The long, sad rabbit hole of politics, healthcare, and the Supreme Court: How I tried to draw a map and failed

Numbers are so, weird. They lack emotion, judgement, subjectivity. And yet they are reflections of ourselves. And we are so willing to manipulate them, fight over them, use them to control one another. They are the good and the bad in us. I know you know this.

But this week, I was reminded of this yet again, when I tried to count states and draw a map.

It was a really tough week. On Wednesday, the Supreme Court heard oral arguments on the King v. Burwell case. That’s a case that will decide whether the feds get to continue giving the subsidies that help people pay for healthcare in a whole bunch of states (Did you get the “a whole bunch” bit? Hold on to that). You can read about the case on Vox in a really good explainer here. Even Michael Cannon likes it (and he doesn’t like the ACA much), except for these parts.

Numbers really matter in this case, and I want to talk about them, but perhaps not in the way that you think. You might be thinking that I’m about to make the case that the people in the states at risk won’t be able to pay for health insurance if they lose subsidies, and that I’m about to show you those numbers, but I’m not. That’s my day job.

How many states would lose subsidies if the Supreme Court decides in favor of the plaintiffs in King v. Burwell?

I want to talk to you about numbers in a different way. Here they are:

  • 37
  • 34
  • two-thirds
  • three-dozen
  • “more than 30”

The numbers above illustrate some of the ways in which different sources (news outlets, pundits, policy experts, advocates, my mom… okay, not my mom… but I bet she’d have an opinion if I asked her) are reporting the number of states that could or would (yes, that distinction is important) lose subsidies if the Supreme Court decides to take them away.

I was trying to design an infographic to illustrate how many states were at risk of losing these subsidies. I figured on about 45 minutes to create a map and a bar chart. But I couldn’t. Because there wasn’t a number. Or rather, because there were many. And each number was more loaded than the rest.

How many states would lose subsidies if the Supreme Court decides in favor of the plaintiffs in King v. Burwell? It’s like the beginning of a “How many people does it take to screw in a lightbulb…” joke. Except there’s no punchline because it’s not funny—families get to lose their health insurance over this one.

So my straightforward question took me down a long, sad rabbit hole of politics, healthcare, and the Supreme Court.

Seriously, how do you count states?

To understand why these numbers matter, you need a basic understanding of how the healthcare exchanges are structured. Bear with me for four sentences. Under the ACA, each state plus the District gets to choose whether to set up its own health insurance exchange or to let the feds do it:

  • If the state sets up its own exchange, it’s called a state-based marketplace and there are 14 (including DC)
  • If the state lets the government do it, it’s called a federally facilitated marketplace and there are 27

If the above two categories were it we’d be all squared away, just a knock-down-drag out fight over people trying to take healthcare away from low- to- middle-income people. No numbers involved. But there’s a gray area with states that have partnerships—and not everyone agrees which of the above categories these gray states could fall into if the ruling goes down.

  • Some state exchanges are called partnerships (a state-partnership marketplace and there are 7 to be painfully precise). This is where the states and the feds divvy up the work of administering the exchange and the whole thing is run off the federal website—healthcare.gov
  • There are also states that do all the heavy lifting of administration and just use healthcare.gov as a technology platform. They basically have a state-based marketplace but happen to run it off the fed website—Oregon, Nevada, New Mexico. (If you are a glutton for wonk terms this is called a federally supported state-based marketplace and there are 3 of these states).

Kaiser has a nice wonky chart that lays it all out here.

Why is the number of states so important in King v. Burwell

Now, the lawsuit in King is basically an argument over which states with which types of exchanges get to give subsidies. The plaintiffs claim that the law intended for subsidies to be provided only to states that run their own exchanges (state-based marketplaces). That requires a definition: What, exactly, is a state that runs its own exchange? And a number: How many states do that?

Then there are those three “gray area” states in play (Oregon, Nevada, New Mexico) that make counting things more complicated: Do they/don’t they meet criteria for being state-based marketplaces? Depending on who you ask, they’re either at risk (see above) or doing just fine, thank-you-very-much (see above). (I know people that would run me out of town for even asking that question. To those people I say, “Yes. They are state-based marketplaces. But not everybody agrees with you. See above.”)

If you are interested in more of an explanation of the politics behind the three “gray area,” so was I and so was Charles Gaba, who is waaaaay smarter than me. His popular ACA blog sums up a longer Politico piece here. The title is as good as the answer: In which Politico reporters Racahan Pradhan & Brett Norman FINALLY answer a question I’ve been wondering for months… (and here’s the original Politico article).

And this matters, why?

Because depending on how the lawsuit goes, which state counts as a state-run marketplace affects who gets subsidies and who doesn’t, either through how the court defines it or how the rules define it after a decision gets handed down. I don’t have the brainpower or the will to begin to cover the arguments in this blog, so I won’t attempt to do so. But it matters. Just ask the people who won’t be able to afford health insurance once they lose their subsidies.

So we have a situation where prominent sources are reporting the numbers differently, and it’s confusing, and it’s political.

These numbers are being reported very differently by, um, everyone. Not just proponents and opponents of the law. Everyone.

  • Some count 13 states plus DC as having exchanges with “state-based marketplaces”, which means that they report 37 states at risk of losing subsidies.
  • Others count the 13 states plus DC and also what I call the three other “gray area” states (Oregon, Nevada, New Mexico).
  • Others use more nebulous characterizations (see below).

Here’s a sampling of the most common reporting that you’ve likely seen already:

So why can’t a poor designer simply catch a break and just draw a map?

Well, politics, obviously. That’s part of the point of this post. To shed light on just how murky things get for the people whose job it is to make things…er… clear.

If you’ve got a day job, drawing a map can mean visualizing—not data—but the political stance of your organization.

You’re caught in the cross-fire between your craft—show what you see/know—and the advocacy goals of your organization. Or, for that matter, the politics of the issue itself independent of your organization. Things don’t always align neatly.

Oh, by the way, I did draw the map for this blog post. Please enjoy it.

Map showing how some states are counted in King v. Burwell case

It’s complicated. But there’s another catch.

And can I just say one more thing? This is a shameless plug for my own outfit. If you really are interested in what will happen to the people who will lose their subsidies (I’m totally serious), please watch this video. Regardless of what “number” we ultimately settle on, not much good will come of it if these families lose their subsidies and can’t afford to pay for health insurance. You can hear them tell you about it in their own words. It’s pretty compelling and yes, we produced it.

Mind the gap: Advocacy journalism fills a void

By now, it’s safe to say that the digital ecosystem is shaking things up for journalists. Traditional journalists are turning into brands (Ezra Klein, Vox and Nate Silver, 538, to name a few). Journalists are getting paid for clicks. Social media tools are creating a new breed of reporting through conflict journalism and citizen journalists—coverage that bleeds into news reporting and advocacy. And mission-driven social media sites (like Upworthy) are partnering with advocacy organizations to create serious, in-depth original content, as the Nieman Journalism Lab reported last month. Phew.

Mind the gap: Advocacy journalism fills a void

And now advocacy organizations are getting into the mix. They’re taking the reins by exposing, researching and writing about the issues they care about in a genre of journalism known as advocacy journalism. Advocacy journalism has been around for a while (remember muckraking?). But today’s digital landscape seems ripe for innovation by those that want to take the genre further.

A recent article by Dan Gillmor in Slate’s Future tense project provides a thought-provoking and current look at the nexus of advocacy and journalism today, one that made me want to dig a little deeper into the subject to see where the field is at and what hurdles it faces.

Advocacy journalism is an interesting genre. On the one hand, it seems like a big deal—by injecting a point of view, it appears, at first blush, to upend the sacrosanct “objective reporting” model that is the foundation of traditional journalism. But in fact, today’s so-called traditional journalism is itself rife with points of view (reporters are human, after all, and routinely bring their personal perspectives to the questions they ask and the subjects they cover).

It’s no coincidence that, at the same time as advocacy journalism is getting more attention, investigative reporting in traditional media—the bread and butter of deep, immersive journalism—is diminishing due to shrinking newsroom budgets, capacity, and interest. (The American Journalism Review wrote about it in 2010, and things don’t look that much rosier if you read about revenues and ad dollars in Pew Research Center’s State of the News Media, 2014 report or the internet marketing firm Vocus’s 2014 State of the Media.)

So, resources for investigative reporting in traditional media may be diminishing, but the need itself certainly hasn’t. The immediacy of the internet and social media reporting make the gaps left by traditional news organizations more transparent than ever before. It has opened up the playing field for those who want, and need, to write about social change, and see advocacy journalism as yet another tool for driving that change. It is here that advocacy organizations are stepping in.

Gillmor mentions the Upworthy partnership with Human Rights Watch, Climate Nexus and ProPublica, but he also reminds us of the work of the libertarian Cato Institute, and the ACLU, noting that these organizations are not just writing about their issues—they have invested in hiring talented, investigative journalists to do the work.

One of my earlier posts this year discusses how advocacy organizations are harnessing social media to effect social change on their own terms (I wrote about the MIT Center for Civic Media’s study of the media coverage of the Travyon Martin tragedy, and of how it was framed and defined in part by digital-savvy advocacy organizations). In the same way, advocacy organizations are equipping themselves with investigative journalists to define the things that need fixing in our society, again, on their own terms.

Transparency and bias concerns apply to all reporting, not just advocacy journalism

As with any form of journalism (see a post that I wrote about the importance of trusted messengers correctly reporting the facts), there are always legitimate concerns around the ability of the “reporter” to be transparent about the perspective and bias that he or she brings to a story, especially when money comes into the picture (for example, a journalist embedded in an advocacy organization writing about an issue that is driven by a funder). But one can easily make the argument that journalism has never been immune to this predicament. Media brands are, after all, owned by corporations—remember Michael Bloomberg’s takeover of his newsroom and Murdoch’s editorial biases? The issue is not so much that money is paying for journalism (it always has). Rather, the issue is one of transparency and fairness (something Gillmor acknowledges in his online book, Mediactive).

Most recently, advocacy journalism was roundly dismissed by Buzzfeed’s Editor-in-Chief Ben Smith. When Eric Hippeau, a venture capitalist (and early investor in Buzzfeed), sat on a panel at the Columbia School of Journalism and asked Smith about the fine line between different forms of journalism and advocacy, Smith responded, “Um, yeah, I hate advocacy. Partly because I think, you know, telling people to be outraged about something is the least useful thing in the world.” (The video is here and and a good article with more on Buzzfeed is here.)

That’s kind of ironic given Buzzfeed’s public missteps and its association with the Koch brothers on the issue of immigration reform. I’m not saying that the partnership is in and of itself a concern (Slate’s Dave Weigel described it as a “pro-immigration reform” panel that was very much in keeping with the Koch brothers’ longstanding interest in the issue). But the association is not one to be ignored, either, particularly from a man who claims to hate advocacy. I’m still coming around to the idea that “Buzzfeed” and “journalism” can be conjoined. I don’t say that to be snarky—I say that to mean that all lines are blurring, including newstainment sites like Buzzfeed that are reinventing themselves in the digital journalism mold, whatever that is.

Medialens has a good take on the back-and-forth skepticism around advocacy journalism (“All Journalism is ‘Advocacy Journalism’ “) and offers some clear-eyed perspective by pointing to numerous examples of how ‘non’ advocacy journalism exhibits bias (ranging from uber-left Ira Glass’s omission of the U.S. role in Guatemalan genocide to Jeff Bezos’s 2013 purchase of the Washington Post alongside Amazon’s $600 million cloud-computing deal with the CIA—on the heels of its decision to stop hosting WikiLeaks in 2010).

Journalism is changing: traditional media gatekeepers are going away

As Gillmor points out (and as I’ve written written previously), back in the day, traditional media were largely gatekeepers to reporting. If you were an advocate or an organization with a story and a point of view, you had to get a reporter’s interest and rely on that person to pitch it to an editor. To stand the best chance of success, you had to do the research, get the facts straight, frame the narrative, and package it up so that a reporter could understand it, pick it up, and pitch it. Those days are disappearing, and in their place is a new frontier of blurry gray lines of people and perspectives, all vying for a chance to shape the news agenda of the next hour. Investigative reporting is what gives all of us perspective, makes us take a collective deep breath, and think beyond that next hour.

It’s unsettling, but also an opportunity to fill in the gaps left by the old guard, as long we do it right. So, what’s right?

Doing it right: some things should never change

I recall reading (and tweeting) about Upworthy’s announcement when I read Nieman Lab’s post last month. Given that I work in a policy and advocacy organization that has a keen interest in seeing its point of view accurately and widely expressed in the media, I myself wondered how we could inject ourselves into a similar partnership. And, if we could, what we would say, how we would separate our social passion from the hard and complicated truths that spell out complex political realities? For me, it raised more questions than I could answer. But it’s tremendously exciting to see where others are going.

I’ll be curious to see how (or if) these partnerships help fill the void left by the diminished investment in investigative reporting in traditional newsrooms. And I’m also eager to see what new best practices emerge as a result. But regardless of how things change, the responsibility of transparency has never been greater. And all of these changes add up to the same principles that should never, ever change in journalism—report the facts, be clear and transparent about your point of view, and tell people where your money is coming from.