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Craft: Lessons From The Field

How to use community engagement to build sources and a lasting audience

Lessons from reporting on Florida’s troubled Medicaid system

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Nearly half of all Florida kids rely on Medicaid for their health coverage, and yet quietly, over the past 10 years in Florida, the $24 billion program underwent fundamental change.

In a plan set in motion in 2005 by former Gov. Jeb Bush, Florida contracted with dozens of private insurance companies to enroll its millions of Medicaid members into health plans, creating a Medicaid managed care model that’s similar to systems operating in 37 other states.

But Florida started its privatization from a much different place than other states. Things in the Medicaid system had gotten so bad that at the same time the managed care transition started in 2005, a group of pediatricians, parents and pediatric dentists sued the Florida Medicaid program in federal court for failing to meet even the most basic standards of care.

My involvement with the story began on Dec. 31, 2014, when a federal judge found that Florida was in fact violating federal law. But the slow legal process means that even though millions of kids are enrolled in a program that doesn’t meet federal standards, it could still be years before the courts demand any substantive changes to the program.

Ultimately, my mission with this series was to explain. Explain how a $24 billion program had been transitioned to private management and why that matters to taxpayers. Explain how 4 million vulnerable children and adults now depend on private, for-profit companies to connect them with health care, and how the change had affected the medical community.

What I didn’t expect were the gut-wrenching human stories — the single mom struggling to save her son’s life as she battled the indifference of his Medicaid insurance company; the pediatrician taking money from her retirement account to keep serving her large number of Medicaid patients despite absurdly low reimbursement rates; the young parents facing ridicule at every turn while trying to provide for their children.

For reporters contemplating similar stories, here are some tips that may help you along the way.

1. Experiment with novel ways of telling the story, and bring more people into the fold.

Instead of writing a narrative history of a complex program, use a timeline. Rather than creating a detailed chart with all your data, think about a compelling data visualization that allows the reader to take a journey through the data. Our talented design team took complex child health checkup data and designed an interactive journey through the life of a fictional child enrolled in the Medicaid program.

We also interviewed many families with compelling stories, but ones that only captured a single issue. Rather than leaving them out, we created a profiles section, where parents, in their own words, could share their experiences with Medicaid, good or bad, big or small. The shorter narratives also gave readers easier entry points if they only have a few minutes to spend on the site.

2. Engage, engage, engage. And not just on the phone!

The people who know the Medicaid system for children best are young parents with children enrolled in the program. They’re typically in their early 20s, which means they text and use Facebook for pretty much everything.

To reach them, I found Facebook groups where young parents swapped baby supplies and parenting tips, and asked each other questions about pediatricians and how to resolve problems with their Medicaid insurance. By joining these groups and asking young moms about the challenges they were facing, I made deeper connections with the women by speaking their language in their preferred environment. With some of them, we never spoke on the phone. All communication was either via text, Facebook or in person.

Thinking through their communication patterns also helped me understand why the messages from the Medicaid program weren’t reaching the young parents. The state Medicaid program has call centers and print brochures, which are incomprehensible or irrelevant to many millennial parents. The call centers are only open during work hours, the hold times eat up valuable minutes on a pay-as-you-go phone, and the detailed websites can suck up a month's worth of cellular data in a few hours.

3. Be purposeful and thoughtful about your tone.

For one of our many community engagement efforts, we printed out a postcard to encourage people to share their story with us. It had a picture of a concerned mom comforting a scared girl with a doctor in the background, in a blue-gray scale. It seemed to fit the message we were sending. At least that’s what we thought.

One of the first parents we spoke with was really upset by the card. She had previously worked as a counselor at a domestic violence shelter and said that she was so tired of seeing victim-based imagery of women and children. Medicaid was a part of their life, but it wasn’t their whole life.

She was dead on. In response to her criticism, we shifted the whole visual and tonal strategy of the project. We used bright and warm colors for the website color scheme. We interviewed and wrote profiles showing parents and kids as whole people, with one aspect of their life made difficult by Medicaid, rather than as defined by the health struggles they were facing.

In the feedback from the series, I’ve heard many people say that they were inspired by the strength of the families in the photos, rather than full of pity for the families facing a tough situation. It’s a subtle distinction, but I know it meant a lot to the families featured and helped elevate the story to go beyond stereotypes.

4. Find those key sources of data.

Any reporter interested in their state’s Medicaid program should check out the child health checkup data collected by the Centers for Medicare and Medicaid Services at the U.S. Department of Health and Human Services.

The data, collected from the CMS-416 form that all states must file, goes back to 1995 and is standardized across states, which allows for comparisons. It’s also a great way to check how the program has changed over time. For my story, the data allowed me to show that even though Florida was arguing in federal court that they had improved their Medicaid program, the same percentage of children were missing out on care as they were 10 years ago.

Reporters interested in Medicaid managed care, which exists in 38 states, should get familiar with the National Committee for Quality Assurance. This nonprofit group accredits, rates and ranks health plans, including Medicaid managed care plans. They set national benchmarks for quality standards in both public and private plans, and their HEDIS (Healthcare Effectiveness Data and Information Set) scores are the standard used to evaluate health plans nationwide.

For instance, in Florida’s Medicaid managed care system, insurance companies must earn minimum HEDIS scores — which measure specific indicators such as the percentage of people who get all their checkups, percentage of children receiving all immunizations, and customer service call abandonment — to continue participating in the Medicaid program.

5. Build a newsroom team and keep it tight.

My newsroom fully embraced this project. Every week for five months, I led a meeting with our projects editor, our assistant managing editor of engagement, a photographer, a reporting partner, out graphics editor and web developer, to plan for the launch of this project.

While the early meetings were mostly me telling them about my reporting process, the regular check-ins gave us all the opportunity to think through the project together and address issues early on, such as incorporating parent feedback into the web app design (make it simple, fast, colorful and inviting).

Because we were in constant communication, the finished product was cohesive in a way that showed we’d all worked together, with everyone sharing the same goals and tracking their progress.

Announcements

There's a growing push by Republican governors to require Medicaid recipients to work to receive care. And the Trump administration is giving them the green light. This webinar will explore what this policy shift means for Medicaid enrollees, and outline questions reporters should be asking now. Sign up here!

Want to improve your data journalism skills?  Apply now for the $2,000 California Data Fellowship -- four all-expenses-paid days of training on data acquisition, analysis and visualization, plus a $2,000 reporting grant and six months of expert mentoring.  Dates:  October 17-20. Deadline: August 27.

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