Objectives. To examine the public health and policy-relevant messages conveyed through local television news during the first stage of Affordable Care Act (ACA) implementation, when about 10 million Americans gained insurance.
Methods. We conducted a content analysis of 1569 ACA-related local evening television news stories, obtained from sampling local news aired between October 1, 2013, and April 19, 2014. Coders systematically collected data using a coding instrument tracking major messages and information sources cited in the news.
Results. Overall, only half of all ACA-related news coverage focused on health insurance products, whereas the remainder discussed political disagreements over the law. Major policy tools of the ACA—the Medicaid expansion and subsidies available—were cited in less than 10% of news stories. Number of enrollees (27%) and Web site glitches (33%) were more common features of coverage. Sources with a political affiliation were by far the most common source of information (> 40%), whereas research was cited in less than 4% of stories.
Conclusions. The most common source of news for Americans provided little public health–relevant substance about the ACA during its early implementation, favoring political strategy in coverage.
In the first year of full implementation of the Affordable Care Act (ACA; Pub L No. 111–148), more than 10 million Americans gained insurance through state and federal marketplaces or through the expansion of the Medicaid program in 24 states to low-income, childless adults.1 These insurance gains were both a public health and health communication success, because those who gained insurance had to recognize their need for insurance, become aware of their plan options, seek help if needed with the application process, and purchase or enroll in health insurance. Survey data indicate that an important source of information about health insurance options was the local news.2 An April 2014 survey of new enrollees conducted by Enroll America revealed that news was the top source of information cited by enrollees, and of those citing news as a top source, 42% cited local television news—more than any other news media type—as their most influential information source.3
Local news both provided information to new enrollees and exposed many more millions of Americans to information with which they might interpret the success or failure of ACA implementation. Jacobs and Mettler reported significant shifts in public attitudes toward the ACA between 2010 and 2014, an attitude change that they attribute to Americans’ evaluations of the benefits following from policy implementation.4 Given that a relatively small proportion of Americans experienced the law directly, most Americans’ perceptions likely came from media depictions, at least at first. In fact, in February 2014, 44% of Americans indicated that their impression of the ACA was based on the media, and only 23% from one’s own experience.2 New evidence suggests that individuals exposed to higher volumes of ACA-related media in October 2013 were more likely to believe that they were sufficiently knowledgeable about the law.5
The aforementioned evidence suggests a relationship between public attitudes about health policy and media coverage volume, but the content of these media portrayals (e.g., the specific messages and tone conveyed in news coverage) may be even more important. Although a few previous studies have examined news media coverage of the lengthy congressional deliberations leading up to the passage of the ACA,6–8 surveys confirm low levels of knowledge about the law prior to the start of the open enrollment period.9 Therefore, the initial policy implementation stage is when Americans could have actually learned about the details of the new insurance options available to them. Yet no previous research has explored in depth the public health–relevant content of news coverage of the ACA in this early implementation phase.10
The current study provides a comprehensive analysis of the content of local television news coverage about the ACA during the first open enrollment period running from October 1, 2013, to April 19, 2014. Although viewership has declined somewhat (particularly among younger people), local television is still the news source most watched by Americans overall.11 This study provides important contextual information for policymakers, health policy scholars, and enrollment advocates seeking to better understand the information environment in the period during which 10 million Americans gained insurance.
To identify local TV news stories about the ACA, we conducted searches for “health care,” “healthcare,” “Obama care,” “Obamacare,” or “Affordable Care Act” in closed captions of the top 2 highest-rated local evening news broadcasts in 208 US media markets for the period that defined the first ACA Open Enrollment Period: October 1, 2013, to April 19, 2014 (including the 2-week special enrollment period following the official end on March 31). Two media markets, Lake Charles (Louisiana) and Bowling Green (Kentucky), did not have closed captioning and therefore were not captured at all. These searches yielded a total of 150 534 “hits,” or matches to the keyword search strings. We next constructed a sample of news content to identify a manageable set of stories for comprehensive content coding, using methods employed and validated in previous work.12,13 For each month in our sample, we created a “constructed week” sample of news coverage, randomly selecting 1 Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, and Sunday from each month. This sampling procedure accounts for the cyclic nature of news content. We then limited the sample to just the news hits that aired on dates within the constructed weeks. This process yielded 5301 total hits.
The first step in the data collection process was to check whether the hits were actually stories about the ACA. Trained coders either watched the entire news clip or, if video was not available, relied on the closed caption transcripts to determine whether it was an ACA-related story. For a hit to be classified as an ACA-related story, (1) it had to mention the ACA, Obamacare, the health care law, health care reform, or Medicaid expansion in the states, and (2) it could not be a duplicate of an already identified ACA story. We excluded a substantial number of hits that coders identified as not being ACA stories, leaving a sample of 2976 identified stories about the ACA. More than a third of the identified stories (n = 1063) came from the month of October. November had the next highest (n = 588) followed by March (n = 467; Figure A, available as a supplement to the online version of this article at http://www.ajph.org).
Missing data from certain news programs or stations are relatively common when collecting data from closed captioning, and our study is no exception. From the sample of 2976 ACA stories, 1407 had missing video or video–audio issues, such that they could not be coded. Fortunately, given information on which videos had problems, we confirmed that the missing data were well dispersed across markets and months and not systematically related to particular time periods, with the exception of October 21 and October 25, 2013, dates for which we have no video for any market. We present proportions in our findings and have no reason to believe that these proportions generated from coded data would systematically differ in the missing data. Our final sample for content coding included 1569 ACA-related stories.
We developed a coding instrument to capture information about the ACA in local news through an iterative process. After screening each hit to identify whether it was an ACA story, the research team then proceeded to code stories for a variety of content features. Coders assessed whether the story concerned mainly (1) the politics of the ACA (i.e., disagreement over the role of government, political disagreements over implementation, plans to repeal and replace the law), (2) the health insurance products available through the ACA and the enrollment process, or (3) a combination of politics and health insurance product–related content.
Within the subsample of news stories that had at least some health insurance product–related content, we then coded for a series of health policy–relevant variables. Specifically, we coded for the overall tone of coverage about the new health insurance marketplace, the major messages about the law and its effects, the framing of the name of the law, the frequency with which stories featured anecdotes of people affected, and the sources cited in coverage (coding instrument is given in the online Appendix). We coded most variables dichotomously—that is, we coded each story element (e.g., whether the story described Web site malfunctions) as either “present” or “absent.” For 1 content code (Medicaid content), we also assessed whether that theme was a “focus of the story” (coded 2), comprised “only a mention” (coded 1), or was “not mentioned” at all (coded 0). We assessed the tone of news coverage about health insurance enrollment using a 4-category variable, coded as neutral, discouraging, encouraging, or mixed (both encouraging and discouraging). We also created a tone summary score by coding discouraging coverage as –1, mixed or neutral coverage as 0, and encouraging coverage as 1, so average values above 0 are positive or encouraging and values below 0 are negative or discouraging.
A team of 32 student coders coded all stories after an extensive training period to ensure reliable application of the coding instrument. For all categorical variables, we estimated item-level interrater reliability (IRR) using κ statistics, a measure that estimates coder agreement for categorical variables and adjusts for the likelihood of chance agreement.14 For 1 ordinal variable (tone of coverage), we estimated Krippendorff’s alpha.15 For some relatively low-frequency items, IRR statistics fell below 0.70, and these variables are not reported here. The IRR for our main news coverage type variable (political coverage vs insurance product coverage vs a mix) was 0.76, whereas the IRR for tone was 0.74. The IRR of all other variables reported herein ranged from 0.70 to 1.0.
The first stage of the analysis was to calculate descriptive statistics of the key messages in news coverage about the ACA. Because we anticipated that local news coverage would differ both geographically and over time, we constructed geographic information system (GIS) maps of news coverage tone and also compared all news coverage variables for the 2013 period (October 1–December 31, 2013) and the 2014 period (January 1–April 19, 2014) or between states that operated their own marketplaces versus those that relied on the federal marketplace, both using 2-sample tests of proportions.
About one quarter (26.5%; n = 416) of the 1569 stories in our analytic sample were all about the politics of the ACA (i.e., political disagreements over implementation, discussion of repealing the law) and did not mention any information about health insurance products. By contrast, just under half (44.9%; n = 705) of the stories were all about the health insurance options available through the ACA. The remaining group (28.6%; n = 448) presented a mix of coverage of both politics and health insurance options available. Overall, then, more than half of all news stories (55.1%, n = 865) presented at least some coverage of politics. This composition changed over time. Figure 1 displays the composition of content over the 6 months, showing that news coverage of political disagreements (those stories that had some or all of their content devoted to politics) was dominant during the first 2 months of open enrollment; although political coverage declined somewhat thereafter, politics persisted as a major component of news coverage throughout the period.
Relatively few of the 1569 news stories mentioned Medicaid (7.4%) or had a Medicaid focus (5.0%); more of these stories focusing on Medicaid were in the subsample that was determined to be all about the politics (10.1% vs 3.1%; P < .01). More than half of the news stories (51.9%) referred to the law by its full name, the Affordable Care Act, or its abbreviation, the ACA. About a third referred to Obamacare (38.8%); other references included the health care law (11.2%) and the President’s health care law (3.8%), or referred to healthcare.gov or state-based exchanges. Stories within the health insurance product–focused subsample were more likely than politics-focused stories to reference the Affordable Care Act or ACA (57.8% vs 35.3%, P < .01), whereas stories in the politics-focused subsample were more likely than product-focused stories to refer to Obamacare (43.8% vs 36.9%, P = .015).
Overall, 57.2% of local TV news coverage was encouraging, 20.6% was discouraging, 13.3% was mixed, and 8.8% was neutral. Figure 2 maps the tone of coverage across the 208 included local media markets, using a measure ranging from –1 (all discouraging) to +1 (all encouraging), and averaged for each market and across the full open enrollment period. This map reveals high levels of geographic variation in the tone of ACA news coverage across the United States. A few states’ sampled local TV news coverage was entirely positive (e.g., North Dakota, Nevada, Arizona, Hawaii), but most states had intrastate variation in news coverage tone. No state had entirely negative coverage, on average. We tested whether tone of coverage varied by whether the states were implementing their own marketplaces versus relying on the federal marketplace; we found no differences between the tone of coverage in state-based marketplace states (mean tone = 0.341; SD = 0.80) compared with federal marketplace states (mean tone = 0.374, SD = 0.80; t = −0.60, P = .55). There were statistically significant differences in the tone of coverage over time. News coverage in 2013 (mean tone = 0.238; SD = 0.84) was significantly more discouraging than news coverage in 2014 (mean tone = 0.513; SD = 0.74; t = −5.88; P < .01).
Table 1 displays the major messages included in the overall sample of news that was at least somewhat about health insurance products (n = 1153), divided into the 2 time periods (late 2013 vs early 2014). Overall, about a third of product-related news coverage—and a significantly larger share in 2014, about 4 in 10 news stories—included some factual policy details about enrollment such as mention of fines, subsidies, or how to get help to enroll. A small proportion of news coverage (13.9%) provided viewers with information on where to go or a number to call to get help. Less than 7% of all stories indicated that subsidies are available to make health insurance more affordable. A comparison of states that offered their own marketplaces and those that relied on the federal marketplace revealed no difference in reporting on subsidies; overall, however, the coverage in news media markets within states defined as federal marketplace states reported on policy details about enrollment (in 39.2% of stories) more than in state-based marketplace states (27.9%; P < .01).
Affordable Care Act (ACA) Implementation Messages in Local News Stories About the ACA, Over Time: United States, October 1, 2013–April 19, 2014
|Message||Overall Sample, % (n = 1153)||2013 Stories, % (n = 617)||2014 Stories, % (n = 536)||P of Difference by Year||κa|
|Factual policy details for individual enrollees|
|Any mention of fines, subsidies, navigators, questions and answers, enrollment events or information||36.3||31.9||41.4||< .001||0.7989|
|Fines or penalties for not enrolling||16.4||12.3||21.1||< .001||0.8908|
|Information on where to go or number to call||13.9||12.3||15.7||.10||0.8508|
|Subsides are available||6.9||6.0||7.8||.22||0.9020|
|Coverage of a past enrollment or informational event||4.6||3.6||5.8||.07||0.7456|
|Population-level contextual information about law|
|Number of enrollees to date||27.0||17.7||37.7||< .001||0.8662|
|Federal or state enrollment goal||9.1||4.7||14.2||< .001||0.8032|
|Number of Web site visitors||5.2||3.2||7.5||.001||0.7136|
|Mentions research or evaluation about ACA||1.8||1.3||2.4||.15||1.0|
|Negative information about ACA implementation or enrollment|
|Any Web site glitch||33.3||41.0||24.4||< .001||0.8118|
|Healthcare.gov Web site glitch||19.1||27.1||9.9||< .001||0.7880|
|State Web site glitches||4.8||3.1||6.7||.004||0.7247|
|Narratives about people affected|
|Narrative of an individual or family helped by law||5.2||2.4||8.4||< .001||0.9501|
aEstimate of the interrater reliability for each variable across the team of coders.
About one fourth of health insurance product–related news stories overall—and about 38% in 2014—presented information on the number of new enrollees to date. Another relatively common message, particularly in 2014 (14.2% of stories), described federal or state enrollment goals. Very few news stories (1.8%) mentioned any research or evaluation evidence about the ACA. Web site glitches were a common message in news coverage; one third of news stories (33.3%) mentioned some type of Web site glitch (including healthcare.gov or state-based marketplace sites). As expected, such stories were significantly more common in 2013 (41.0%) than in 2014 (24.4%; P < .01). Finally, narratives or exemplars describing particular individuals affected by the law were featured in few news stories overall (less than 10%). Stories were more likely to describe people helped by the law in 2014 than in 2013 (8.4% vs 2.4%; P < .01).
Table 2 displays the sources of information cited in local TV news stories about the ACA, combining neutral information sources and those cited with particular positions about the law. The most common sources overall were President Obama (cited in 38.9% of news stories) and a White House or other federal executive agency figure (28.7%); also common were Republican (22.3%) or Democratic (15.9%) politicians or officials. Each of the other sources was cited in less than 10% of news stories, including governors, health insurance navigators, or insurers. Researchers or those with an academic, think tank, or foundation affiliation were cited in only 3.9% of news stories. President Obama, Republicans, and Democrats were all more likely to be included as sources of information in 2013 than in 2014 (P < .001). Insurance company representatives were also more likely to be cited in 2013 (9.1%) than in 2014 (2.8%; P < .001).
Sources Cited in Local News Stories About the Affordable Care Act (ACA), Over Time: United States, October 1, 2013–April 19, 2014
|Source||Overall Sample, % (n = 1153)||2013 Stories, % (n = 617)||2014 Stories, % (n = 536)||P of Difference by Year||κa|
|President Obama||38.9||46.4||30.2||< .001||0.8146|
|Executive: White House Administration, HHS, other federal agency||28.7||27.2||30.4||.23||0.7240|
|Republican politicians or officials at any level||22.3||30.6||12.7||< .001||0.8832|
|Democratic politicians or officials at any level (not Obama or administration)||15.9||24.6||5.8||< .001||0.7858|
|Navigators or certified application counselors||6.9||5.5||8.4||.053||0.7140|
|Insurance representative||6.2||9.1||2.8||< .001||0.7716|
|Researcher, academic, think tank, foundation||3.9||3.2||4.7||.21||0.7933|
Note. Table does not include sources cited in less than 1% of news coverage, including religious organizations and the advocacy group Enroll America. We also attempted to code for additional sources, including representatives of business, patient advocacy organizations, state exchange or other state authority, physicians, and average citizens, but reliability fell below 0.70 for these codes, likely because they had very low frequency (below 5% of news stories). HHS = Department of Health and Human Services.
aEstimate of the interrater reliability for each variable across the team of coders.
This study is the first to our knowledge to comprehensively examine local TV news media messaging about the ACA during its critical implementation stage, the full first open enrollment period. We found that only half of all news coverage about the ACA focused on the health insurance products available through the ACA. Even within the news coverage that did discuss health insurance products, key policy aspects of the ACA content were surprisingly uncommon. For instance, policy analysts attribute a large portion of insurance gains from the ACA to the voluntary state Medicaid expansions to low-income childless adults,1 yet Medicaid was only mentioned in 7% of news stories. Only 7% of news stories discussed the availability of subsidies, a critical provision for encouraging enrollment by making coverage more affordable. Overall, fewer than 4 in 10 news stories presented policy details that would be useful for consumers interested in enrollment, such as where to sign up, subsidies, or the availability of navigators for assistance.
Rather, news stories provided comparatively more attention to reporting on figures on enrollment expected or achieved or to Web site glitches. These emphases are consistent with the typical political strategy or “horse race”–focused journalistic style of covering campaigns or policy contests—with an emphasis on who is winning or losing.16–18 This manner of coverage is also consistent with how the political deliberations prior to the passage of the ACA were covered in news media in 2009 and 2010,7 and also with how the news media tended to cover the health care reform legislative debates in the 1990s.19,20 In this case, political strategy framing was represented by a strong emphasis on “wins” for ACA proponents (e.g., mentions in news coverage of the numbers of Americans who had established accounts, signed up, and gained insurance) compared with “losses” for ACA proponents (e.g., mentions of Web site or enrollment glitches). Attention to Web site glitches decreased but persisted through the latter half of the first open enrollment period, appearing in a full quarter of news stories in 2014.
This emphasis on strategic over substantive reporting in local TV news is further supported by the sources that reporters solicited for their perspectives. Political and partisan sources dominated; these elected officials’ viewpoints were far more represented in local news coverage about the ACA than any other group. Surprisingly, few news stories included any public health, medical, research, or health advocacy perspectives. This dominance of political sources suggests that viewers’ impressions of the law, already polarized dating back to the initial legislative debates in 2009, would remain so during the policy implementation stage. Research indicates that when political source cues are presented in news media, particularly for issues that are already politicized, changes in public perceptions are unlikely because viewers use these political cues to interpret and filter the information presented, in accordance with their own predispositions.21 Indeed, public opinion data demonstrate strong and persistent political polarization in public views of the ACA.4 These findings help explain why the law’s fate is in jeopardy as of this writing: even during the early phase of ACA implementation, the local news discussed the law using a political strategy frame (similar to political campaign coverage), thus limiting citizens’ exposure to the substance of ACA policy content while heightening the public’s likelihood of perceiving the law via politically charged heuristics.
This research has several limitations worth noting. First, although this large-scale content analysis comprehensively analyzed the messages in a constructed week sample of video and transcripts for more than 1100 local TV news stories about the ACA across media markets, because of missing data, this sample is not representative of all local television news coverage about the ACA. However, our investigations into the missing data by network and station representation indicate that any bias in included versus missing data is small (e.g., our sample included 20% NBC affiliates whereas the original sampling frame included 22% NBC affiliates).
Second, this study only includes local broadcast TV news coverage of the ACA, not other sources of news coverage including national news, online news, print news, or radio or other media. However, local TV news remains the most common source of news for Americans overall11 and the most common source of information for new 2014 enrollees in particular.3 Furthermore, given the localized nature of health insurance—with plans and prices varying dramatically across the United States—local news sources are likely among the most relevant sources of information about health insurance enrollment for consumers.
Third, as with all media content coding, there is some subjectivity to the process of interpreting video or text. Given the sheer volume of news to code, we relied on more than 30 coders. However, interrater reliability was greater than 0.70 for all coded measures included, increasing our confidence in the coding process. That said, we required precise and specific references for particular terms; thus, we may have missed more oblique messages that could be better captured using a qualitative approach to content analysis.
Finally, this is a descriptive study of news content. This work is important for understanding what Americans were plausibly exposed to in the local news environment; however, we cannot assert claims of actual news effects with the data and design presented here. In other work, we are linking media data to survey data at respondents’ county of residence to better understand how ecological measures of media are associated with various outcomes, including public attitudes and health insurance enrollment.5,22
As we look back at 2014, the ACA achieved great insurance gains in spite of a local TV news environment that relatively infrequently provided detailed and policy-relevant information to consumers. Many other media sources—including paid media by insurers, states, and healthcare.gov—may have at least partially filled this information vacuum. It will be important to build on this analysis by quantifying the extent to which various media sources and channels were associated with attitudinal or behavioral changes among both potential new health insurance enrollees and the general public during this critical phase of ACA implementation, as well as understanding how the media will contribute to public perceptions in a post-2016 political era wherein repeal or changes to the ACA loom large.
See also Parekh, p.
This research was funded by the Robert Wood Johnson Foundation State Health Access Research and Evaluation (SHARE) program, grant no. 72179. This research was also supported through the McKnight Land-Grant Professorship at the University of Minnesota; additional support was provided by Wesleyan University.
We presented an earlier version of this article at the Association for Public Policy Analysis and Management Fall Research Conference on November 5, 2016, in Washington, DC.
We thank the numerous student researchers at Wesleyan who made this project possible, especially Courtney Laermer and Alison Mann. Finally, we thank CommIT Technology Solutions for coding system support and acquisition of data.
HUMAN PARTICIPANT PROTECTION
Institutional review board approval was not needed because there were no human participants involved in the study.