal for his vote.

In any future national broadcasts of "Obama's Deal" — and on the version of the program that we stream on our web site — we will reflect the senator's denial. We have already updated our web site to include: links to the senator's public statements on the matter; the chronology of events produced by his office; and a transcript of his interview with Fox News that aired the morning after our broadcast. We hope that this will correct the record, and improve an otherwise strong film on the complicated process that yielded an historic piece of legislation.

My Thoughts on This

I have some sympathy for Sen. Nelson on this matter, and think Frontline did the right thing in acknowledging its omissions. I also think that had the film made a little room for covering the reconciliation aspect, that it would have naturally brought it back to clarify the Nelson episode. By not doing so, it left itself vulnerable on both points — failure to cover what ended up becoming the final law and failure to explain Nelson's role more fully.

Frontline did, concisely and dramatically, capture that moment just before Christmas when Nelson, indeed, became the final, crucial 60th vote of the overall "deal" that the president was prepared to bless and that the program sought to illuminate. The Nebraska deal — $100 million for increased Medicaid funding for his state — immediately smelled badly to almost everybody, even to the governor of Nebraska (a Republican) and most Nebraskans.

But if you watched only this program, you would have the impression that the "Cornhusker Kickback" was not just part of "Obama's Deal" but part of the final legislation. It was in the health-care reform bill, but was removed, along with other things, during the reconciliation process.

Even before then, explanations were being offered. Early in January, Nelson was saying publicly that his objective was to bring the Nebraska treatment to the rest of the country and was calling for Democrats to get rid of the special provision that Senate Majority Leader Harry Reid had offered him in December. By February, Nelson was saying he was pleased that the measure was to be stripped from the latest White House proposal. As it turned out, the White House and Democratic congressional leaders did make this aid provision apply to all the states, which will considerably increase costs.