National Conversations About the Costs of U.S. Health Care

Abstract

This study evaluated 531 newspaper articles and television transcripts to examine how the U.S. media presented the issue of rising health care costs from 1993 to 2010. The prominence of health care coverage, the expert sources, and the presentation of the causes of rising health care costs were assessed. Results suggest that the president influenced health care news coverage, while expert sources quoted in the reports influenced how the causes of rising health care cost were presented. Findings contribute to the growing body of academic literature on agenda building theory and provide insights for health care reform advocates interested in maximizing their media advocacy efforts.

Keywords

agenda building health media content analysis

Introduction

Health care in the United States has become one of the top social issues of the past decade (DeNavas-Walt, Proctor, & Smith, 2010). With heath care costs rising and 16.3% of the U.S. population uninsured in 2010, the “best health care system in the world” now faces system-wide flaws and needs significant revamping (Bentley, Effros, Palar, & Keeler, 2008; Federal Trade Commission [FTC], 2011, Executive Summary, p. 1). Without health care system reform, experts predict health care costs will continue to grow. Between January of 2010 and December of 2011, health care expenditures as a percentage of the national gross domestic product (GDP) increased from 16.8% to 18.2% (Aaron & Ginsburg, 2009; Miller, Hughes-Cromwick, & Turner, 2012).

Economists have tracked the complex issue of health care costs in the United States since the 1960s, describing rapid growth between 1970 and 1989 that slowed and leveled off in the decade that followed (FTC, 2011). Since the 1990s, increases in health care costs, along with increases in the use of ever more expensive medical services (Bodenheimer, 2005), have driven spending steadily higher. U.S. spending on health care (as a percentage of the GDP) now outpaces health care spending in other developed countries by more than 6 percentage points, increasing from 5.1% of the GDP in 1960 to 16.2% in 2007, easily the highest per capita health expenditure in the world (Bentley et al., 2008).

Rising health care costs and the issue of health care reform have been a focus in the news media especially during the past three U.S. presidential administrations, and reform efforts topped President Obama’s agenda when he took office in 2009. Ensuring access to basic health care in the United States continues to challenge political leaders today as the struggling U.S. economy drives more people out of employer-sponsored insurance coverage and weakens the government safety net provided by Medicare and Medicaid (FTC, 2011).

As the issue of health care affects all Americans, it is not surprising that this ongoing national conversation about rising health care costs has produced voluminous discussion in the news media. Gitlin (1980) proposed that the way issues, such as rising health care costs, are portrayed by the media tells the audience what is important to know about an issue. These media portrayals can have significant effects on audience attitudes and public policy. Furthermore, news media are among the key forces in the process of building the health and news agenda for the general public and policy makers by identifying, selecting, and developing story ideas and then disseminating these messages to the public (Bennett, 2005; DeVreese, Peter, & Semetko, 2001; Graber, 2006).

Research has shown the power of the mass media in helping to shape public policy (Cook et al., 1983; Gamson & Modigliani, 1989), and studying the media coverage of important social issues can highlight possible avenues to address these issues, particularly through influencing public perception and policy (Iyengar, 1991). The media themselves are also subject to influence from news routines and national level politics, among other influences. The purpose of this study is to examine how the U.S. media, including newspapers and television, presented the issue of health care costs from 1993 to 2010. Specifically, the prominence of health care news coverage across media outlets over time, types of expert sources, and the presentation of the causes of rising health care costs are assessed in an effort to explore how forces in and outside of the newsroom influenced the coverage of the rise in health care costs for nearly three decades.

This research is guided by agenda building theory, first identified in Cobb and Elder’s (1971) study of politics and the news, which recognizes that many players influence the news agenda, both internally (i.e., individual journalists and the news organization) and externally (i.e., sources of information and the public). Guided by the demands of normative media routines, journalists identify, select, and develop story ideas and, along with their news organizations, play key roles in the agenda-building process; their roles include determining how prominently to showcase a story (e.g., placement in newspaper and length of article) and weighing the importance of sources and facts in a news story. A number of studies have shown that, particularly in the case of complex science or health topics, journalists rely on experts sources for help in not only providing information but also choosing a focus for a story (Len-Rios et al., 2009; Tanner, 2004).

The presentation of the causes of rising health care costs is also addressed in this study. Therefore, framing theory, as it pertains to attribution of responsibility, also contributes to the theoretical underpinnings of this research. Previous studies have examined media coverage of health or social issues from the perspective of agenda building and attribution of responsibility (Entwistle, 1995; Kim, Carvalho, & Davis, 2010; Len-Rios et al., 2009).

The current study, on the other hand, examines news coverage of health costs and examines findings in the context of media routines and agenda building research. In this way, this study contributes to the growing body of academic literature on how various influences in and outside of the newsroom help shape, or build, the health news agenda regarding health and social issues. Furthermore, by examining the quantity and the nature of the news coverage, combined with an analysis of the changes over time, study findings may also provide important insights for health care reform advocates on both sides of the political spectrum who are interested in developing a strategic communication plan to maximize the effectiveness of their media advocacy efforts.

Literature Review

It is well documented that mass media serve as agenda setters for important health care and other political issues, transferring these issues from the media to the public’s agenda (McCombs & Shaw, 1972). However, there are also significant influences on the media’s agenda. Agenda building theory suggests that multiple entities, such as government, societal influences, and media themselves, reciprocally influence one another to construct the issues receiving attention in the press. Lang and Lang (1983) addressed the influences on media’s content, suggesting a series of feedback loops that produce and are produced by the media’s content. More than a decade later, Shoemaker and Reese (1996) emphasized the complexity of the process through their examination of news media routines, even when the field is narrowed to focus only on the media involved in the production of news.

Scholars have defined a widely accepted set of key influences on the news media. First, expert sources of information, such as public officials, play a pivotal role in the development and shaping of a news story (Johnson et al., 1996; Len-Rios et al., 2009; Wanta, 1991). Not only are sources used to provide perspective and add balance to a story (Boyce, 2007; Conrad, 1999), they may also help journalists generate story ideas and aid in the development of a particular idea (Tanner, 2004). For example, Curtin (1999) found that one in four newspaper managing editors frequently use public relations sources as the basis for a news story; Sigal (1973) contends that media relations materials from governmental sources are indispensable for the Washington press. The president of the United States has the most access to news media, and thus the power to influence media agendas (Lang & Lang, 1983).

News routines of individual journalists or of a news organization influence reporting on an issue, from how the issue is presented to the prominence the issue receives (Corbett & Mori, 1999; Kim et al., 2010; Lang & Lang, 1983; Tanner, 2004; Tanner & Friedman, 2011; Tanner, Thrasher, & Blake, 2012). The amount of time, or the amount of space, given to a news report as well as the placement of that report (i.e., the “lead” story in a television newscast or a front-page story in a newspaper) are often based on the traditional news values (e.g., impact, proximity, timeliness, conflict, oddity, prominence, and currency of an event) that news publishers and producers know will appeal to their audience (Shoemaker & Reese, 1996). News staffers must also decide how much time and resources should be spent pursuing particular stories and sources of information (Gandy, 1982). As suggested by Corbett (2006) and Tanner (2004), although it may appear that media “take the lead” on a complex issues, it is more likely that media are receiving cues from elsewhere in the social system, such as national politics and media routines. Furthermore, because of the complex nature of the issue of rising health care costs, journalists who cover this issue may be even more reliant on expert sources of information (Boyce, 2007; Entwistle, 1995). Research suggests that the media are often dependent on the expert sources when covering complex medical or scientific issues and for explanations of the importance of this information (Bauer, Allum, & Miller, 2007; Boyce, 2007; Corbett, 1998, 2006; Corbett & Mori, 1999; Dennis, 1991; Tanner, 2004; Tanner & Friedman, 2011).

The type of medium (print vs. television) in which news content appears may also influence the presentation of an issue. Kaniss (1993) contends that television news reporters often cover stories that are easy to do rather than those that should be covered (see also Tanner, 2004). Other studies support these findings, suggesting that local television stations are passive in their news discovery and rely heavily on routine news events (i.e., press conferences) and officials for story ideas (Berkowitz, 1987; McManus, 1990). Furthermore, television news is more likely to present news reports as episodic rather than thematic (Iyengar, 1991). Episodic framing involves storytelling, often focusing on the “personal” or “human” aspects of an issue, whereas thematic framing places a topic in a larger social context, often requiring detailed research and data collection (Iyengar, 1991; Kim et al., 2010).

By analyzing health care cost news content, a primary goal of the current research is to explore how the news media presented the problem of rising health care costs from 1993 to 2010 by examining the news media’s use of expert sources and the prominence of health care cost news coverage. The type of medium (television and newspapers) is also considered.

Research Question 1: How much attention, or prominence (front-page placement), has the issue of rising health care costs received across media outlets between 1993 and 2010?

Research Question 2: What associations exist between the sources of information included in the news reports and media type (television vs. print)?

The Presentation of Health Care Cost News Coverage

News media topically and thematically “frame” news content in easy-to-understand interpretive packages, and it is realistic to presume that audiences use these frames to process the information. As noted by Entman (1993), framing “determines whether most people notice and how they understand and remember a problem” (p. 54). It is for this reason that politicians and corporations often compete with each other and with other journalists over the frames that will be used in media stories (Hallahan, 1999). Iyengar (1991) suggested that the news media may shape people’s perceptions of who is responsible for a particular social problem. For example, Kim and Willis (2007) found that media portrayals of who is responsible for obesity both shape and are shaped by people’s perceptions of the issue.

As health care cost is a complex topic with many social, economic, and political contributing factors, the current study focused on five potential causes for rising health care costs as a means to assess the content of the news coverage. First, patients themselves can be a reason for the increasing costs by making poor lifestyle choices, including unhealthy food selections and sedentary routines. These practices can lead to poor health and a demand for more extensive and expensive medical services (Thorpe, Florence, Howard, & Joski, 2004). Health care providers (e.g., doctors, hospitals) can be another cause. Profit-driven health care entities increase costs to cover uncompensated care and the rising costs of doing business (Bodenheimer, 2005). Physicians can contribute to rising costs by ordering unnecessary tests because patients want them or because the physicians fear litigation if something is missed (Bodenheimer, 2005). Insurance companies might also be a cause of rising costs. Insurance price increases may be related to increasing medical spending as well as the decrease in market-level control of prices as insurance companies consolidate and gain market power (Robezniek, 2012). The government may contribute to rising costs through bureaucratic waste and inefficiency, especially in Medicare and Medicaid (Kronick, 2009). Finally, pharmaceutical companies can be a cause as they push for higher profits by raising drug prices and sending powerful lobbies to Washington to work against regulation of these industry practices (Angell, 2004).

The current study explores how the media presented the issue of rising health care costs between 1993 and 2010, specifically focusing on the relationships among the cause of rising health care costs and the sources and type of content contained in the reports.

Research Question 3: What associations exist between presentation of the cause of rising health care costs and the content of the health care cost reports (i.e., expert sources of information and news vs. editorial content)?

Finally, real world events, especially presidential politics, also serve to prompt media coverage of specific issues. Since the 1960s, when President Lyndon B. Johnson signed into law Medicare and Medicare legislation, the issue of health care and health care reform has frequently dominated the media’s and the public’s agenda (Goodridge & Arnquist, 2009). Therefore, the final research question was developed.

Research Question 4: How did presidential administrations (Clinton, Bush, Obama) influence the news coverage of rising health care costs (i.e., prominence of news articles, sources used, and presentation of the cause of rising health care costs)?

Method

Sample

Newspaper and television news content examined for this study was obtained from a keyword search using the LexisNexis and ProQuest databases, which are widely used, searchable archives of media content. Sources for this content include network and cable television news and newspapers. Using “health care cost” or “medical cost” as keywords appearing in the headline, lead paragraphs, or index terms, we used LexisNexis to retrieve articles published in six national and regional newspapers: The New York Times, The San Francisco Chronicle, The Birmingham News, The Dallas Morning News, and Star Tribune. News articles from The Wall Street Journal, which were not available in LexisNexis, were retrieved using the identical keyword search in the ProQuest database.

In selecting these newspapers, we tried to include as many different regions of the country as possible. The New York Times and The Wall Street Journal represented the Northeast Region. The San Francisco Chronicle and Star Tribune were selected to represent the West (California) and the Midwest (Minnesota). The Birmingham News and The Dallas Morning News represented the South (Alabama) and the Southwest (Texas). In selecting these local newspapers, we also considered each paper’s circulation size and availability in the LexisNexis database. From each state (California, Minnesota, Alabama, Texas), we first examined which newspapers were available in the LexisNexis. From those available, we then picked the paper with the largest circulation size. Using the same keywords, we also retrieved news transcripts from five television networks (ABC, CBS, NBC, Fox News, CNN). This procedure for gathering newspaper and television news content for analysis has been used in previous examinations of health-related information (Kim & Willis, 2007).

Our analysis included news stories published or aired between January 1993 and August 2010, except for those from NBC and Fox News, in which news transcripts were available starting from January 1997 for NBC and January 1999 for Fox News in the LexisNexis database. The time frame for data collection (1993-2010) was chosen because this 18-year span allowed the researchers to capture health care cost coverage spanning the Clinton, Bush, and Obama (first term) presidencies. The 18-year time period includes the years 1993 and 1994 when President Clinton made his unsuccessful proposal to reform health care. The time period also includes the first 2 years of the Obama administration (2009 and 2010), during which the president’s proposal for health care reform was introduced and heavily debated and some version of it (Patient Protection and Affordable Care Act) was passed.

Our search yielded 4,635 newspaper articles and 635 television news transcripts, a total of 5,270 news stories, matching the search terms “health care cost” or “medical cost.” We chose to use these broad search terms in order to ensure that we would not miss any relevant content. While this strategy does produce a substantial number of articles that must be excluded because they simply mention the keywords, it prevents missing content that might be related and not be captured by a narrower search. In anticipation of capturing a number of articles not focusing on health care “cost,” we oversampled (n = 80) news articles and transcripts in order to ensure we would be able to draw at least 50 related stories from each news outlet. Using systematic sampling, we then produced a manageable sample of 480 newspaper articles and 338 television news transcripts for content analysis. An additional screening by the coders, which was guided by specific rules developed to make consistent exclusion decisions for articles not focused on health care cost, further eliminated 180 articles and 107 transcripts that were (a) outside of our specific focus on health care cost or (b) duplicates of the original news item (e.g., same articles appearing in different weekly edition or, in the case of broadcast transcripts, a tease for later in the program). While intercoder reliability was not calculated for exclusion decisions, this strict set of guidelines ensured that the primary focus of each included article was on health care cost. A total sample of 300 newspaper articles and 231 news transcripts related to the topic of health care cost was obtained. This sampling method is based on similar studies of health content (Kim et al., 2010; Kim & Willis, 2007). For purposes of this study, a “health care cost” news story was one that contained information on the issue of large and increasing health care cost in the United States, as related to, for example, government, regulations, industry analysis, and policy debates in politics.

Coding

General coding variables included the date on which the news report was published or aired and newspaper section (e.g., national news, business, health, politics). Section codes indicating front-page placement of print news stories, along with word length for print and broadcast news stories, were used to produce a measure of story prominence (Myhre, Saphir, Flora, Howard, & Gonzalez, 2002).

Regarding the coding of more specific news content, this study adapted coding categories developed in previous research of health news content (Foster et al., 2012; Friedman & Kao, 2008; Friedman & Tanner, 2007; Kim et al., 2010; Kim & Willis, 2007; Tanner et al., 2012; Tanner & Friedman, 2011). To evaluate the sources of information, we examined whether each article or transcript included an expert source, either indirectly or directly interviewed for the story (i.e., layperson, medical doctor, elected government official, nonelected government official, nonprofit representative, for-profit representative, other health care professional [e.g., nurse], academic researcher, in-house reporter, journalist from other media outlet, business/economic expert, clergy/ethicist, and health insurances provider). Journalists frequently interviewed more than one person for a single story, providing arguments and counterarguments in keeping with the normative practice of providing balance in news reporting. Each source was coded as “not present” (0) or “present” (1). In many cases, the same person appeared more than once in a single news story but was only coded once in the same article. Additionally, coders categorized what sources said about health care cost into five areas of responsibility.

As shown in Table 1, coding for health cost responsibility was coded in five categories: patients, doctors/hospitals/medical providers, the government, insurance companies, and drug companies/medical technology/medical device companies.

Table 1.

Responsibility Variables (With Latent Variables).

Who is responsible?
Patients	People choosing unhealthy lifestyles—poor nutrition, no exercise, drinking, smoking, stress; people choosing not to seek preventive care; patients demanding unnecessary services; people choosing to litigate over medical errors; people living longer; changes in disease prevalence; insurance fraud by patients
Doctors/hospitals/medical service providers	Waste in service/overpayments; inefficiency in administrative costs; limited access to medical care; too many medical errors; monopoly/rising provider expenses; excessive marketing costs for services
The government (Medicare/Medicaid), politics	Waste in service/overpayments; inefficiency in administrative costs; unnecessary government mandates and regulations
Insurance companies	Inefficiency in administrative costs; monopoly—insurance companies monopolize the market; excessive marketing costs for services; letting insurance fraud happen
Drug companies/medical technology/medical device companies	Spending on technology; new treatments; new drugs; excessive marketing costs for drugs treatments or medical devices

Intercoder Reliability and Data Analysis

After a series of training sessions, news reports were coded independently by two research assistants to ensure consistency. An early check of intercoder reliability revealed some discrepancies, and adjustments were made to the coding protocol. Using Krippendorff’s (2010) alpha, we calculated intercoder reliability by double-coding a random subsample (n = 125 or 24%) of the data. The professional identity of the first directly quoted sources ranged from .70 to 1 with an average of .79. Six causes of responsibility showed .97 for patients, .95 for doctors/hospitals/medical service providers, .93 for the government, .92 for insurance companies, and .91 for drug companies/medical technology/medical device companies. Reliability for both section and word length was 1.0.

Data were analyzed using SPSS Version 16.0. Descriptive statistics and frequencies were generated for all data. T tests were conducted for continuous variables in Research Questions 1 and 2. Additionally, chi-square and t-test analyses were conducted for relationships among variables in Research Questions 3 and 4. Two research assistants aided in the collection and coding of data.

Results

Of the 531 news reports analyzed for this study, 43.5% (n = 231) were from network television newscasts (ABC: 27.3%, n = 63; CBS: 22.9%, n = 53; NBC: 13.0%, n = 30; Fox: 13.4%, n = 31; and CNN: 23.4%, n = 54) and 56.5% (n = 300) were from newspapers (The New York Times: 16.7%, n = 50; The Wall Street Journal: 16.3%, n = 49; The San Francisco Chronicle: 15.7%, n = 47; Birmingham News: 18.7%, n = 56; The Dallas Morning News: 16%, n = 48; and Star Tribune: 16.7%, n = 50). As illustrated in Figure 1, 4 of 10 news reports (40%, n = 210) aired or were published during the Clinton administration (i.e., 1993-1999), 40% (n = 213) during the Bush administration (i.e., 2000-2008), and 20% (n = 108) during the first 2 years of the Obama administration (i.e., 2009 and 2010). There were four peaks in news coverage, which occurred in 1993, 2003, 2004, and 2010 (see Figure 1).

Figure 1.

Media coverage 1993-2010, by presidential administration.

Research Question 1 assessed the prominence of the health care cost reports (report placement in newspapers). Overall, newspapers featured health care cost news reports on the front page of Section A in less than 10% (8.7%, n = 26/300) of the reports between 1993 and 2010. Adding all front-page coverage (including front page: n = 26; business front page: n = 36; and metro front page: n = 35), the issue appeared on front pages 97 times out of 300 total print stories (32%). Instead, reports most often appeared inside the News section (37.7%, n = 113), followed by Business (14.3%, n = 43), and Editorial (14%, n = 42). Health care cost stories never ran on the front page of the Health section but were occasionally included within the Health section (1.7%, n = 5). Coverage of this issue rarely appeared within the National News section (1%, n = 3). Prominence of health care cost news reports based on placement for television coverage was not reported because the transcripts did not provide placement information.

Research Question 2 examined the associations between expert sources of information included in the health care cost news reports and media type (television vs. print). Expert sources were quoted in a majority of news reports (80%, n = 422/531). The type of source most often cited was elected government official (27.9%, n = 148), followed by nonprofit representative (26.9%, n = 143), for-profit representative (26.4%, n = 140), non–elected government official (22.6%, n = 120), layperson (18.3%, n = 97), and health care professional (15.4%, n = 82). Less often cited sources were academic researchers (15.1%, n = 80) and health insurance company representatives (10.2%, n = 54).

We found statistically significant differences between the types of expert sources used in different media (print vs. broadcast media). As shown in Table 2, newspaper reports were more likely than television reports to include a nonprofit representative (30.7%, n = 92 in newspapers vs. 22.1%, n = 51 in television reports), a for-profit entity (31%, n = 93 vs. 20.3%, n = 47), a nonelected government official (25.7%, n = 77 vs. 18.6%, n = 43), an academic researcher (17.7%, n = 53 vs. 11.7%, n = 27), and a representative of the health insurance industry (15%, n = 45 vs. 3.9%, n = 9). Television news reports were more likely to cite an elected government official (36.8%, n = 85 in television reports, vs. 21%, n = 63 in newspapers), a layperson (24.2%, n = 56 vs. 13.7%, n = 41), and a health care professional (19%, n = 44 vs. 12.7%, n = 38).

Table 2.

Sources in Health Cost News Stories by Type of Medium (Newspaper vs. Television).

	Newspaper (n = 300)		Television (n = 231)
Source	%	n	%	n	χ²	Degrees of freedom	n
For-profit	31	93	20.3	47	7.630	1	.004*
Nonprofit	37.7	92	22.1	51	4.892	1	.017*
Nonelected government official	25.7	77	18.6	43	3.710	1	.034*
Elect government official	21	63	36.8	85	16.199	1	.000*
Academic	17.7	53	11.7	27	3.645	1	.036*
Health insurance industry representative	15	45	3.9	9	17.614	1	.000*
Layperson	13.7	41	24.2	56	9.777	1	.001*
Health care professional	12.7	38	19	44	4.069	1	.029*
Journalist	0.7	2	6.5	15	14.298	1	.000*
Other	2	6	2.6	6	0.211	1	.430
No person	22	66	18.3	42	1.122	1	.171

p < .05.

Presentation of Causes of Health Care Cost News Coverage

Overall, this research showed that patients were most frequently presented in the news coverage as the cause of rising health care costs (43.7%, n = 232), followed by health care providers (35%, n = 186), insurance companies (27.3%, n = 145), government (23.2%, n = 123), and the pharmaceutical industry (13.7%, n = 73).

Regarding the relationship between sources and the presentation of the cause of rising of the health care costs (Research Question 3), Table 3 shows the number of expert sources that were quoted and these sources’ relationship to the presentation of the causes of rising health care costs. A series of chi-square analyses suggested that news reports that contain quotes from health care professionals (19.8%, n = 46, χ² = 6.067, degrees of freedom [df] = 1, p = .014) and academics (21.6%, n = 50, χ² = 13.544, df = 1, p = .000) were significantly more likely to present patients as the cause of rising health care costs. News reports with nonprofit sources (33.3%, n = 62, χ² = 5.965, df = 1, p = .015), academics (19.9%, n = 37, χ² = 5.212, df = 1, p = .022) and insurance industry representatives as sources (16.1%, n = 30, χ² = 11.130, df = 1, p = .001) were significantly more likely to present health care providers as the cause of rising health care costs. Nonelected government officials (30.1%, n = 37, χ² = 5.124, df = 1, p = .024) and elected government officials (42.3%, n = 52, χ² = 16.522, df = 1, p = .000) as sources were most often quoted in stories that presented the government as the cause for rising health care costs. Alternately, stories with lay persons (21%, n = 88, χ² = 12.857, df = 1, p = .000), for-profit representatives (30.6%, n = 125, χ² = 16.557, df = 1, p = .000), and insurance professionals (12%, n = 49, χ² = 6.530, df = 1, p = .011) as sources were least likely to focus on government as a cause of rising health care costs (see Table 3).

Table 3.

Attributions of Responsibility in News Coverage of Health Care Costs.

	Causes of rising health care costs
Sources (n)	Patients	Health care providers	Insurance companies	Government	Pharmaceutical companies
Non-profit representative (143)	60	62	48	21	21
Health care professional (82)	46	41	24	11	9
Academic (80)	50	37	20	14	13
Layperson (97)	50	31	32	9	10
Nonelected official (120)	56	42	31	37	13
Elected official (148)	63	50	36	52	15
For-profit representative (140)	59	61	55	15	22
Insurance representative (54)	20	30	27	5	9
No source (108)	42	27	30	35	15

Note: Entries are the number of articles and transcripts mentioning each cause of health care costs.

When comparing the presentation of the cause of rising health care costs between news and editorial content, only one cause (government-caused health care cost increases) was significantly different between the two. Editorial content presented the government as the cause of rising health care costs more often than news reports (47.9%, n = 34 vs. 19.3%, n = 89, respectively, χ² = 28.147; df = 1; p = .000).

Finally, Research Question 4 assessed how news coverage of rising health care costs (i.e., prominence of news articles, sources used, and presentation of the cause of rising health care costs) varied by presidential administrations (i.e., Clinton, Bush, Obama). Regarding the prominence of health care cost reports (placement in print news and length for all print and broadcast) over time, prominence as indicated by story placement showed no statistical differences across administrations. When analyzing expert sources by presidential administrations, as Table 4 illustrates, our analyses suggested significant differences by administration. For example, elected government officials were significantly more likely to appear in news reports during the Bush administration (37%, n = 55) as opposed to the Clinton (31.5%, n = 47) and Obama administrations (31.1%, n = 46). Health care professionals (χ² = 8.601, df = 2, p = .014) and for-profit representatives (χ² = 5.962, df = 2, p = .051) were significantly more likely to appear in reports during the Clinton administration.

Table 4.

Expert Sources by Presidential Administration.

Source	Clinton, % (n)	Bush, % (n)	Obama, % (n)
For-profit	31.9 (67)	23.9 (51)	20.4 (22)^a
Nonprofit	28.6 (60)	30.5 (65)	16.7 (18)^b
Elect government official	22.4 (47)	25.8 (55)	42.6 (46)^c
Nonelected government official	21.9 (46)	21.6 (46)	25.9 (28)
Health care professional	21 (44)	10.8 (23)	13.9 (15)^d
Academic	17.6 (37)	12.7 (27)	14.8 (16)
Layperson	17.6 (37)	22.1 (47)	12 (13)
Health insurance representative	12.4 (26)	9.4 (20)	7.4 (8)
Other	2.4 (4)	2.8 (6)	0.9 (1)
Journalist	1.9 (4)	3.3 (7)	5.6 (6)
No person	23.8 (50)	17.5 (37)	19.4 (21)

χ² = 5.962, degrees of freedom (df) = 2, p = .05.

χ² = 7.461, df = 2, p = .024.

χ² = 15.236, df = 2, p = .000.

χ² = 8.601, df = 2, p = .014.

The media’s presentation of the causes of rising health care costs also varied significantly by presidential administration. Patients were most often mentioned as the cause of rising health care costs in reports disseminated during the Bush administration (53.1%, n = 113), followed by the Obama (39.8%, n = 43) and Clinton (36.2%, n = 76) administrations (χ² = 13.048, df = 2, p = .001). The government was most often mentioned as the cause of rising health care costs during the Obama administration (37%, n = 40), followed by the Clinton (23.3%, n = 49) and Bush (16%, n = 34) administrations. Pharmaceutical companies were most often mentioned as the cause of rising health care costs during the Bush administration (20.2%, n = 43), followed by the Clinton (10%, n = 21) and Obama (8.3%, n = 9) administrations (χ² = 12.608, df = 2, p = 002). The insurance industry and health care providers were equally likely to be presented as the cause of rising health care costs across presidential administrations.

Discussion

This study, the first to examine U.S. media coverage of rising health care costs spanning the three most recent presidential administrations, explored how prominent news sources, journalistic norms, and real world events, specifically presidential politics, might be related to the quantity and nature of news coverage of this complex issue. The findings of this content analysis may be interpreted in various ways, depending, in part, on the context in which they are examined. Guided by agenda building theory and the concepts of normative media routines, however, this study examines the results with interpretations based on the documented efforts of presidential administrations to command news attention (or quell it) and the well-documented literature relating to media routines, especially in terms of news values, declines in beat specific reporting, and journalists’ dependence on expert sources when reporting on complex topics.

First, our research showed that while the amount of news coverage has been cyclical with peaks and valleys during the 18-year period examined, few reports about health care costs made front-page news. From 1993 through 2010, less than 10% of newspaper reports about health care costs were featured in front-page (A-1) positions. Front-page reports were equally likely to appear during the Clinton, Bush, and Obama administrations. There are several interpretations of this finding. Based on previous agenda building research (Lang & Lang, 1988), one interpretation is that regardless of who was in the Oval Office or his stance on the issue of health care, neither Clinton nor Bush nor Obama was more skilled at positioning the issue of rising health care costs on the media’s news agenda in a way that it would garner frequent front-page appeal. Another interpretation might be that, in some cases, the administration may have pushed the issue back because it was either not a priority (other issues took precedence) or it was politically risky. Furthermore, as recognized in the literature on news routines (Shoemaker & Reese, 1996), the complexity of the topic may have contributed to less prominent coverage as media often prefer “easy-to-follow” lead stories that can sell papers or attract viewers (Nelkin, 1996; Semir, 2000). Additionally, hard economic times have led to the loss of dedicated health and economic journalists, leaving a few to work harder to get the stories and meet deadlines (Pew Research Center’s Project for Excellence in Journalism, 2013), making coverage of this difficult complicated issue even more challenging.

Even stories deemed advantageous to a presidential administration or important for the public’s participation in policy making may not see the front page if the topic does not fit an easy-to-follow format or if the topic requires time consuming and expensive specialized reporting. Taking this line of thinking a step further, the lack of prominence of the news media’s reporting on health care costs may leave American voters ill-informed on how best to tackle the problem of health care reform. In fact, a Kaiser Family Foundation (2013) tracking poll found that less than half of Americans (44%) said they have enough information to adequately understand the Affordable Care Act, the health care reform law that began to be implemented in 2010.

Although news coverage (not front page) focusing on rising health care costs was equally likely to appear during all three presidential administrations, spikes in news coverage over the 18-year time period examined (i.e., 1993, 2004, and 2009) concur with previous studies of agenda building, suggesting that high-profile public officials, such as the president, can influence the news agenda (Corbett & Mori, 1999; Johnson et al., 1996). Specifically, we found that events focusing on presidential policy or politics, as presented in the Kaiser Family Foundation’s (2012) time line of health care reform, correlate with spikes in the number of news stories on the subject. For example, in 1993, when the Clinton administration pushed for health care reform (notably led by first lady Hillary Clinton), health care costs reports appeared 64 times. In 2003-2004, the number of Americans without health insurance hit an all-time high (45 million), and the issue was highlighted in the televised presidential debates between George Bush and John Kerry. Along with Bush’s subsequent passage of Medicare-Part D, these events produced 73 stories. Finally, during Barack Obama’s push for health care reform in 2009 and 2010, health care cost reports appeared 69 times.

As maintained by Johnson et al. (1996) and Shoemaker and Reese (1996), it can be difficult to unravel and assess the numerous influences on the news agenda, and findings from the current study on rising health care costs concur. Our findings specifically explore how expert sources of information play a role in shaping news coverage (Bauer et al., 2007; Boyce, 2007; Corbett, 1998, 2006; Corbett & Mori, 1999; Dennis, 1991; Tanner, 2004; Tanner & Friedman, 2011). Overall, and not surprisingly, elected officials and for-profit representatives dominated the conversation over rising health care costs in the media. This aligns with existing research suggesting that it is these individuals who have the most influence (e.g., money and power) to influence the media’s agenda (Len-Rios et al., 2009). However, differences among sources most often used in reports during the Clinton, Bush, and Obama administrations provoke thought. Government officials appeared more often in news reports during the Bush administration than during the Clinton and Obama administration. As noted by Foster et al. (2012), President Bush often tried to monitor what his key science and health advisors said to the news media in an attempt to control the message that was relayed to the American public. Though the appearance of government officials as sources in health cost news stories during the Bush administration could be interpreted in a number of ways, it is interesting to consider this fact in light of research highlighting Bush’s efforts to control media attention on specific issues, especially in hot-button politically charged cases such as climate change and health care costs. Findings from this study could perhaps suggest that the appearance of more government officials as sources during Bush’s administration could represent his efforts to ensure that the conversation was controlled to reflect his ideology.

On the other hand, findings revealed that health care professionals were more prevalent sources of information for media reports during the Clinton administration. Again, these findings are simply counts that can be interpreted in a number of ways. However, exploring the findings in terms of agenda building’s considerations of the power of presidential politics to shape media coverage suggests some possible interpretations. For example, these findings may reflect Clinton’s lack of control over the health care reform process. Research on Clinton’s health care reform efforts suggests that his loss of control of the reform process eventually led to a change in how health care reform was framed in the media, ultimately moving the conversation from a focus on health care reform to a detailed, and primarily negative, description of the politics of the process (Bok, 1998). The administration’s attempts to make reforms behind closed doors, reportedly without input from key stakeholders, drew loud protests from every sector of the health care system. One of the most vehement disagreements came from the Association of the American Physicians and Surgeons, whose February 1993 lawsuit against the administration for exclusion from the process sent reporters flocking to interview physicians in conflict with the administration (Bok, 1998). That media would focus on the conflict adheres to the normative routines of media news values defined by Shoemaker and Reese (1996) and others.

Also related to the media’s use of sources and how these sources may influence or “shape” media content, findings suggest that newspaper reports were more likely than television reports to include nonprofit representatives, academics, nonelected government official and for-profit or health insurance representatives as a source. On the other hand, television reports were more likely to quote health care professionals, laypersons, and elected government officials. As television news coverage often focuses on personal experiences (episodic frames), citing a layperson or health care professional about the individual, or personal, impacts of rising health care costs aligns with previous research on media routines and how these routines influence coverage (Iyengar, 1991; Kim et al., 2010; Kim & Willis, 2007). Television’s use of elected government officials also concurs with previous research showing that television stations are more likely to rely on easy-access sources like government officials who are often willing to make television news appearances in an effort to “push” their own agenda onto to the media and public agenda (Clayman & Heritage, 2002; Huls & Varwijk, 2011).

Regarding the presentation of the cause of rising health care costs, reports most often pointed to patients as the cause of increasing costs. For example, in an interview on NBC Nightly News, reporter Tom Costello spoke with John Banzhaf, a law professor at George Washington University, who said,

Obesity costs the American public over $100 billion a year, most of which is paid by the people who are not obese, in the form of higher taxes and health insurance . . . So it’s only fair to make them pay at least a small portion of that . . . It also incorporates personal responsibility; everybody agrees we ought to have personal responsibility in health care, that’s what this does, it says that if you maintain a lifestyle which keeps you morbidly obese, over 40 BMI, then you should be responsible for some of the costs. (Costello, 2009)

Not surprisingly, this victim-blame can result in unfair treatment of people who are unhealthy, including social ostracism and higher financial burdens (Lusk & Ellison, 2013), again suggesting the looping influences of the media, political actors, and the public (Corbett & Mori, 1999; Lang & Lang, 1983; Tanner, 2004).

Reports with health care professionals as sources were more likely to suggest that patients cause rising costs than stories relying on other sources. This finding is consistent with existing research suggesting that health care providers tend to blame patients’ lack of compliance, unreasonable expectations, and other behavioral factors for patients’ rising demand for health care, driving costs up (Bodenheimer, 2005). Academic sources’ association with patients as the cause of rising costs is harder to understand and should be explored. Because analyzing the content of the quotes from expert sources was beyond the scope of this research, a closer examination of this content is a fruitful avenue for future research.

It is particularly interesting to note that reports that quoted elected government officials were more likely to blame the government as the cause of rising health care costs. This, perhaps, could be the case because officials from opposing political parties regularly blame the other party for issues related to public policy. For example, in a Fox News Special Report (FoxNews.com, 2009), the prominent Republican congressman John Boehner said, “When you look at what my Democrat friends are offering on health care, you have to watch what they do, not listen to what they say.”

Finally, editorial content was more likely than news coverage to present the government as a cause of rising health care costs. For example, an editorial in The Wall Street Journal on March 22, 2010, placed blame for health care costs on government:

This week’s votes don’t end our health-care debates. By making medical care a subsidiary of Washington, they [Democrats] guarantee such debates will never end. . . . Democrats have taken responsibility for what comes next—to insurance premiums, government spending, doctor shortages and the quality of care. They are now the rulers of American medicine. (“The Doctors of the House,” 2010)

The difference between editorial and news content confirmed expected findings based on accepted news standards of balance in reporting (Bedingfield, 2012; Druckman & Parkin, 2005; Shoemaker & Reese, 1996). While some news reports did seem to suggest government as the cause of rising health care costs, editorial content was more likely to include more (and likely stronger) government responsibility frames. Editorials may place blame more openly than news stories because editorial content is not tied to sources and normative routines of balanced coverage under deadlines, whereas news stories must often rely on readily available government sources to shape news content and meet deadlines.

Several limitations should be considered when interpreting the study findings. Although LexisNexis is regarded as the best source for obtaining news content for content analysis research, our data collection process yielded a large number of irrelevant and duplicate news reports, as has been the case in similar content analyses of news coverage. Future research should explore the best manner in which to collect news content produced by media outlets. Furthermore, this analysis examined only traditional newspaper and television resources and not the wide array of web resources available to news consumers. While a recent Gallup Poll showed that 64% of Americans receive their news from traditional broadcast (television) or print (newspapers; Saad, 2013), the spread of mobile technology is adding to news consumption (Pew Research Center, 2013). Future research should also explore how to systematically assess the ever-growing assortment of digital news resources. Finally, because of the time frame in which this study was conducted, we could include only 2 years of the Obama administration in the analyses. Future research should revisit the findings when the Obama years are added.

Nevertheless, these findings contribute to the growing body of academic literature on agenda building and may have practical implications for communication practitioners or health care reform advocates interested in building effective media strategies. Results indicating that (a) few health care cost reports received front-page coverage and (b) television news outlets had fewer reports on rising health care costs than their newspaper counterparts suggest that there may be a need for advocates on both sides of the debate to provide media training for expert sources, especially those who specialize in highly technical fields such as economics, medicine, technology, or system administration, to teach these experts how to relay complex and complicated information in basic language that is easy for television viewers and newspaper readers to understand.

As findings from the current study concur with previous research suggesting that television reports tend to frame reports episodically (Iyengar, 1991; Kim et al., 2010; Kim & Willis, 2007), reform advocates wanting media exposure should consider locating individuals who have a personal story to tell and are willing to be interviewed, either on camera or off camera. Finally, as news coverage of rising health care costs is influenced by real world events, advocates should build story ideas around high-profile events and public figures, increasing news values and likelihood of media exposure (Huls & Varwijk, 2011).

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research funded by the Science and Health Communication Research Group at the University of South Carolina.

Author Biographies

Caroline Foster, PhD, is an assistant professor in the Department of Communication at the College of Charleston, in Charleston, South Carolina. Her research focuses on health and science communication, media routines and social media.

Andrea H. Tanner, PhD, is an associate professor in the School of Journalism and Mass Communications at the University of South Carolina. Her research evaluates how media present health information and how mass communication can be utilized to promote healthy behavior and public awareness of health issues.

Sei-Hill Kim, PhD, is an associate professor in the School of Journalism and Mass Communications at the University of South Carolina. His research interests are in the areas of public health, science, and political communication.

Soo Yun Kim is a PhD student in the School of Journalism and Mass Communication at the University of Wisconsin–Madison. Her research focuses on the role of media in shaping public perceptions of science and environmental issues.

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