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A content analysis of US newspaper coverage of Canada and the UK’s healthcare systems during America’s… Blackadar, Kerry Jean 2010

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A Content Analysis of US Newspaper Coverage of Canada and the UK‟s Healthcare Systems during America‟s Healthcare Reform  by Kerry Jean Blackadar B.A., The University of British Columbia, 2007  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF JOURNALISM in  The Faculty of Graduate Studies  (Journalism)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  August 2010  © Kerry Jean Blackadar 2010  ii  Abstract This study examines how Canadian Medicare and the United Kingdom‟s National Health Service (NHS) were represented in US newspaper coverage between January 2008 and the first quarter of 2010, a period marked by changing healthcare policy in America and dramatic shifts in the journalism industry at large. Through a content analysis of print news from the New York Times, Wall Street Journal, and USA Today, this paper tracked and assessed reporting dimensions and coverage themes to illustrate the quantity and quality of coverage. The analysis was based on the seminal work of Pauline M. Vaillancourt Rosenau, who performed a content analysis of newspaper coverage of Canada‟s healthcare system between 2000 and mid-June 2005 in the NYT and WSJ. Findings from this thesis reveal that recent US newspaper coverage of Medicare, though narrow, is more accurate and balanced compared to coverage during Rosenau‟s study timeframe. The NHS received far greater attention in US newspapers, indicating that outside factors, potentially including collaboration in the Iraq war, have spawned greater US media interest in the UK at large. On occasion, this study found coverage of the NHS to be critical, relying on anecdotal evidence to suggest systematic failure of aspects of healthcare in the UK. With respect to coverage themes, wait lines for treatment was a dominant issue in US newspaper reporting of both Canadian Medicare and the NHS. Medical tourism and problems associated with paying for universal healthcare also emerged in US representation of the NHS. This paper concludes with a discussion of outside factors that may have influenced American newspaper coverage during the study period. Considering the current state of print journalism, this paper predicts that, in the years ahead, American print coverage of foreign healthcare will continue to decline. However, in conjunction with this, it is likely that increased  iii online representation of foreign healthcare stories will occur, as new journalism platforms, such as blogs, continue to proliferate. Finally, as American reporters continue to gain greater access to online healthcare research databases, this study suggests that the quality of US coverage of Medicare and the NHS is likely to improve.  iv  Table of Contents ABSTRACT ................................................................................................................................... ii TABLE OF CONTENTS ............................................................................................................ iv LIST OF TABLES ....................................................................................................................... vi ACKNOWLEDGEMENTS ....................................................................................................... vii DEDICATION............................................................................................................................ viii 1  INTRODUCTION................................................................................................................. 1  2  LITERATURE REVIEW .................................................................................................... 4 2.1 2.2 2.3 2.4 2.5 2.6  Understanding the Role of the Media: Entman on News Framing .................................. 4 American Media Representation of Canada‟s Healthcare System................................... 6 American Media Representation of the United Kingdom‟s Healthcare System .............. 9 American Media Representation of US Healthcare ....................................................... 10 The Value of Cross-National Health Policy Research in Media Reporting ................... 13 Summary ........................................................................................................................ 16  3  HYPOTHESES ................................................................................................................... 17  4  METHODOLOGY ............................................................................................................. 21 4.1 Study Scope .................................................................................................................... 21 4.2 Data Collection ............................................................................................................... 22 4.2.1 Database and Search Terms .................................................................................... 22 4.2.2 Inclusion Criteria .................................................................................................... 23 4.3 Sample Size .................................................................................................................... 24 4.4 Data Analysis ................................................................................................................. 26 4.5 Reporting Dimensions .................................................................................................... 27 4.5.1 Thematic Analysis .................................................................................................. 30  5  RESULTS ............................................................................................................................ 31 5.1 Finding 1: Overall Representation in US Newspaper Coverage .................................... 31 5.2 Finding 2: Accuracy, Balance, and Completeness of Coverage .................................... 32 5.3 Finding 3: Coverage Themes ......................................................................................... 45 5.3.1 Canada – Shifting Themes ...................................................................................... 45 5.3.2 UK – Wait Lines, Medical Tourism, and Financial Framing ................................. 48 5.4 Summary of Findings ..................................................................................................... 49  6  DISCUSSION ...................................................................................................................... 51 6.1 Quantity of Foreign Healthcare News Coverage ........................................................... 51 6.1.1 Journalistic Pressures .............................................................................................. 52 6.1.2 Political Influence ................................................................................................... 54 6.2 Reasonably Accurate Reporting ..................................................................................... 56 6.2.1 Online Access to Research Databases .................................................................... 56 6.3 Prominent Coverage Themes ......................................................................................... 57  7  CONCLUSION ................................................................................................................... 59  v 8  LIMITATIONS ................................................................................................................... 60 8.1 8.2 8.3 8.4 8.5  9  Rosenau‟s Limitations Left Unaddressed ...................................................................... 60 Nature of Content Analysis ............................................................................................ 60 Database Shortfalls ......................................................................................................... 61 Inclusion Parameters ...................................................................................................... 62 Small Sample Size.......................................................................................................... 62  SUGGESTIONS FOR FURTHER RESEARCH............................................................. 63  BIBLIOGRAPHY ....................................................................................................................... 65 APPENDIX A: SAMPLE ARTICLES...................................................................................... 76  vi  List of Tables Table 4.3a:  Summary of Database Search Outcomes......................................................  25  Table 4.3b:  Article Exclusion Factors..............................................................................  26  Tables 5.2.1a:  Reporting Dimensions for Canada – Dimension 1.......................................  33  Table 5.2.1b:  Reporting Dimensions for UK – Dimension 1..............................................  34  Table 5.2.2a:  Reporting Dimensions for Canada – Dimension 2.......................................  34  Table 5.2.2b:  Reporting Dimensions for UK – Dimension 2..............................................  35  Table 5.2.3a:  Reporting Dimensions for Canada – Dimension 3.......................................  39  Table 5.2.3b:  Reporting Dimensions for UK – Dimension 3..............................................  39  Table 5.2.4a:  Reporting Dimensions for Canada – Dimension 4.......................................  40  Table 5.2.4b:  Reporting Dimensions for UK – Dimension 4..............................................  41  Table 5.2.5a:  Reporting Dimensions for Canada – Dimension 5.......................................  42  Table 5.2.5b:  Reporting Dimensions for UK – Dimension 5..............................................  43  Table 5.2.6a:  Reporting Dimensions for Canada – Dimension 6.......................................  44  Table 5.2.6b:  Reporting Dimensions for UK – Dimension 6..............................................  45  Table 5.3:  Thematic Coverage for Canada and the UK.................................................  46  vii  Acknowledgements I would like to first acknowledge my primary advisor, Dr. Mary Lynn Young at the Graduate School of Journalism, University of British Columbia. Young‟s ability to offer constructive criticism and soften concerns throughout each stage of this project was highly appreciated. I would also like to acknowledge the assistance of my secondary advisor, Dr. Steve Morgan at the School of Population and Public Health, University of British Columbia. His keen interest and insights into healthcare policy matters have been integral to this study‟s development. Finally, for her time and willingness to teach me how to conduct a content analysis, I would like to extend thanks to Dr. Anne Marie Nicol, Centre for Health and Environment Research (CHER) at the University of British Columbia.  viii  Dedication For all the cups of coffee, and for all the warm support, I dedicate this thesis to my family, Don, Janet, and Alana Blackadar, and the greatest constant in my life, William Gallagher. I would also like to dedicate this thesis to my fellow graduates, as well as the professors and staff at the University of British Columbia‟s Graduate School of Journalism, a group of individuals that have the capacity to offer edits and hugs with equal vigour.  1  1 Introduction This thesis assesses American print media coverage of Canada‟s health care system, Medicare, and the United Kingdom‟s National Health Service (NHS) during the introduction and implementation of recent US healthcare reforms (January 2008 through to the first quarter of 2010). More specifically, it examines the accuracy, fairness, and completeness of US news coverage through a detailed qualitative and quantitative content analysis of the New York Times, the Wall Street Journal, and USA Today. This study is important at this time, as it coincides with a defining moment in US history – the introduction (and implementation) of health policy change. In 2008, close to forty six million people in the United States lacked any form of health insurance and medical bills were the second major cause of personal bankruptcy (Marmor, “American Health Care Policy and Politics” 4). The following year, during President Barack Obama‟s first year in office, healthcare reform was placed near the top of the domestic policy agenda and, after a year of bipartisan debate, new health legislation was introduced in the first quarter of 2010. The $940billion law marked the beginning of some potentially positive changes to healthcare insurance policy, bringing America close to universal health coverage for the first time in its history. But such change did not come without resistance, and ultimately, compromise. The new law, which places insurance companies under stricter moral obligation and offers greater insurance affordability and coverage for the nation‟s poorest, did not receive a single vote in favour from the Republican Party. Ultimately, the legislation represents only a fraction of the changes Obama hoped to bring about to healthcare in America. Opposition to healthcare reform in America is nothing new. In 1993, L.R. Jacobs recognized that the mixture of government “support and dread [was] the defining characteristic  2 of American public opinion toward health reform” (634). Prior failed healthcare initiatives include Theodore Roosevelt‟s national plan in the early 1900s, Harry Truman‟s public health insurance proposal in the 1950s, and, more recently, Bill Clinton‟s Health Security initiative at the close of the 20th century. The polarization of Democrats and Republicans over the passage of healthcare legislation in 2010 suggests America‟s anxiety and uncertainly over the government‟s role in healthcare continues to play an important role in policy decision-making. Much of the debate over healthcare reform was carried out in the mainstream media. In fact, a study conducted by the Pew Research Center‟s Project for Excellence in Journalism reveals that “in the 10-month period from June 2009 through March 2010, the health care debate was the leading subject in the mainstream [US] news media”, putting it ahead of the economy and well ahead of the war in Afghanistan (“Six Things to Know About Health Care Coverage”). The study‟s authors further note America‟s mainstream media “seemed to focus far more on the politics and passions that drove the debate than the health care system it was trying to reform” (n.pag). In order to gauge the role that traditional journalism platforms (specifically newspapers) played in the healthcare debate, this thesis sought to determine the fairness, accuracy, and comprehensiveness of American coverage of healthcare beyond the US border. More specifically, it sought characterize how US newspapers represented Canadian Medicare and the United Kingdom‟s NHS, which have frequently served as foils to America‟s largely private insurance-based healthcare system. This study both replicates and builds on Pauline M. Vaillancourt Rosenau‟s seminal study, “US Newspaper Coverage of the Canadian health System – A Case of Seriously Mistaken Identity” (2006), which explored coverage of Canadian Medicare in the New York Times and  3 Wall Street Journal between 2000 and mid-June of 2005. Rosenau‟s methods for data selection and coding were adopted in order to test the study‟s protocols and try to extrapolate change between periods of study. Consistent with Rosenau‟s work, the present study relies largely on quantitative analysis, focusing specifically on the presence of coverage themes and various reporting dimensions to measure accuracy and fairness. Key differences from Rosenau‟s study include a briefer sample period (two and a quarter versus five years), expanded scope (encompassing both Medicare and NHS) and an increase in the number of sources (with the addition of coverage from USA Today). This thesis has three main objectives: 1) to provide a reliable benchmark for comparing the quality of pre- and intra-reform US coverage of Canada‟s healthcare system, 2) to assess American print media coverage of the NHS, and 3) to illustrate the overall impact of shifting healthcare policy on US print coverage of external, publically-funded healthcare systems, such as Medicare and the NHS. The first section of this paper presents a review of the literature, followed by a summary of hypotheses and the methodological approach that was employed. The next sections offer the results of the study and a thorough discussion of coverage trends. In closing, the study‟s limitations, particularly the methodological shortfalls, are outlined and suggestions for further research are provided.  4  2 Literature Review This section begins by establishing the theoretical framework behind the role of media as it pertains to this study. The main purpose of this literature review, however, is to illustrate what the existing body of literature reveals about American media coverage of healthcare in Canada and the United Kingdom.1 In order to properly gauge the significance of such analyses, research that addressed America‟s coverage of the US healthcare system was also examined. The final part of the literature review touches on the vast and growing body of research that explores cross-cultural perspectives on healthcare policy. This field of research illustrates the combined value, yet inherent difficulty of comparative healthcare studies, and emphasizes the increased difficulty of cross-cultural healthcare reporting, particularly during times of policy change, when both stakes and emotions run high.  2.1  Understanding the Role of the Media: Entman on News Framing A common theory, known as the agenda setting effect, contends that “the news sets the  public opinion agenda, bringing some issues to the forefront and minimizing others” (Krippendorff and Bock 205). Under this view, “media content doesn‟t so much tell the audience what to think as it tells the audience what to think about” (205). Related to this theory is the notion of framing, which involves media selection or emphasis of certain aspects or features of an issue (Entman 52). Robert M. Entman‟s approach to news framing and the power of the media served as the guiding theoretical framework for this thesis. Entman defines framing 1  Journal articles considered for this literature review were taken from the following three databases: Academic Search Complete, Medline, and Communication and Mass Media Complete. Articles were selected using a combination of the following search terms: Canada, Canadian, Medicare, UK, United Kingdom, Great Britain, NHS, America*, United States, health care reform, healthcare, newspaper coverage, and media representation.  5 as the selection and emphasis of “some aspects of a perceived reality” in a communicating text (52). Frames, according to Entman, are manifested by the presence or complete absence of “key words, stock phrases, stereotyped images, sources of information, and sentences that provide thematically reinforcing clusters of facts or judgements”, which channel, or guide thinking (52). In other words, “frames select and call attention to particular aspects of the reality described, which logically means that frames simultaneously direct attention away from other aspects” (54). In agreement, Rosenau suggests that “the details journalist‟s select for their articles subtly construct reality and thereby influence readers” (“U.S. Newspaper Coverage of the Canadian Health System” 28). With respect to American newspaper coverage of foreign healthcare systems, Rosenau argues that “there is evidence that newspapers shape citizens‟ perception and opinions by cueing the coverage” (27). Consequently, she maintains, there is good reason to believe that Canada‟s national image on the global stage is influenced, to some extent, by the media (27). The same speculation could arguably be applied to American newspaper coverage of the UK. Entman‟s position on the relationship between news framing and journalistic objectivity is of particular interest to this study. According to Entman, the formulaic norm of journalistic objectivity does not guarantee balanced reporting. Instead, he states, journalists “frequently allow the most skilful media manipulators to impose their dominant frames on the news” which subsequently leads to reporting that “prevents most audience members from making a balanced assessment of a situation” (56). For the purposes of this analysis, the media was understood to be both knowingly and, more often, unintentionally influenced by external forces, particularly politicians and special interest groups. As a result, it was anticipated that the viewpoints and stories of „media manipulators‟ would be highlighted in US news coverage and lead to the  6 dominance of particular news frames (and coverage themes) in American reporting of Canada and the UK‟s healthcare systems.  2.2 American Media Representation of Canada’s Healthcare System Over the past decade, there have been several key academic studies on American media coverage of Canada‟s healthcare system: Pauline M. Vaillancourt Rosenau‟s “U.S. Newspaper Coverage of the Canadian Health System – A Case of Seriously Mistaken Identity?” 2006; Christopher M. Belch‟s “A View from Abroad: An Analysis of Canadian Coverage in U.S. Newspapers” 2004; and Theodore R. Marmor‟s “Fact and Fiction: The Medicare „Crisis‟ Seen From the US” 2000. These scholars focused on several areas of study, including the limited nature of US coverage of Canada‟s healthcare system, the quality of reporting (accuracy, completeness, balance, and tone), and the representation of key themes, such as wait times. They approached areas of research using different methodologies, varying from qualitative and quantitative content analysis through to an isolated case study. The diversity of their findings reflects the methodological approach as well as period differences and the application of different theoretical frameworks. Rosenau‟s study, a content analysis of five and a half years of newspaper coverage of thirty-eight articles from the New York Times and twelve from the Wall Street Journal, provides the greatest insight into American print media coverage of Canadian healthcare to date. Her aim was to determine the fairness, accuracy, and completeness of US coverage. Overall, she found substantial gaps in knowledge, which led her to conclude that “US newspaper reporting on the topic of the Canadian health system in The New York Times and Wall Street Journal is poor”, and that “the complex reality of the Canadian health system would be better understood in the U.S. if coverage were fairer, more accurate, more complete, and not so often a source of  7 confusion, oversimplification, omission, and error” (“U.S. Newspaper Coverage of the Canadian Health System” 44-45). Rosenau found that coverage relied heavily on anecdotal information and tended to oversimplify variation between the provincially administered healthcare systems, particularly with respect to coverage of Quebec (a province neglected almost entirely by the NYT and WSJ over the study period of half a decade). She further noted that reporters often focused on controversial issues or ongoing healthcare themes, such as emergency wait times or doctor shortages. Such discretionary news coverage, she argued, “reinforces preconceived, often mistaken ideas about the Canadian health system and does little to correct commonly held misconceptions” (“U.S. Newspaper Coverage of the Canadian Health System” 44). In concert, Rosenau believes that these shortfalls and inaccuracies logically contribute to confusion and argued that “newspaper coverage may be misleading the U.S. public as well as policy-makers” (46). While Rosenau‟s study added substantially to the knowledge base in this area, it also had a number of inherent limitations that were acknowledged by the author. Firstly, the study was limited to only two (granted major) national newspapers. Her conclusions, therefore, cannot be extrapolated with confidence to other newspapers or locations and therefore do not fully satisfy the study‟s objective to assess the perceptions of US citizens (as a whole). Furthermore, Rosenau presents no evidence as to whether US newspaper coverage is better or worse than domestic (Canadian) coverage of Canada‟s healthcare system. And, finally, the study did not examine how US newspapers cover the US health system as a point for comparison. The inadequacy of coverage of Canada‟s healthcare system was also noted by Christopher Belch, who conducted a topical analysis of American print coverage of Canadian  8 news in four state newspapers (The Detroit News, The Dallas Morning News, The San Francisco Chronicle, The St. Louis Post-Dispatch) and one national American newspaper (the New York Times) over a two-month period in 2004. Belch noted that “the underlying ethos of American media exposure to Canada seem[ed] to be through sports, particularly hockey and auto racing” (43). In the New York Times, for example, healthcare articles accounted for less than ten per cent of overall coverage (83). Yet, though coverage of healthcare north of the border was found to be narrow, Belch concluded that the Canadian healthcare system was positively depicted and framed to suggest similarities between the US and Canada (71). In contrast, Ted Marmor found that various publications, including the New York Times, tended to highlight differences between healthcare in America and Canada, often presenting the Canadian system in a negative light. However, it is important to note that Marmor‟s conclusions are limited, as they stem from a single case study, which exclusively analyzed US media coverage of North American emergency room overcrowding during the seasonal flu outbreak of December 1999 through to February 2000. During this outbreak, Marmor discovered that US reporters tended to portray Canadian healthcare as “a program in deep trouble, overcome by problems of access, cost, and quality” (“Fact and Fiction” 1). Such representations, he asserts, conflict with data and analysis offered by independent, not-for-profit organizations, like the Canadian Institute for Health Information (1). In reflecting on the larger media scene, Marmor argues that US “journalistic interest in Canadian Medicare reflects the place of health insurance issues on the national agenda” (“Fact and Fiction” 2). As such, “attention is intermittent, not very well informed and mostly [a] reflect[ion] [of] the preoccupations of American interest groups”, whom, he notes, bring stories and documentation to the press (2-3). In conclusion, Marmor points out that “the media‟s  9 commitment to even-handedness actually undermines a balanced view of Medicare” and argues that “as long as stories are the mechanism for understanding Medicare, distortion of the program‟s strengths and weaknesses will continue” (3). Such an analysis, though helpful on a national level, is somewhat limited by its approach to media as a single entity, without regional and political variation.  2.3 American Media Representation of the United Kingdom’s Healthcare System A search of the literature revealed that academic endeavours relating to American media‟s coverage of the UK‟s healthcare system are underdeveloped. While there has been little in the way of academic interest, casual observation of American television news programming and newspaper editorials suggests that unsubstantiated claims about the NHS have circulated in US news in recent years. As a case in point, in 2007, Fox News dedicated a segment to the contentious proposition that universal healthcare in the UK acts as a breeding ground for terror. Together, program host Neil Cavuto and guest Jerry Bowyer alleged that the bureaucratic nature of state run health care invites terror (Bennet). The segment, in which Bowyer proposed that doctor shortages in the UK have paved the way for increased physician recruitment from Muslim nations, juxtaposed images of explosives and car bombs with patients receiving MRIs, an ironic comment on Fox’s commitment to their trademarked slogan: fair and balanced (Your World). With the onset of Obama‟s push for reforming healthcare insurance coverage in the US, the debate over state-run healthcare remerged in public view, and myths about the NHS circulated in American news coverage once more. While the existence of widespread inaccuracy in news coverage of the NHS cannot yet be confirmed by academic reports, observations by UK journalists reveal that misrepresentation of the NHS did occur during this timeframe. In August,  10 2009, for example, journalist Raphael Satter of HuffPost Social News wrote that criticism of the NHS “stung Britain‟s left-leaning Labour government” so hard that the “Department of Health took the unusual step of contacting The Associated Press” to rebut “what it said were misconceptions about the NHS being bandied about in the U.S. media” (n.pag). In summary, this literature review reveals that more formal studies are required to determine the true nature of US coverage of the NHS, and whether reporting inaccuracies pervade outside of narrow observation of selected news reports – an objective of this particular study.  2.4 American Media Representation of US Healthcare A number of scholars (Limor Peer et. al, Trudy Lieberman, Gary Schwitzer, and Melinda Voss) have studied healthcare reportage in the United States over the last decade. A main finding of their studies relates to the overall nature and changing quality of healthcare coverage in the US in recent years, and suggests a general bias towards influence of external factors, such as the economy and industry demands, on reporting scope and complexity (Schwitzer 11). Limor Peer et al. argue that the broad category of health/fitness/medicine receives limited coverage in American newspapers. In “The daily diet of news: Variation in newspaper content” (2000), the authors examined the average allocation of news content (quantified by story space) devoted to particular topics, and explored how market characteristics (such as circulation, competition, ownership, and literacy) impact categorical emphasis (5). The authors determined, through the categorization of a week of content from 101 daily newspapers, that the combined topic of health/fitness/medicine represented just over three per cent of all story space in newspapers (18). The market characteristic that had a significant impact on space devoted to this particular category was region, with the northeast and Midwest regions of the US devoting the most relative space, followed by the west and south (13). In contrast, nearly a quarter of all story  11 space was devoted to sports, followed by politics/government at eighteen per cent and business and crime at eight per cent each (18). With specific reference to healthcare journalism, Trudy Lieberman argues that “there are plenty of good, hardworking reporters on the healthcare beat” in America, but affirms that there are too many cases where the media actively undermine trust in healthcare (“Trustworthy Information: The Role of the Media” 115). The deterioration of US trust in healthcare fostered by the media happens, she says, “in identifiable ways and for understandable, if not laudable, reasons”, with industry norms and pressures influencing the ability of journalists to accurately report health and healthcare news (115). Together with the time-sensitive nature of news, Lieberman cites journalism culture – the way journalists are trained to look at and write about particular issues – as another factor that leads to inaccurate and unreliable examples of healthcare reporting (115-117). In an effort to demonstrate her claim, Lieberman refers to a study that she conducted in 2002, where she examined 127 articles from major US newspapers, exploring the congressional debate over adding a prescription drug benefit to America‟s Medicare program. Lieberman discovered that the vast majority of articles focused on the political angle: “Reporters piled quote upon quote from Democrats, Republicans, the Speaker of the House, and the leaders of the Senate and offered various prognostications about which political party would benefit more, if the drug bill were passed or if it were killed” (117). Only a few articles, she states, examined the human angle, looking at how the bill would have impacted the people it was intended for (117). In summary, Lieberman believes that as a result of standard journalism practice, some US media outlets “fail to provide readers or viewers with the accurate information they need”, or provide “too much information that is misleading, unreliable, or simply useless” (115).  12 HealthNewsReview.org, launched in 2006 and led by Gary Schwitzer, provides greater insight into the overall quality of health journalism in America today. Using a standardized rating system, reviewers from the fields of journalism, medicine, health services research and public health asses the accuracy, balance, and completeness of online health stories from a wide range of news outlets, including the NY Times, WSJ, and USA Today.2 The site is largely critical of health stories on medical treatments, tests, products, and procedures, illustrating that the quality of health journalism in the US stands to be improved. Factors, particularly journalistic and economic, influence the ability of journalists to report health and healthcare news. Melinda Voss‟s 2002 study “Checking the Pulse”, which examined self-perceived reporting ability among health journalists in five Midwestern states, stands as evidence that inadequate training of healthcare reporters may negatively impact the state of healthcare journalism in the US. A large number of respondents in Voss‟s study found that understanding key health issues, putting health news in context, producing balanced stories on deadline, and interpreting statistics was “sometimes to nearly always difficult” (1159). Such concerns, Voss suggests, stem from inadequate training, pointing to the fact that nearly 83 per cent of respondents reported having received no training for covering health news (1158). In 2009, the Kaiser Family Foundation, a US-based private non-profit organization that focuses on matters related to American healthcare, issued a report exploring the state of health journalism in the US, focusing specifically on how recent changes in American newsrooms are affecting coverage. It noted that in the last three years, cuts in budget and staff have led to  2  HealthNewsReview.org examines daily online news stories from: USA Today, Wall Street Journal, NY Times, LA Times, Washington Post, Chicago Tribune, Houston Chronicle, Arizona Republic, Denver Post, and the Dallas Morning News. Also checked daily: National Public Radio health & science page, Reader's Digest.com health news page, MSNBC.com health news section, CNN.com health news section, WebMD health news section. Checked weekly: websites of news magazines Time, Newsweek, U.S. News & World Report.  13 several troubling trends in US health journalism, including 1) “An emphasis on stories that can be produced quickly – often meaning more stories on medical studies, and sometimes sacrificing on quality”; 2) “Fewer in-depth or complex stories, especially about health policy, and more „hyper local‟ stories along with stories variously described as lifestyle, consumer, or news-youcan-use”; 3) “Reliance on stories produced and syndicated elsewhere, by non-traditional news sources”; 4) “The influence of commercial interest on health news” (Schwitzer 9). The study also found that the topic of health policy receives far less coverage than other stories related to health, noting that out of all journalism platforms, the traditional (and declining) platform of newspaper provides the greatest coverage of health policy (11).  2.5 The Value of Cross-National Health Policy Research in Media Reporting As Ted Marmor has noted, “times of policy change increase the demand for new ideas – or at least new means to old ends” (“Comparative Perspectives and Policy Learning in the World of Health Care” 4). In the late 1980s and early 90s there was increased academic, media, and public interest in America in examples of successful healthcare reform in other nations, particularly Canada (Hamburger et al. 5). With this interest emerged extensive commentary that may have inhibited accurate assessment and understanding of foreign healthcare at large. A study conducted by Christopher Potter and Janet Porter, which explored the perpetuation of stereotypes and myths of UK‟s healthcare system in American culture, enforces this view. In “American Perceptions of the British National Health Service: Five Myths” (1989), Potter and Porter examined five myths thought to be commonly held by Americans about the British National Health Service. Each myth, chosen on the basis of discussions with students, health service professionals, academics, and citizens during Potter‟s two-year placement as a visiting scholar at the University of  14 Minnesota, was evaluated to determine its factual accuracy. With reference to health service research and policy reports, the authors evaluated the truthfulness of whether: 1) healthcare care in the UK is a form of socialized medicine, 2) widespread rationing occurs, 3) patients have long wait times, 4) there is no free choice of healthcare providers, and 5) private medicine is taking over (342). They concluded that ethnocentricity and cultural biases have led to America‟s misgivings about the NHS and the perpetuation of stereotypes that serve to discredit the British system (364). Ultimately, they suggest that the five myths “limit the ability of Americans to objectively evaluate the NHS and prevent them from learning about the British system” (341). It has been noted that despite the growth of US health policy research into cross-national comparisons and the potential for improved coverage of foreign healthcare and greater public awareness during the early 1990s, some journalists failed to explain how lessons from abroad could be adapted to the US system and struggled to illustrate the sheer complexity of foreign healthcare systems (Cano 157). In reflection, Carlos Cano states that the Canadian model of national health insurance “could not possibly [have] be[en] accurately understood from the mix of myths, half-truths, and misleading evaluations that the special-interest groups in American medicine understandably express[ed] and to which the media g[a]ve excessive attention” (157). The mis-use of anecdote has been cited as one of the greatest threats to reporting accuracy and in-depth social analysis (Rosenau, “US Newspaper Coverage of the Canadian Health System” 34). Marmor is particularly sceptical of the mainstream media‟s inclination to dramatize problems. With respect to coverage of Canada‟s healthcare system, he argues that “as long as stories are the mechanism for understanding Medicare, distortion of the program‟s strengths and weaknesses will continue” (“Fact and Fiction: The Medicare „Crisis‟ Seen From the US” 3). American sociologist Todd Gitlin further recognizes that stereotyping “solves an  15 enormous number of practical problems in journalism”, but also propagates inaccuracies and creates barriers to cross-cultural understanding (267). Yet, while academics may be quick to criticize the work of reporters, it is important to note that a number of journalism industry norms are based in sound judgement. The emphasis placed on anecdotal information, for example, reflects the underlying view that audiences are more likely to engage with reporting that is conveyed through personal stories. Reporters must also conform to the ideals of newsworthiness, which includes factors such as timeliness, proximity, prominence, consequence, human interest, and shock value. Such guidelines thus lead to the selectivity of certain story lines over others. Today, the wealth of health policy research into cross-border comparisons of medical systems has only grown larger, and arguably led to increased access to information for journalists, the overall improvement of reporting quality, and enhanced public awareness. However, recent examples during America‟s healthcare reform, suggest that partial truths and rhetoric of Canada and the UK‟s healthcare systems continue to prevail in US public discourse. In 2009, for example, Allan S. Brett noted that amid all the rhetoric of health care reform in the US – the most prominent claim was that single-payer health care – “a Canadian-style Medicarefor-all system – [wa]s antithetical to „American values‟” (440). Brett argues that this notion was designed to “stop discussion of a government-sponsored single-payer system” in the US (440). According to others, the UK‟s National Health Service also served as “a „whipping boy‟ in America‟s [most recent] healthcare debate”, inaccurately portrayed as an example of “the „failed Socialist‟ model of healthcare” (Kilkenny). The fact that unsubstantiated claims over the foreign healthcare experience continue to circulate holds a number of significant consequences to transatlantic learning (Quam and Smith  16 530), and arguably points to the need for improved usage of cross-national research by American journalists who report on foreign healthcare systems. However, obtaining academic standards of in-depth cross-national analysis may remain an unrealistic expectation of reporters, who work within the framework of an event-driven medium and who face increasing pressure to meet shifting industry demands.  2.6  Summary To date, studies reveal that US journalistic interest in Canada and the UK‟s healthcare  systems tends to be intermittent, with influxes reflecting larger policy shifts taking place in the US. Most scholars indicate that US coverage of Canada tends to focus on the differences, and less so on the similarities between the healthcare systems. Research also reveals that US news reports of Canada and the UK often rely on stereotypes associated with single-payer public healthcare systems, such as wait times and doctor shortages. As a point of comparison, it is important to note that examples of inaccurate reporting also appear in US healthcare journalism. The current state of the media industry, particularly economic factors, is cited as a common reason for compromised accuracy of reporting. Finally, the literature suggests that despite the growth of academic cross-cultural healthcare policy research and analysis over the past several decades, only modest improvement in the state, particularly the complexity, of American reportage of foreign healthcare systems has occurred.  17  3 Hypotheses The decision to assess US-coverage of the Canadian and UK healthcare systems at this particular point in time stemmed from the supposition that American news coverage would be influenced by a number of time-sensitive factors, including the advent of healthcare reform, and the current state of the media. In this context, the study explores three major hypotheses. The initial hypothesis involved the idea that news coverage of Canada and UK‟s healthcare systems in American newspapers would be limited compared to Rosenau‟s study as a result of President Obama‟s early framing of healthcare reform in the US. Obama maintained that US healthcare reform required a “uniquely American approach” – a vow that arguably shaped the media‟s subsequent coverage of healthcare in Canada and the UK (Lucas). As a result, this study anticipated that both Medicare and the NHS would receive somewhat equivalent, but limited attention in all three newspapers. Within this context, however, a potential focus on Canada was suggested by Obama’s contention in August, 2009, that Canadians were likely to continue to get dragged in to the debate, despite the fact the Canadian model had no place within America‟s proposed legislation (“Obama: Canada Not a Boogeyman”). Reduced coverage of international healthcare plans (Medicare and the NHS) was also anticipated as a result of the depressed state of the media industry, particularly the print industry, which has suffered a steep decline in advertising revenue, sharp cutbacks, and the elimination of newsroom staff (Pew Research Center, “The State of the News Media 2009 - Introduction”). Under such increased financial pressure, reductions in international news, particularly from developed countries like Canada and the UK, which tend to produce less sensational news than  18 developing nations, are to be expected. It was anticipated that cost-cutting measures in the newsroom would lead to less reporting of both healthcare systems. Reduced newspaper coverage was also anticipated because of the increasing shift in recent years to on-line reporting. Since Rosenau’s study was published half a decade ago, technological advances (and increased newsroom acceptance of online reporting tools) have contributed to increased volume, diversity, and readership of online newspaper content (Newspaper Association of America). The online journalism boom has seen a parallel decline in print stories, which provide the foundation for this thesis. I hypothesized that there would be the least amount of international healthcare coverage in USA Today, which is a national newspaper and less likely to cover international stories unless they have a particular connection or local tie to American health reform. Representing a respected global media outlet, the New York Times was anticipated to have the greatest number of stories, followed by the financially-minded Wall Street Journal. The second hypothesis tested involved comparing whether US reporting of Medicare is better now than it was during Rosenau‟s study timeframe, and how coverage of Canada‟s system today compares to that of the UK‟s. As a result of recent increased access to online healthcare research and statistics from both Canada and the UK, American journalists have increased potential to report more accurately, which was anticipated to be observed in articles reviewed in this study. The Health Council of Canada, the Canadian Institute for Heath Information (CIHI), and the Canadian Health Services Research Foundation (CHSRF) are just some of the bodies supporting websites that provide accurate and timely updates on the state of Medicare – including research on wait times, primary care, and the future of Canada‟s national pharmaceutical strategy. Also, in July 2009, the Canadian government introduced PubMed  19 Central Canada (PMC Canada), a free digital archive of published, peer-reviewed health and lifesciences literature, which builds upon the PubMedCentral (PMC) archive in the US (Canadian Institute for Health Information, “Canada Joins International Efforts to Provide Access to Health Research”).3 The burgeoning availability of, and increased access to on-line healthcare research in the UK has also been a factor in recent years. In 2007, for example, UK PubMed Central was launched. The National Institute for Health and Clinical Excellence, a health technology agency, and the King‟s Fund, an independent charitable organization, also serve as online repositories of research and health policy analysis in the UK. Perhaps related to improvements in online resources, reporters increasingly rely on obtaining data from the web. I hypothesized that both of these factors would contribute to high-quality reporting of healthcare in Canada and the UK in US newspapers. The final hypothesis tested in this study involved exploring whether external factors, particularly the advent of America‟s healthcare reform and the global economic downturn, influenced coverage themes. This study also anticipated that a number of themes that emerged during Rosenau’s study, such as “ongoing problems paying for universal health care coverage”, “waiting lines for treatment”, “privatization of healthcare”, and “doctor shortages/too few specialists” would remain pertinent issues in more recent coverage of Canada’s Medicare system, and would also feature prominently in coverage of Britain’s NHS (“US Newspaper Coverage of the Canadian Health System” 34). The carry-over of past themes was anticipated because such matters represent contentious issues that continue to garner attention from politicians and the public in Canada and the UK. 3  PubMed Central Canada is a three-way partnership between the Canadian Institutes of Health Research (CIHR), the National Research Council's Canada Institute for Scientific and Technical Information (NRC-CISTI), and the US National Library of Medicine (NLM).  20 It was further anticipated that a significant percentage of American articles on Medicare and the NHS would deal with fiscal matters, due, in part, to the economic downturn, but also reflecting the characterization of American healthcare reform as a cost-control measure under the Obama administration (Whitesides). The reform bill, for example, was pushed forward as one of the most significant efforts to reduce the US deficit since the 1990s, and was predicted, once passed, to cut the US federal deficit by $138 billion over a decade (“US healthcare bill „will reduce deficit by $138bn‟”). US coverage of single-payer systems, like Medicare and the NHS, was thus expected to reflect the political rhetoric surrounding US healthcare reform, with articles placing emphasis on the financial perspective.  21  4 Methodology The methodology followed in this thesis substantially replicated that used by Rosenau in order to foster comparisons between the two studies. However, in order to accommodate the expanded scope and objectives of the thesis, a number of modifications were introduced. Salient elements of methodology are summarized in the following sections.  4.1 Study Scope As noted above, this study expanded on Rosenau‟s work in order to accommodate changes that have occurred to the socio-political landscape since the beginning of the 21st century and to expand the level of understanding of this subject area. The present study differs from Rosenau‟s work in three significant ways, which are described below. TIME FRAME AND DURATION  This study spans the period from January 2008 to the end of March 2010 (two and a quarter years), approximately half the period examined in Rosenau‟s study (five and a half years from January 2000 – mid-June 2005). The narrowed timeframe was chosen deliberately, to satisfy the objective of this thesis to appraise US newspaper coverage at a defining moment in US history – the introduction (and implementation) of fundamental health policy change. NEWSPAPER SOURCES  In addition to the New York Times and Wall Street Journal, carefully selected by Rosenau as publications that offer political balance, this thesis included articles from one of America‟s highest circulating national papers, USA Today. By doing so, it provides greater insight into how other factors, such as audience and corporate culture, influence newspaper coverage. It is worth noting that both the NYT and WSJ were also chosen by Rosenau on the basis that they were two  22 of the top three highest circulating newspapers in the US, and because “they have a reputation for reliable, accurate journalism” (Rosenau, “U.S. Newspaper Coverage of the Canadian Health System” 27). INCORPORATION OF THE NHS  This thesis seeks to fill a significant gap in the literature by examining US print coverage of the United Kingdom‟s National Healthcare Service (NHS) in addition to Medicare. The NHS was chosen over other foreign healthcare systems because, like Canadian Medicare, it has served as a foil to America‟s largely private insurance based system.  4.2  Data Collection  4.2.1 Database and Search Terms This thesis sourced articles using Factiva, a database owned by Dow Jones & Company. Factiva was chosen over LexisNexis Academic Universe, the database employed by Rosenau, because it provides full-text article access for all three publications (NYT, WSJ, and USAT), unlike LexisNexis, which only aggregates abstracts, not full articles from The Wall Street Journal.4 In order to optimize sampling consistency, Rosenau‟s search terms (“Canada” in combination with health care, health system, health policy, Medicare, hospital, doctor, and physician), were maintained for the Canadian part of this study.5 While the terms applying to healthcare were also used for the UK search, the location was duly adjusted to include, and  4  Librarians at the University of British Columbia suggested that using different databases would not make a significant difference to research findings. 5 Canadian search set: Canad* AND (health care OR health system OR health policy OR medicare OR hospital* OR doctor* OR physician*)  23 separately list the four regions (England, Scotland, Wales, and Northern Ireland) where singlepayer publically funded healthcare applies in the UK.6  4.2.2 Inclusion Criteria Materials for this study were selected on the basis of Rosenau‟s three inclusion criteria: form, word count, and extensive coverage. FORM  Like Rosenau‟s study, the purpose of the present study was to determine if US news reporting was fair, accurate, and complete. The study was therefore limited to news articles, while “letters to the editor, opinion essays, commentaries, and obituaries were excluded” (Rosenau, “U.S. Newspaper Coverage of the Canadian Health System” 29). WORD COUNT  While it is worth noting that articles of a shorter length can, and are often influential, Rosenau‟s decision to only retain articles that were a minimum of 500 words was maintained for the purposes of this study to foster accurate comparisons. A length of 500 words was chosen by Rosenau on the rationale that “an article would have to be of substantial depth and length to be significant in forming public opinion” (“U.S. Newspaper Coverage of the Canadian Health System” 29). EXTENSIVE COVERAGE  Finally, articles where “the Canadian health system did not play an important role in an article” were not included in Rosenau‟s study (29). In other words, if the article did not substantially consider information about the Canadian healthcare system, it was eliminated from  6  UK search set: (England OR Scotland OR Wales OR Ireland OR NHS OR United Kingdom OR UK OR British OR Britain) AND (health care OR health system OR health policy OR medicare OR hospital OR doctor OR physician).  24 Rosenau‟s and, by extension, from my analysis (30). For the purpose of this thesis, detailed article summaries provided the basis for determining whether articles were substantive or not. As a case in point, several articles cited Canadian studies on general healthcare matters (such as hip fracture rates), but were excluded because they did not deal with the Canadian healthcare system per se. Finally, because this study aimed to explore how US newspapers framed and used the Canadian and UK healthcare systems as a discursive tool to inform citizens regarding proposed U.S. health care policy changes, articles that dealt, perhaps only marginally, with the two systems in the context of US healthcare reform were retained for analysis.  4.3 Sample Size As shown in Table 4.3a on the following page, the search of Factiva yielded a total of 4033 articles. However, while 614 dealt with the Canadian and UK healthcare systems at some level, only 28 (6 on the Canadian healthcare system and 22 on the NHS) met the combined inclusion criteria and were retained for analysis. After eliminating over 4000 articles on the basis that they did not meet one or more of Rosenau‟s inclusion criteria, 28 articles were retained for analysis.  25 Table 4.3a: Summary of Database Search Outcomes Table 4.3a: Summary of Database Search Outcomes In Passing Source  Total  No.  NYT WSJ USAT Totals:  787 437 174 1398  156 135 64 355  NYT WSJ USAT Totals:  1630 731 274 2635  NYT WSJ USAT Totals:  2417 1168 448 4033  Included %  No.  CANADA 20% 31% 37% 25.4%  %  Included + In Passing No. %  4 1 1 6  0.5% 0.2% 0.6% 0.4%  160 136 65 361  20.3% 31.1% 37.4% 25.8%  131 98 30 259  UNITED KINGDOM (UK) 8.0% 15 13.4% 6 10.9% 1 9.8% 22  0.9% 0.8% 0.4% 0.8%  146 104 31 281  9.0% 14.2% 11.3% 10.7%  287 233 94 614  COMBINED (CANADA + UK) 11.9% 19 19.9% 7 21.0% 2 15.2% 28  0.8% 0.6% 0.4% 0.7%  306 240 96 642  12.7% 20.5% 21.4% 15.9%  Canada Included + In Passing Included Included %  361 6 1.7%  UK  Combined 281 22 7.8%  642 28 4.4%  Many articles did not meet two or more of the inclusion parameters; but the most common reason for exclusion was content (see Table 4.3b on the following page). In fact, close to ninety-seven per cent of all articles satisfying database search criteria were excluded because they were either off-topic entirely, or lacked substantive content on the healthcare systems. A further thirty-two per cent of articles were excluded because they were not news, while another nineteen per cent were under the 500 word minimum. Similar to Rosenau‟s study, the majority of articles retained for analysis came from the NYT (19), while only seven were from the WSJ and two from USA Today.  26 Table 4.3b: Article Exclusion Factors Table 4.3b: Article Exclusion Factors CANADA Not News 278 116 45  Under 500 146 65 42  Content 759 418 161  439  253  1338  UK Not News 560 207 78  Under 500 288 156 51  Content 1596 700 272  845  495  2586  COMBINED (CANDA + UK) Source Not News Under 500 NYT 838 434 WSJ 323 221 USAT 123 93 1284 748 Totals Exclusions: 4033 4033 Total Articles: 32% 19% Percentage Excluded:  Content 2355 1118 433 3906 4033 97%  Source NYT WSJ USAT Totals:  Source NYT WSJ USAT Totals:  4.4 Data Analysis For a number of practical reasons, Rosenau chose to perform the content analysis without computerized assistance. She notes that the “diversity of topics covered in the newspaper articles would make the „systematic application of rules,‟ required by this technique, almost impossible”, and argues further that “the coding strategies that computerized systems of automatic content analysis employ often miss topics or themes” (“U.S. Newspaper Coverage of  27 the Canadian Health System” 30). Similarly, the research for this study was also performed without content analysis software. Both the quantitative and qualitative analyses for this study were adapted from Rosenau‟s analysis, which was predominantly quantitative and “based on a simple count of characteristics of the articles”, such as reporting dimensions and article themes (Rosenau, “U.S. Newspaper Coverage of the Canadian Health System” 29). However, applying Rosenau’s established coding scheme only represented part of the analysis for this study. In order to accommodate developments in the Canadian healthcare system that have taken place since Rosenau‟s study, and to further address issues specific to US healthcare reform and the addition of the NHS to this study, the coding scheme was slightly adjusted. This adjustment involved the inclusion of emergent themes, arising since Rosenau‟s study, which were identified and applied to all articles within the sample. Like Rosenau‟s work, this study appraised the accuracy of newspaper coverage on the basis of how closely results aligned with established knowledge of Canada and the UK‟s healthcare system in peer reviewed journals and government sources.7  4.5 Reporting Dimensions The accuracy, fairness, and comprehensiveness of US newspaper coverage was assessed using Rosenau‟s coding scheme, which analyzed each article on the basis of six reporting dimensions: 1) the proportion of news events versus ongoing theme stories, 2) the role of evidence versus anecdote, 3) the incidence of oversimplification/omission, 4) the appearance of material taken out of context, 5) the presence of incomplete information due to the exclusion of essential details, and 6) the degree to which reporting leads to confusion or factual errors 7  Results were further scrutinized by health economist Dr. Steve Morgan, who is the Associate Director for the Centre for Health Services and Policy Research and an associate professor with the University of British Columbia‟s School of Population and Public Health.  28 (Rosenau, “U.S. Newspaper Coverage of the Canadian Health System” 30). These dimensions, including implications to this thesis, are described further in the following sections. THE PROPORTION OF NEWS EVENTS VERSUS ONGOING THEME STORIES:  Articles were first classified as either hard news (defined as event-related or episodic), or soft news, which Rosenau defined as discretionary coverage, “about ongoing themes or controversial issues” (“U.S. Newspaper Coverage of the Canadian Health System” 31). THE ROLE OF EVIDENCE VERSUS ANECDOTE:  Articles were further tracked on the basis of whether they employed anecdotal information (human interest stories, focusing on individuals and real world experiences) or evidence (stories that focus on facts and figures), or a combination of the two. THE INCIDENCE OF OVERSIMPLIFICATION/OMISSION:  Oversimplification and or omission, as classified by Rosenau, refers to the tendency among journalists to generalize the Canadian health care system “as a national, single payer system dominated by the Canadian federal government”, downplaying the importance of local input and variation between provincial systems (“U.S. Newspaper Coverage of the Canadian Health System” 36). The National Health Service, as four single-payer healthcare systems within the United Kingdom, is similarly complex. In this study, articles were determined to be oversimplified if they portrayed either the Canadian or UK healthcare systems as a unified system, without administrative variation between geographical regions. THE APPEARANCE OF MATERIAL TAKEN OUT OF CONTEXT:  Material was deemed out of context with respect to three coverage trends : 1) failing to portray the Canadian or UK health system in the context of other Western industrialized countries (Rosenau‟s study looked at this matter with specific respect to wait times), 2) implying that privatization of either healthcare systems would directly reduce and „solve‟ the problem of  29 wait times, and 3) not adequately identifying and providing the intellectual orientation of information sources, such as the Canadian think tank, the Fraser Institute. For the purposes of this study, articles that failed to examine contentious healthcare issues (such as wait times and doctor shortages) in the context of other Western industrialized nations (trend 1) were also assessed as material being taken out of context. THE PRESENCE OF INCOMPLETE INFORMATION DUE TO THE EXCLUSION OF ESSENTIAL DETAILS:  Reporting was determined to be incomplete based on the exclusion of essential details, which Rosenau defined as: 1) favouritism of certain geographical regions over others 2) failure to mention important facts required for an adequate understanding waiting lists, and 3) the misinterpretation of why some Canadians cross the border to receive healthcare in the US (“U.S. Newspaper Coverage of the Canadian Health System” 39-42). For the analysis of UK articles, the geographical regions were adjusted appropriately for trend 1), while trend 3) was revised to read: the misinterpretation of why individuals in the UK travel to receive health services abroad (Europe or the US). THE DEGREE TO WHICH REPORTING LEADS TO CONFUSION OR FACTUAL ERRORS:  Coverage of Canada‟s healthcare system was considered inaccurate, and believed to lead to confusion or factual error if it indicated that Medicare was “leftist” or socialist. As Rosenau indicates, “the role of the private sector in the Canadian health system is substantial and the delivery of medical care is predominately private”, which means that, although “Canadian hospitals are largely private-non-profit rather than private-for-profit”‟ this form of ownership “does not qualify as „socialist‟” or “„government‟ owned” (“U.S. Newspaper Coverage of the Canadian Health System” 43). Reporting that made the assumption that Canadians would trade their single-payer public healthcare system for the US system or not recommend Medicare to those in the US was also deemed factually inaccurate (43-44).  30 In the strictest sense, the NHS could be defined as „leftist‟ or „socialist.‟ However, these terms are politically charged and generally misrepresent the UK‟s healthcare system. For this study, reporting of the NHS was classified inaccurate or capable of leading to confusion if it demonized the government while sympathizing with upset or angry patients, or downplayed the role and complexity of healthcare administration. Reporting was also considered confused if an article made the assumption that UK citizens would like to trade their healthcare system for one like the US or would never recommend the NHS to those in the US.  4.5.1 Thematic Analysis The second component of this study, also adopted from Rosenau, involved a thematic analysis of each of the selected articles, which were closely examined and categorized based on the presence of overt content referring to one or more of the themes. This study analyzed articles and recorded the presence of Rosenau‟s themes, as well as emergent issues in the context of Canadian and UK healthcare.  31  5 Results My analysis revealed three major findings with respect to the quantity and quality of American coverage of Medicare and the NHS. The main finding was that representation of Canada‟s healthcare system was narrow compared to coverage during Rosenau‟s timeframe, and that healthcare in the UK received greater coverage in US newspapers than Canada between 2008 and the first quarter of 2010. The second finding was that the quality of reporting on Canadian healthcare is slightly better compared to coverage during Rosenau‟s study period. American coverage of the NHS appears, on the other hand, slightly less accurate and balanced than treatment of Canadian Medicare. Finally, the thematic analysis revealed that US media interest in Canadian healthcare has shifted slightly since Rosenau‟s study, and was affected by global events, such as the Olympics and the outbreak of H1N1. Coverage themes of the NHS tended to focus on financial concerns and rationing of treatment, and were overall more varied compared to coverage themes of Medicare. It is important to note that these results are limited to the articles included in this study sample, and cannot be generalized or extended to publications beyond the New York Times, Wall Street Journal, and USA Today, or outside of the study‟s timeframe (January, 2008 through to the first quarter of 2010).  5.1 Finding 1: Overall Representation in US Newspaper Coverage While a large number of articles satisfied the search criteria for Canadian healthcare, a surprisingly small number, only six articles, met the inclusion criteria and were retained for analysis. This represents less than two per cent of the total number of articles yielded from the database search. Of these six articles, the NYT provided the bulk of coverage, with 4 articles,  32 followed by one article from the WSJ and one from USA Today. In Rosenau‟s analysis of 50 newspaper articles referencing Canada‟s healthcare system, the NY Times’s coverage was most comprehensive (38 articles), followed by 12 from the WSJ. American media provided more coverage of the UK‟s National Health Service. A total of 22 articles were retained for analysis, with the NY Times again providing the greatest amount of coverage, (19), followed by the WSJ (7) and USA Today (2). For more detail, see Table 4.3a and 4.3b (above), which summarize the database search outcomes and factors for article exclusion respectively.  5.2  Finding 2: Accuracy, Balance, and Completeness of Coverage This analysis revealed that the quality of Canadian healthcare coverage is better (more  accurate, balanced, and complete) compared to earlier examples of newspaper reporting assessed by Rosenau. The quality of US reporting of the NHS was reasonably good, but a subtle difference in quality is indicated when compared with US coverage of Canada. As mentioned above, the accuracy, balance, and completeness of coverage for this study was determined using Rosenau‟s coding scheme: the proportion of hard vs. soft news, the role of evidence vs. anecdote, incidence of oversimplification/omission, the appearance of material taken out of context, the exclusion of essential details, and the degree to which reporting leads to confusion or factual error. The prominence and influence of each of these factors are explored below in greater detail. 1) The proportion of news events versus ongoing theme stories Hard news, or event-driven coverage of Canada‟s healthcare system represented 67 per cent of articles in this analysis (see Table 5.2.1a on the following page). Soft news, on the other hand, was more limited (33 per cent), compared to Rosenau‟s study, which found that soft news  33 accounted for 46 per cent of her sample. In Rosenau‟s view, soft news “play[ed] an unexpectedly important role in what [was] published in U.S. newspapers about the Canadian health system” (“U.S. Newspaper Coverage of the Canadian Health System” 31). She states that many of the thematic topics (eg: waiting lines for treatment, jumping cues for care) reflect a general frustration with the public health care system, which may have led newspaper readers to think that Canadians were fundamentally dissatisfied with Medicare (33). Table 5.2.1a: Reporting Dimensions for Canada – Dimension 1 Dimension 1: Articles Citing News Events vs. Ongoing Theme Stories (Canada) Year 2008 2009 2010 Total G.Total %  NYT Hard Soft 0 1 3 0 0 0 3 1 4 75.0% 25.0%  WSJ Hard Soft 0 0 0 1 0 0 0 1 1 0.0% 100.0%  USAT Hard Soft 1 0 0 0 0 0 1 0 1 100.0% 0.0%  Totals Hard Soft 1 1 3 1 0 0 4 2 6 66.7% 33.3%  Academics, like Rosenau, often note that soft news coverage tends to be more critical in perspective than episodic coverage (Collins et al. “Are we expecting too much from print media?” 99). It is problematic to conjecture that a form of news is a direct reflection of reporting accuracy. However, on the basis Rosenau‟s evaluation of soft-news coverage as tending to highlight and reflect controversial themes, the significant role that hard news played in coverage of Canada in this particular analysis reveals there was perhaps, at the very least, less room for bias. Reporting of the UK‟s healthcare system was slightly more reliant on soft-news (45 per cent) than reporting of Medicare (see Table 5.2.1b on the following page). Thematic coverage, particularly issues related to paying for universal healthcare, medical tourism, and rationing,  34 represented an important part of American newspaper coverage of the NHS, a finding that will be explored in greater detail below (Finding 3: Coverage Themes). Table 5.2.1b: Reporting Dimensions for UK – Dimension 1 Dimension 1: Articles Citing News Events vs. Ongoing Theme Stories (UK) Year 2008 2009 2010 Total G.Total %  NYT Hard Soft 3 4 3 3 1 1 7 8 15 46.7% 53.3%  WSJ Hard  Soft 1 4 0 5  1 0 0 1 6  83.3%  16.7%  USAT Hard Soft 0 1 0 0 0 0 0 1 1 0.0% 100.0%  Totals Hard Soft 4 6 7 3 1 1 12 10 22 54.5% 45.5%  2) The role of evidence vs. anecdote Results from this study indicate that US coverage of Canada‟s healthcare system is a mix of evidence and anecdote (see Table 5.2.2a below). However, it is important to note that all articles contained evidence, with anecdote playing a factor in only a half of the sample. Table 5.2.2a: Reporting Dimensions for Canada – Dimension 2 Dimension 2: Articles Citing Evidence vs. Anecdote (Canada) Year 2008 2009 2010 Total %  NYT Anec. Evid. 1 1 1 3 0 0 2 4  WSJ Anec. Evid. 0 0 1 1 0 0 1 1  USAT Anec. Evid. 0 1 0 0 0 0 0 1  Totals Evid. 1 2 2 4 0 0 3 6 50.0% 100.0%  Anec.  Anecdotal information factored more heavily in US coverage of Canadian healthcare during Rosenau’s study, and was contained in 42 per cent of articles from the New York Times, and 50 per cent of the Wall Street Journal sample (“U.S. Newspaper Coverage of the Canadian Health System” 33). Rosenau notes that “sometimes isolated cases of medical error [were] presented as routine”, and that injustices were portrayed as “frequent, typical, and widely  35 tolerated” (35). However, overall, most articles in Rosenau‟s study were also a mix of anecdote and evidence/facts, with “only eight [that] made no reference at all to sound evidence” (26). While Rosenau notes that “heavy reliance on anecdotal information means that sophisticated social analyses, fine distinctions, and subtle differences are overlooked”, it is also important to recognize that the mere presence of anecdote is not necessarily indicative of poor reporting (“U.S. Newspaper Coverage of the Canadian Health System” 44). Instead, anecdotal information serves as a useful tool for reporters to highlight a case in point, or to bring the story to life for readers. The inclusion of anecdote only becomes problematic when it is used to overgeneralize, or stand as evidence in support of a false claim. In this study, anecdotal information was justified and appropriately used in all articles on Canadian healthcare. US coverage of the NHS was also a mix of evidence and anecdote (see Table 5.2.2b below). All articles contained evidence, and 55 per cent also contained anecdote. Table 5.2.2b: Reporting Dimensions for UK – Dimension 2 Dimension 2: Articles Citing Evidence vs. Anecdote (UK) Year 2008 2009 2010 Total %  NYT Anec. Evid. 5 7 3 6 1 2 9 15  WSJ Anec. Evid. 1 2 2 4 0 0 3 6  USAT Anec. Evid. 0 1 0 0 0 0 0 1  Totals Anec. 6 5 1 12 54.5%  Evid. 10 10 2 22 100.0%  Anecdotal usage in the case of the UK‟s healthcare system was, however, sometimes problematic. One article, which explored the debate over creating a national long-term care system for elderly in England and Wales, appears to argue in favour of elder-care reform and evokes sympathy by framing the article around a London resident, who wants additional home support but cannot afford it (Appendix A, Werdigier “In Britain, a Debate Over Home Care for Elderly People”). In brief, anecdote is used as a narrative device to encourage reader interest and  36 address journalism norms of humanizing policy news. However, factual evidence that supports a more nuanced understanding of elder care8 is only presented later in the article, which serves to downplay important factors required for understanding elder-care reform issues in Britain (n.pag). In another article, the story of an upset cancer patient looking to supplement her publicly financed cancer treatment with private co-payments is used as evidence of systematic failure (Appendix A, Lyall “Those Who Pay for Private Care Are Testing Britain‟s Public Health System”). The reporter advocates for the patient, noting that the British health service has denied the patient Avastin, a drug that is noted to be widely used in the US and Europe to keep cancers at bay (n.pag). By adding information, such as the fact that the patient has turned to raising thousands of dollars and was “preparing to sell her house to raise more”, the reporter garners an emotional response from the reader (n.pag). Only later does the article note that a number of outstanding considerations were involved with this particular case, a brief indication that not all individuals in Britain are being denied new treatments under the UK‟s healthcare system. In summary, while this particular story certainly highlights anomalies in treatment rules under the NHS, it unnecessarily demonizes the British government, sympathizes with the patient and her advocating doctor, and simplifies the complexity of factors that are used to review and make decisions as to which drugs should be publically financed in the UK (n.pag). In addition, more often than not, cost is implied as the only factor weighed to make such decisions. Also of interest is the fact that in an article focused on patient access to expensive drugs for cancer, no reference is made to the National Institute for Health and Clinical Excellence (NICE), which 8  Evidence later mentioned in the article included: the fact that state-financed care is already available to seniors with low incomes, that the current generation of pensioners is Britain‟s wealthiest, and that enacting a national longterm care system for the elderly alongside the health care system would place greater financial strain on a government looking to cut its “record budget deficit” (Appendix A, Werdigier “In Britain, a Debate Over Home Care for Elderly People” n.pag).  37 makes recommendations to the NHS on medicines, treatments, and procedures (based on efficacy and cost-effectiveness). However, NICE serves a central role in another article that speaks to the issue of Britain‟s efforts to balance the benefit (life-value) vs. the cost of new drugs (Appendix A, Harris “British Balance Benefit Vs. Cost of Latest Drugs”). The story illustrates the moral issues facing the healthcare system through the story of one man who is fighting kidney cancer that has spread to his lungs. Discussion of the institute and the British government is framed in a negative light. The reporter expresses clear sympathy for the patient, who is interested in receiving a new, yet expensive cancer treatment (a pill from Pfizer known as Sutent). It is strongly noted that the patient has been “refused medicine” by “the British health authorities” (n.pag). At “an estimated treatment cost of $54,000”, the reporter comes to the conclusion that that the patient‟s “life is not worth prolonging, according to the British government agency” (n.pag). The article further juxtaposes the patient‟s chances of survival in the UK with his opportunities if he had lived in the United States (“or just about any European country other than Britain”), where, the article states, he would most likely get the drug (n.pag). In effect, NICE is portrayed as a stringent rationing body that puts a price tag (of “$15,000 or about $22,750”) on citizen‟s lives, while other systems are illustrated as offering a more humane response to serious cancers (n.pag). This article later exemplifies more nuanced journalism, qualifying its framing of NICE through a discussion of drug costs. It indicates, for example, that the NHS has been recognized as a global leader for being “among the first to balk” at paying high prices (Appendix A, Harris “British Balance Benefit Vs. Cost of Latest Drugs”). The reporter also makes reference to America‟s interest (and growing concern) with controlling drug and device expenses, and cites that US experts believe “„people see NICE as the only workable paradigm‟” (n.pag). However,  38 the benefits of NICE and US interest in implementing cost-control measures are downplayed for the most part, as the article concludes with a moving image of the cancer victim barely able to speak because of the tumour “press[ing] on a nerve that governs his voice” and his wife, who now speaks for her husband, asking ““What price is life?‟” (n.pag). Framed around a cancer victim‟s struggle, the article paints a picture of a somewhat heartless and cost-concerned governing health body, leaving unaddressed questions that might ameliorate that image, such as the fact that the patient is undoubtedly already undergoing NHS-financed treatment. The article also attaches little attention the fact that Sutent, which a clinical trial showed to delay cancer progression “for six months”, comes at a high cost of treatment – an estimated $54,000 – to the healthcare system (n.pag). Overall, the conflicting portrayal of NICE in US newspaper coverage points to the general challenges of exploring the complexities of healthcare in newspapers. As the abovementioned articles illustrate, while anecdote draws readers in, over-emphasis on a single event or character can lead to coverage that is slanted. 3) The incidence of oversimplification/omission In this study, (see Table 5.2.3a on the following page) a third of articles presented Canadian Medicare as a unified system, illustrating that reporting may stand to benefit from greater attention to provincial variation. In contrast, Rosenau found that US journalists were largely unaware of the enormous power of Canadian provinces and often depicted them “as simply administering the federally organized health system”, similar to the “relationship between the U.S. federal government and the states” (“U.S. Newspaper Coverage of the Canadian Health System” 36).  39 Table 5.2.3a: Reporting Dimensions for Canada – Dimension 3 Dimension 3: Articles that Oversimplify (or Omit Content) (Canada) Year  NYT  2008 2009 2010 Total %  WSJ 1 1 0 2  USAT 0 0 0 0  Totals 0 0 0 0  1 1 0 2 33.3%  Oversimplification in US coverage of the NHS was a factor in less than 20 per cent of articles (see Table 5.2.3b below). In fact, some articles highlighted differences in treatment availability across the British Isles. In one article, for example, elder-care reform in England and Wales was the focus, but attention was also drawn to elder-care policy in Scotland, where, it was noted, “some home care has been free since 2002” (Appendix A, Werdigier “In Britain, a Debate Over Home Care For Elderly People”). Table 5.2.3b: Reporting Dimensions for UK – Dimension 3 Dimension 3: Articles that Oversimplify (or Omit Content) (UK) Year 2008 2009 2010 Total %  NYT  WSJ 1 1 0 2  USAT 0 2 0 2  Totals 0 0 0 0  1 3 0 4 18.2%  4) The appearance of material taken out of context Only one article on Canada’s healthcare system presented material taken out of context (see Table 5.2.4a on the following page). The article focused on the potential impact of severe cases of H1N1 on intensive care units (ICUs) in America, highlighting results from international studies that examined the severity of swine flu cases in Canada, Mexico, Australia, and New Zealand (Appendix A McKay “Swine-Flue Wave Poses Threat to Hospitals ICUS, Studies  40 Warn”). The article was earmarked as an example of unbalanced reporting and inadequate contextualization (1) because it emphasized supply shortages and high occupancy levels in Canada’s ICUs at the height of the outbreak, but failed to reference study results from nations other than Mexico, leaving readers without a suitable comparison for understanding the challenges facing other Western industrialized nations (particularly Australia and New Zealand). Table 5.2.4a: Reporting Dimensions for Canada – Dimension 4 Dimension 4: Articles Citing Material out of Context (Canada)  Year 2008 2009 2010 Total Gp. Total %  1 0 0 0 0  NYT 2 0 0 0 0 0 0.0%  3  1 0 0 0 0  0 1 0 1  WSJ 2 0 0 0 0 1 16.7%  3  1 0 0 0 0  0 0 0 0  USAT 2 0 0 0 0 0 0.0%  3  1 0 0 0 0  0 1 0 1  Totals 2 0 0 0 0  3 0 0 0 0  1 16.7%  The rare incidence of material taken out of context in this study stands out against Rosenau’s analysis, which detected that newspaper articles often took material out of context, particularly by (1) not placing Canada’s wait times in the context of other Western industrialized nations, (2) framing privatization as the solution to long wait times, and (3) inadequately identifying the intellectual orientation of Canadian-based information sources (“U.S. Newspaper Coverage of the Canadian Health System” 38). As noted in Table 5.2.4b on the following page, coverage of the UK involved six articles with material taken out of context. The most common issue (1) was for journalists to report on controversial issues, such as wait times and overcrowding, while overlooking what the situation was like in other Western industrialized nations.  41 Table 5.2.4b: Reporting Dimensions for UK – Dimension 4 Dimension 4: Articles Citing Material out of Context (UK)  Year 2008 2009 2010 Total Gp. Total %  1 1 3 0 4  NYT 2 1 0 0 1 5 22.7%  3  1 0 0 0 0  0 0 0 0  WSJ 2 0 1 0 1 1 4.5%  3  1 0 0 0 0  0 0 0 0  USAT 2 0 0 0 0 0 0.0%  3  1 0 0 0 0  1 3 0 4  Totals 2 1 1 0 2  3 0 0 0 0  6 27.3%  5) The presence of incomplete information due to the exclusion of essential details As seen in Table 5.2.5a on the following page, the presence of incomplete information in this study was most often a result of (1) favouritism of certain geographical regions over others. Most articles on Canada‟s healthcare system, for example, had a national focus (six references), with passing mention of healthcare matters affecting five out of Canada‟s ten provinces: Alberta, BC, Manitoba, Quebec, and Ontario (1 reference each). However, considering the small sample size, even limited representation of healthcare at the territorial and provincial level remains commendable. Other factors believed to be responsible for incomplete reporting in this study, including (2) failure to mention important facts needed to understand Canada’s wait times (no articles) and (3) misinterpretation of why some Canadians cross the border to receive healthcare (one article), were not significant.  42 Table 5.2.5a: Reporting Dimensions for Canada – Dimension 5 Dimension 5: Articles Incomplete Due to Exclusion of Essential Details (Canada)  Year 2008 2009  2010 Total  NYT 1 2 1 (N) 0 3 (N) 1 (O) 1 (A) 1 (B) 0 7  3  0  1  1 1(N) 1(M) 0  0 0  0 1  0 2  0  WSJ 2 0  3 0  0  0  0 0  0 0  USAT 1 2 1 (N) 0 1 (Q) 0 0  0 2  0 0  3 0  Totals 1 2 5 0  3 0  0  6  0  1  0 0  0 11  0 0  0 1  During the timeframe of Rosenau‟s study, articles with a national focus made up over half of Canadian coverage. Similarly, US coverage of the Canadian healthcare system favoured particular geographical areas and neglected others. Rosenau notes that thirty eight per cent of articles published “focused on the Ontario health system”, while, Alberta, British Columbia, and Quebec were the focus of only two per cent of the sample (“U.S. Newspaper Coverage of the Canadian Health System” 39). Rosenau acknowledges that Ontario was a focus of many articles simply because “it was the geographical location of the breaking news”, but argues that the Ontario was also a heavy focus of many discretionary articles about thematic topics, indicating the existence of provincial favouritism in US coverage of Canadian healthcare (39). In this study, similar to US coverage of Medicare, the most common factor leading to incomplete information of the NHS was (1) geographical favouritism (see Table 5.2.5b on the following page). Britain was the focus of most articles with a total of 22 references, followed by Scotland (5 references), and Wales (4 references). Some articles also had a national focus (4 references), but healthcare in Northern Ireland, which is part of the broader National Health Service, was neglected completely.  43 Table 5.2.5b: Reporting Dimensions for UK – Dimension 5 Dimension 5: Articles Incomplete Due to Exclusion of Essential Details (UK)  Year 2008  2009  2010  Total  NYT 1 2 6 (B) 1 1 (S) 2 (N) 6 (B) 0 1 (S) 1 (W) 2 (B) 0 2 (S) 2 (W) 23 1  3 0  0  1 2 (B) 1 (N)  WSJ 2 0  3 0  USAT 1 2 1 (B) 0 1 (S) 1 (W) 0 0  0  0  0  4 (B) 1 (B) 2 (N) 0  0  0  0  0  10  0  0  3  3 0  Totals 1 2 15 1  3 0  0  15  0  0  0  0  6  0  0  0  0  36  1  0  6) The degree to which reporting leads to confusion or factual error No articles in the present study (1) portrayed Medicare as „socialist‟ or „leftist‟ or (2) made the assumption that Canadians would like to trade Medicare for the US system (see Table 5.2.6a on the following page). In fact, one article published by the New York Times actually sought to clarify Senator John McCain‟s comments leading up to healthcare reform in the US, in which he accused Obama of wanting to implement a massive government takeover of healthcare in America, and further characterized the Canadian healthcare system in disparaging terms (Appendix A, Cooper and Bosman “Parsing McCain on the Democrats‟ Health Plan”). The article mitigated McCain‟s statement, noting that “Mr. McCain, of Arizona, has inaccurately described the Democrats‟ healthcare proposals, using language that evokes the spectre of socialized medicine”, further indicating that Canadians do not have government-run healthcare, but a single-payer system (n.pag).  44 Table 5.2.6a: Reporting Dimensions for Canada – Dimension 6 Dimension 6: Articles Where Reporting Leads to Confusion / Errors (Canada) NYT Year  1 2008 2009 2010 Total  WSJ 2  0 0 0 0  1 0 0 0 0  USAT 2  0 0 0 0  1 0 0 0 0  Totals 2  0 0 0 0  1 0 0 0 0  2 0 0 0 0  0 0 0 0  In contrast, Rosenau found that U.S. newspaper coverage of the Canadian health system was confused on the basis that at least one quarter of her sample articles indicated that the system was “leftist” or socialist, despite the fact that very few Canadian doctors work for the government, but are “entrepreneurs to some extent”, paid on a fee-for-service basis (“U.S. Newspaper Coverage of the Canadian Health System”43). A second inaccuracy that led to confused reporting during Rosenau‟s study was “the assumption that Canadians would like to trade their health system for the U.S. health system, or that they would never recommend the Canadian health system to those in the U.S.” (43-44). While some Canadians are critical of their healthcare system, Rosenau noted that “it would be a mistake to interpret this criticism as an approval” among Canadians to adopt a US style health system (44). In US coverage of the NHS factual error and reporting that could lead to confusion were rare (see Table 5.2.6b on the following page). In one article, however, the NHS, while never referred to as a socialist or leftist, was nonetheless depicted as such, in part by repeated emphasis on the „sick‟ and „innocent‟ patient being denied service at the hands of the „government‟ (Appendix A, Lyall “Those Who Pay for Private Care Are Testing Britain‟s Public Health System”). Yet, overall efforts were made to redress stereotypes of the NHS (particularly those that emerged during Obama‟s proposed reforms). One Associated Press article that was published by the New York Times (the only wire service article included in the sample) noted that  45 even though “the British love to mock their National Health Service”, they do not want it “dismantled or transformed into an American-style, profit-oriented system” (Appendix A, AP “Britain Responds to Criticism of Its Universal Health System”). Table 5.2.6b: Reporting Dimensions for UK – Dimension 6 Dimension 6: Articles Where Reporting Leads to Confusion / Errors (UK) NYT Year  1 2008 2009 2010 Total  WSJ 2  1 1 0 2  1 1 0 0 1  USAT 2  0 0 0 0  1 0 0 0 0  Totals 2  0 0 0 0  1 0 0 0 0  2 1 1 0 2  1 0 0 1  5.3 Finding 3: Coverage Themes 5.3.1 Canada – Shifting Themes Only six coverage themes emerged in US news coverage of Canadian healthcare (see Table 5.3 on the following page). In contrast, Rosenau identified twenty themes, with the top three most prevalent issues being: ongoing problems paying for universal health care coverage in Canada, waiting lines for treatment, and privatization of healthcare. Themes that also arose more often than others in Rosenau‟s analysis included: doctor shortages/too few specialists, importing prescription drugs from Canada, Canadians traveling to the U.S. for health care treatment, overflowing emergency rooms, and medical technology shortages and slow adoption of technology (“U.S. Newspaper Coverage of the Canadian Health System”34).  46 Table 5.3: Thematic Coverage for Canada and the UK9 Table 5.3: Thematic Coverage (Canada + UK) NYT  UK WSJ  1  Top heavy bureaucracy  9.1%  4.5%  2  Challenges of accessing medical records by new clinics  4.5%  3  International collaboration on health programs and policies  9.1%  4  Emerging innovation in healthcare venues  9.1%  5  Drug financing (surrounding issues of efficacy vs. cost)  9.1%  6  Financial constraints on purchase of medical technology  4.5%  7  Funding challenges in eldercare reform  8  Ongoing problems paying for universal healthcare  No.  Themes  NYT  USAT  4.5%  4.5% 27.3%  9  Doctor shortage / too few specialists  4.5%  10  Importing medical supplies to address local shortages  4.5%  11  Limitations on medical resources and services  12  Medical technology shortages / slow adoption of technol.  13  Wait lines for treatment  14  Concern over maintaining core values of existing healthcare system  4.5%  15  Jumping wait lines affluent and connected  16  Patient demand for longer work hours by family doctors / clinics  17  Regional disparity re: access to drugs and treatment  18  Universal healthcare preventing medical bankruptcy of patients  4.5%  19  Criticism of existing preventative diagnostics  4.5%  20  Criticism of hospital conditions (crowding, staffing, cleanliness)  9.1%  21  Health system is losing public confidence  4.7%  4.5%  22  Canadian patients traveling to US for treatment  23  UK citizens seeking medical treatment abroad  18.2%  9.1%  24  NHS as an international leader in prescription drug policy  25  Patients importing prescription drugs from foreign countries  26  Prescription drug advertising regulations  27  Doctors against public health insurance  9.1%  28  Patients paying out-of-pocket for healthcare  4.5%  29  Privatization of healthcare  4.5%  9.1%  30  Abortion debate  31  Changing guidelines re: legality of assisted suicide  9.1%  4.5%  32  Pursuit of prevention as a key aspect of healthcare  9.1%  9.1%  33  Backlash to negative US portrayal of local system wrt US reform  9.1%  4.5%  34  Healthcare system characterized negatively by US reform opponents  13.6%  4.5%  35  Healthcare system characterized positively wrt US reform  13.6%  4.5%  22.7%  4.5%  9.1%  4.5%  16.7% 66.7% 33.3% 9.1% 18.2% 4.5%  16.7% 4.5% 4.5% 16.7%  4.5%  Total Articles:  9  Canada WSJ USAT  33.3%  4.5% 6  22  Total Number of Themes  6  31  Total Theme Incidents:  11  81  Note that percentages are based off of number of articles that contained the theme.  47 While some of Rosenau‟s themes remained relevant to articles included in this study, most did not, indicating that American media interest in Canada has shifted. Two themes new to this study were negative characterization of Canada‟s healthcare system by US reform opponents (one third of the sample), and, more peripherally, prescription drug advertising regulations (in the context of a study exploring television access to and influence of US direct-to-consumer advertising in Quebec versus Canada‟s English-speaking provinces). It is interesting to note that important issues, such as Canada‟s doctor shortages and increased experimentation with privatization, which have received ample domestic coverage in recent years, were largely ignored. However, as in earlier coverage, US journalists remain highly interested in Canadian wait lines (a theme present in two-thirds of the sample), and placed emphasis on the issue of jumping wait lines by affluent and connected Canadians. In one article, for example, waiting times for treatments are characterized as a “perpetual political issue for Canada‟s public health-care system”, and reader comments offered on the CBC‟s website are cited as evidence that “any suggestion that a particular group might receive priority can be explosive” (Appendix A, Austen “Team Canada‟s Doctor Wants His Athletes in Front for Swine Flu Shots”). Another article, focusing on a Canadian “swine flu distribution brouhaha”, highlighted public disproval with respect to connected members of the Canadian population (members of the Calgary Flames hockey team and their families) jumping “long public lines” to receive vaccination “one day before the province cancelled mass immunizations after demand created shortage” (Appendix A, McNeil “Official Endorses Workplace Clinics for Vaccine Distribution”). This article reveals that a second member of the Alberta provincial health administration lost his job over the issue, a  48 statement that highlights the fact that equality remains a fundamental value of Canada‟s healthcare system.  5.3.2 UK – Wait Lines, Medical Tourism, and Financial Framing US newspaper coverage of the NHS was much more varied, with a total of 31 coverage themes ranging from poor hospital conditions to top heavy bureaucracy, to more positive issues, like the emergence of innovative healthcare venues and the pursuit of preventions as a key aspect of healthcare in the UK (see Table 5.3 above). Similar to US coverage of Canadian healthcare, wait lines featured prominently in coverage of the NHS (27 per cent of the sample). Another prominent theme in US newspaper coverage of healthcare in the UK was medical or health tourism, with one third of articles (27 per cent) making reference to citizens seeking treatment or medical services abroad (either in the US or other European countries). One article cited the practice of UK citizens seeking private, cosmetic surgery in the US as a growing trend (Appendix A, Rundle “Europeans Take Beauty Trip to U.S.”), while another reflected on individuals travelling to countries, like Spain and Belgium, to obtain sperm donations because of low-supply in Britain (Appendix A, Grady and Kent “Shortage of Sperm Donors in Britain Prompts Calls for Change”). Another common issue, related to the broader category of medical tourism, was euthanasia and physician-assisted suicide, which is currently illegal in the UK, but which was referenced as a medical procedure that “dozens of terminally ill Britons” had sought abroad (in Switzerland) over the last decade (Appendix A, Lyall “BBC Host Admits Killing Ailing Partner”). The thematic analysis of US newspaper coverage of the NHS further exposed a financial frame, which ran through nearly a third of the articles. Reporting frequently reflected, for example, on ongoing problems paying for universal healthcare in the UK. In fact, references to  49 the high cost of providing universal healthcare (Appendix A, Werdigier “In Britain, a Debate Over Home Care for Elderly People”)and statements that portrayed the NHS as a system struggling to cope with rising medical costs were not uncommon (Appendix A, Grady “Shortage of Sperm Donors in Britain Prompts Calls for Change”). However, it is important to note that reporting that framed the NHS in a critical light was also balanced by positive coverage. Some reporters, for example, highlighted the UK‟s dedication to preventative health measures (such as public health campaigns and flu vaccination safeguards and monitoring) (Appendix A, Dewan “Regarding Tamiflu, Doctors and Patients Face a Question of When to Act”). Furthermore, on the flip side of coverage representing NICE as a threatening rationing body, another angle emerged, which, as noted above, framed the institute as a global leader in cost-effective research and one whose decisions are seen affecting market shifts in the pharmaceutical industry (Appendix A, Harris “British Balance Benefit vs. Cost of Latest Drugs”).  5.4 Summary of Findings Based on an evaluation of the six reporting dimensions, the quality of US newspaper coverage of the Canadian healthcare system appears somewhat better compared to Rosenau‟s study timeframe. Incidences of material taken out of context, for example, were rare and no articles presented factually inaccurate information that would have led readers to mistakenly perceive Canada‟s healthcare system as socialist. Representation of the NHS, which was more reliant on thematic coverage (or soft-news), was somewhat less accurate than coverage of Canada. Factors, such as inadequate contextualization and the frequency at which anecdotal information served to frame the NHS in a negative light, were to blame. With respect to coverage themes, wait lines remained dominant, but there was also a slight shift in interest since  50 Rosenau‟s study timeframe (with topics reflecting issues related to global events, particularly the outbreak of H1N1, as well as US healthcare reform). Emphasis was also placed on wait lines in US newspaper coverage of the UK‟s healthcare system, but overall a broader range of issues related to the NHS (compared to Medicare) were represented in American newspaper coverage, due, in part, to the larger sample size of articles on the UK system.  51  6 Discussion Both the quantity and quality of American newspaper reporting can be explained, at least in part, by examining external factors at play during this study‟s timeframe. I suggest that shifts in the journalism industry, economic pressures, and America‟s inward focus on healthcare reform influenced the overall quantity of coverage of foreign healthcare. I further suggest that coverage was thematically influenced by Obama‟s early framing of healthcare as a matter of economic sustainability.  6.1 Quantity of Foreign Healthcare News Coverage Between January, 2008 and the first quarter of 2010, a number of newsworthy healthcare events occurred beyond the American border. In Canada alone, for example, a number of controversial healthcare incidents took place. Particularly memorable headlines included: “$30,000 for 78 hours: Scandal grows at eHealth Ontario” (June 2009), “Manitoba First Nations outraged over H1N1 body-bag shipments” (September 2009), “Saint John doctor shortages forces weekend closure of Sussex ER” (April 2009), “N.L. Premier Williams set to have heart surgery in U.S.” (February, 2010), and “Woman sues surgeon, hospital over mastectomy done amid no-cancer diagnosis” (March 2010). However, none of these stories were represented in US publications, specifically the NYT, WSJ, or USA Today. Reasons for more narrow US coverage of Canadian healthcare compared to Rosenau‟s study period, and variance between Canada and the UK, can be explained by looking at pressures facing today‟s journalism industry and the influence of politics in America.  52  6.1.1 Journalistic Pressures Examples of journalistic factors that may have been responsible for the quantity of articles available on Canada and the UK‟s healthcare systems include: low US media (and perceived public) interest in foreign healthcare stories, fiscal pressures within the newsroom, and the growing emphasis and worth placed on online news. The State of the Media: Drops in Ad Revenue and International Coverage The slight amount of coverage of Canada and the UK‟s healthcare system in the NYT, WSJ, and USA Today illustrates that there is a close tie between economics and the quantity (and quality) of journalism produced. Over the last several years, the journalism industry has been defined by steep drops in advertising revenue, sharp cutbacks, and the elimination of entire newsroom positions at local, national, and international levels. Newspapers have been hit particularly hard, entering into “something perilously close to free fall” (Pew Research Center, “The State of the News Media 2009” 9). News coverage of foreign healthcare was likely further impacted by the accelerated decline of international news in recent years. A 2008 study conducted by the Pew Research Center‟s Project for Excellence in Journalism, for example, revealed that “papers both large and small have reduced the space, resources, and commitment devoted to a range of topics”, but emphasized that “international news is rapidly losing ground at rates greater than any other topic area” (“The Changing Newsroom”). Limited Journalistic Interest in Healthcare Complementing the impact of restrictive newsroom budgets and the decline of international news, American media interest in Canada and the UK‟s healthcare systems may have also been limited as a result of lowered editorial interest in investigative and analytical  53 healthcare coverage overall. In “The State of Health Journalism in the US” it is noted that a shift in the nature of health stories has taken place in recent years. The paper states that “while health and medical stories feature prominently in the news”, journalists are increasingly encouraged to take the path of least resistance, which has led to softer features and health coverage that centers on topics like “exercise and fitness” (Schwitzer 11). More recent proof of low interest in covering healthcare came in the summer of 2009, when MSNBC host, Dylan Ratigan was reported to have called US healthcare “„bad for ratings”, a view further supported by chief Washington correspondent for CNBC and NY Times‟s writer, John Harwood, who stated that healthcare is “„not only not a cable TV-friendly story; it‟s not a journalism-friendly story‟” (Lieberman, “Health Reform Too Boring for Broadcast?”). Arguably, if the topic of US healthcare – at a time when policy change had the potential for great consequence in America – was unable to garner enough ratings, and ultimately attention from US journalists, foreign healthcare coverage was likely thin. Increased Shift towards Online News Coverage The Internet also opened up the possibility for certain stories to be selected only for online publication, ultimately limiting the availability of published material further. In a review of online healthcare coverage, it appears that new journalism forms (particularly blogs) do play an important role in educating the public about healthcare. A New York Times blog, entitled “Prescriptions: The Business of Health Care”, for example, was particularly useful at dispelling myths during America‟s healthcare reform. Other posts were dedicated to examining healthcare delivery in other countries. In “Health Care Abroad: Canada”, for example, the journalist posted a Q&A she had with healthcare policy scholar, Ted Marmor, who provided an accurate description of Canadian  54 Medicare, indicating the benefits and fallbacks of such a system, as well as details of how Americans could stand to gain from looking north of the border (Arnquist). However, as cited earlier, research conducted by Gary Schwitzer for the Kaiser Family Foundation illustrates that health news does not receive as much prominence online as it does in more traditional journalism platforms (“The State of Health Journalism in the US” 16). As a result of this development, “while insiders and highly motivated news users may be more able to seek out detailed news on blogs or cable news segments, the more casual news consumers may end up less informed in the years ahead” (16).  6.1.2 Political Influence Changes to the political landscape of America that occurred during this study‟s timeframe may have also influenced the amount of media attention afforded to Canada and the UK‟s healthcare systems. President Obama and US Healthcare Reform Overall, the small amount of media coverage of Canadian and UK healthcare may be a sign that healthcare policy in America has matured as of late. Several years ago, Ted Marmor noted the decline in American interest in Canada‟s healthcare system. He states that while “considerable support has been expressed at various times for versions of national health insurance modeled on Medicare, the Canadian national health insurance program”, “[support] is less so in 2008 than in either the early 1970s or the period leading up to the Clinton reform struggle of 1993-4” (“American Health Care Policy and Politics” 5). A 2009 report by the Commonwealth Fund supports Marmor‟s viewpoint, and notes that while, “in the past, discussion often focused on the merits or deficiencies of single-payer social insurance models, such as Canadian or French approaches, or public systems”, “more recently, attention has turned  55 to countries that combine universal coverage with private insurance and regulated market competition” (Leu et al. vii). As of late, healthcare systems in Switzerland and the Netherlands garnered particular attention “for their use of individual mandates combined with public oversight of insurance markets” (vii). Examples of media mirroring this shift already exist. In 2007, an article published by The New York Times centered on the fact that “the Swiss and Dutch health care systems are suddenly all the rage in the United States” (Harris). The early denial of rumors that single-payer healthcare systems would serve as models of US health reform by Obama and the leaders in the Senate and House of Representatives stands as continued evidence of maturing healthcare policy in America. At a press conference in August, 2009, Obama stated: “The Canadian model works for Canada. It would not work for the United States, in part, simply because we have evolved differently. We have an employer based system, and a private based system…so we‟ve got to develop a uniquely American approach to this problem” (“Obama: Canada Not a Boogeyman”). Other Democrats, like Senator Max Baucus, also made it clear that a single-payer insurance model for the US was off the table: “„Most Americans want to reform our system...We have to work together to find out a better solution, which is still a uniquely American solution, which is public and private. We‟re not, you know, Great Britain. We‟re not Canada. We‟re not the Netherlands. We‟re American‟” (Pear and Herszenhorn). The early framing of healthcare reform (as moving away from single-payer models) likely impacted media coverage of US healthcare reform, and may have led to an overall lowered interest and representation of Canada and the UK‟s healthcare system in American newspapers.  56 More Coverage of UK - Special Relationship with US The greater representation of the NHS compared to Medicare in US newspaper coverage can also be examined by looking at external factors, such as US military alliances. In 2003, as a result of British support for America‟s invasion of Iraq, the US/UK “special relationship” was likely reinforced, and strengthened. A 2010 parliamentary report on global security by the UK‟s Foreign Affairs Committee makes reference to the close cooperation between the UK and US in Afghanistan and Iraq in the years following 2001, and states that “„wars and conflict tend to emphasize the vitality of the relationship‟” (qtd. in UK House of Commons 71). It is possible that American media‟s overall coverage of the UK has been influenced by this event and that greater representation of UK healthcare, over Medicare, in American newspapers reflects an overall trend towards increased US interest in many aspects of British life that have taken place more recently as a result of political war ties.  6.2 Reasonably Accurate Reporting 6.2.1 Online Access to Research Databases As the World Wide Web continues to evolve and grow, there has been an explosion of online Canadian research databases dedicated to maintaining up-to-date information on the state of Medicare – including research on wait times, primary care, and the future of Canada‟s national pharmaceutical strategy. The Health Council of Canada, the Canadian Institute for Heath Information, and the Canadian Health Services Research Foundation (CHSRF) are just some of the bodies that currently have websites that provide accurate and up-to-date information on the state of Canada‟s healthcare system. In the UK, the availability of on-line healthcare information is also growing. NHS Evidence Health Information Resources (formerly the National Library for Health) and the King‟s Fund, an independent charitable organisation in the  57 UK, are just two examples of initiatives that provide online access to current research and health policy analysis in the UK. The proliferation of online resources, combined with reporters‟ increased reliance on and preference for obtaining data from the web, were likely contributors to the relatively accurate level of coverage of Canadian and UK healthcare systems in US newspapers.  6.3 Prominent Coverage Themes In “Metaphor and Health Policy” (2004), Nancy Lee pointed out that “American analysts working for the expansion of healthcare insurance [in the US] face a contemporary political and cultural environment that is basically unreceptive to redistributive social policies that involve raising taxes and expanding the regulatory presence of government, twin fears that all but tune out the moral argument for the expansion of public health insurance to all Americans” (19). America‟s long-standing interest in and hesitancy towards government control re-emerged under President Obama‟s push for US healthcare reform and was reflected in the dominance of certain themes in American newspaper coverage of Canada and the UK‟s healthcare systems, such as government rationing and problems associated with paying for universal healthcare. American media interest in the UK‟s National Institute for Clinical Excellence (NICE) was also likely influenced by changes that took place to the US healthcare agenda under Obama. In February, 2009, shortly after being inaugurated, the President signed a bill for $1.1 billion for comparative-effectiveness research for drugs, medical devices, and surgery methods in America (Pear, “US to Compare Medical Treatments”). It is probable that this move resulted in greater US media interest in the NHS, a system which has relied on comparative-effectiveness research for over a decade. However, and of particular consequence to US healthcare reform, this study found that American media coverage of NICE was oftentimes unbalanced. No references, for  58 example, were made to the fact that many Americans face barriers to accessing care. In the US, care is rationed on the basis of ability-to-pay, instead of scientific evaluation (as it is in the UK). As Jae Kennedy and Steve Morgan note, “sophisticated diagnostic and surgical treatment are widely available [in the US], but access to these services depends on insurance coverage”, and, as a result, a large portion of the American population remains vulnerable (698-699). Essentially, the contrasting portrayal of rationed healthcare treatment and services in the UK with the medical options available in the US misconstrues the reality of the complex nature of healthcare administration and coverage in both countries.  59  7 Conclusion As this study reveals, three of America‟s most widely circulated newspapers, the New York Times, Wall Street Journal, and USA Today, dedicated more space to coverage of the NHS than Medicare, a system that received less coverage between 2008 and the first quarter of 2010 compared to Rosenau‟s study timeframe. However, overall, US reporting of both Canada and the UK‟s healthcare systems was relatively accurate, balanced, and complete. It is suggested that the prominence and treatment of certain themes, like wait times and rationing, may have reinforced stereotypes of universal healthcare, which could have inhibited US reception to cross-cultural healthcare learning during a major shift in US healthcare policy. America‟s rather simplistic, and often negative portrayal of the UK‟s rationing body, NICE, arguably serves as a case in point. In conclusion, the economic and practical pressures facing journalists today present barriers to more nuanced reporting. Yet, the growth of new journalism platforms, particularly online blogs, are proving worthy substitutes for coverage and in-depth analysis of the foreign healthcare experience. Finally, with reporters‟ increased reliance on online healthcare research databases, it is anticipated that future improvements in the accuracy of American reporting of Canada and the UK‟s healthcare systems will take place.  60  8 Limitations This study was subject to a number of limitations relating to scope, content analysis protocols, database constraints, and sample size. These limitations are discussed in greater detail in the following sections.  8.1 Rosenau’s Limitations Left Unaddressed While this study expanded upon the work of Rosenau, it was subject to the same practical limitations as her (or any) study, primarily that “results cannot be generalized to all other U.S. newspapers”, but are limited to the publications analyzed “for the period of time sampled” (Rosenau, “U.S. Newspaper Coverage of the Canadian Health System” 46). Furthermore, the scope of this study was limited to US coverage and so, like Rosenau’s study, didn’t address the subject of whether “U.S. newspaper coverage is better or worse than Canadian [and UK] newspaper coverage” (46).  8.2 Nature of Content Analysis The limitations of content analysis as a research method are well known. In “Synthesising qualitative and quantitative evidence: a review of possible methods”, scholars note that content analysis “is inherently reductive and tends to diminish complexity and context” (Dixon-Woods et al. 50). Furthermore, they note, “frequency-counting may fail to reflect the structure or importance of the underlying phenomenon” (50). In other words, overemphasis on trends that emerge as a result of quantitative analysis may simplify the level of detail actually present in coverage. With respect to this study, great efforts were made to prevent generalized  61 conclusions about US newspaper coverage of Canada and the UK‟s healthcare systems on the basis of quantitative results alone.  8.3 Database Shortfalls While the tools of the digital age, including sophisticated content databases and search engines undoubtedly benefit the efficiency of the research process, sole reliance on these tools may also pose some limitations and potential risks in the interpretation of results. The potential shortfalls of this approach were amply demonstrated during the research phase of this thesis while gathering information via Factiva. Using the same search terms and criteria, the number of available articles was found to reduce over time. ProQuest, the publishing company which owns Factiva, confirmed that they normally find that content available on the database increases over time as new articles are published and appended to the dataset. However, they noted that content may fluctuate and dramatically drop at certain periods of time, as a result of contractual changes or expirations with publishers. In other words, conducted at a different time, this study may have resulted in greater (or fewer) articles found, and slight variance in results and overall conclusions in US newspaper coverage of Canada and the UK’s healthcare systems. The implication, in a broader context, is that the integrity of academic research can be compromised by database content dynamics that are fundamentally driven by business protocols between database providers and publishers, which probably, at least in part, reflect the profit motive.10 This is a potentially significant limitation and risk, which researchers need to be aware of and strive to mitigate.  10  It is assumed but has not been validated, that these limitations also apply to other database content providers since they are subject to the same business constraints.  62  8.4 Inclusion Parameters Rosenau‟s constraint on article length, focusing on articles of 500 words or more, was maintained in this thesis to foster reliable quantitative comparisons. While Rosenau‟s justification for limiting the length of articles to 500 words is valid, it is important to recognize that this word count criterion seems rather arbitrary and is relatively restrictive and that shorter news stories can also be significant in forming public opinion. For this study, a number of news articles that may have provided key insights into US coverage were excluded from analysis simply because they were below the 500 word cut-off.  8.5  Small Sample Size Sample size is an important consideration in quantitative and statistical analysis. Within  reason, larger samples tend to contribute to more reliable and confident interpretation. The relatively small sample size referenced in this study imposes some limitations on the verity of the interpretations or at least the confidence of those interpretations. This is particularly true of discussions related to Medicare where the sample size was limited to only six articles; less true of the NHS, where a larger sample size (22 articles) was involved.  63  9 Suggestions for Further Research Investigation into the accuracy, comprehensiveness, and balance of domestic coverage of Canadian and UK healthcare would be particularly insightful, providing a measure for assessing the true quality of American coverage of foreign healthcare systems. Furthermore, it would be illuminating to compare the results of this study to a content analysis of US newspaper coverage of other foreign healthcare models, such as the Swiss or Dutch healthcare systems, which are more reliant on private insurance. Such models are arguably more relevant to the US healthcare policy context, and thus, it would be interesting to research whether American media coverage, as a result, is any more accurate than coverage of publically-financed healthcare systems. In addition, with the shrinking size of newspapers and the emergence of new journalism platforms, a worthy endeavour for future research could involve an analysis of the tenor of shorter print news articles (i.e.: less than 500 words) as well as online US coverage of Canada and the UK‟s healthcare systems. Furthermore, it could be expected that with the advent of staff cutbacks and the acceleration of online journalism during this study‟s time frame, reporters were met by increased time and editorial pressures, trends that have led some to question what the impact will be on the quality of health journalism (Schwitzer 8). Therefore, a study, involving interviews with journalists and editors, would provide greater insight into how industry norms and shifting practices directly influenced US coverage of Canada and the UK‟s healthcare systems. Reader surveys could also be conducted to help establish the larger societal impact of media coverage in the New York Times, Wall Street Journal, and USA Today. In brief, a study examining whether the prominence and popularity of certain story lines actually led to reinforced  64 stereotypes of Medicare and the NHS would reveal the greater influence of American newspaper coverage on public opinion during the period of US healthcare reform.  65  Bibliography Alberts, Sheldon. “Obama‟s plan to set up government-run health insurance drops into legislative limbo.” The Vancouver Sun. 9 Sept. 2009. 15 Oct. 2009 <http://www.vancouversun.com/cars/Obama+plan+government+health+insurance+drops +into+legislative+limbo/1974536/story.html>. Alberts, Sheldon. “Obama‟s historic health care reform bill passes.” The Vancouver Sun. 22 Mar. 2010: B1. 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Host Neil Cavuto. “National Healthcare: Breeding Ground for Terror?” Fox News 6 July 2007.  76  Appendix A: Sample Articles Articles from the New York Times, Wall Street Journal, and USA Today that met the criteria for inclusion for this study: Associated Press. “Britain Responds to Criticism of Its Universal Health System.” The New York Times 15 Aug. 2009. Austen, Ian. “Team Canada‟s Doctor Wants His Athletes in Front, for Swine Flu Shots.” The New York Times 17 Oct. 2009. Bryan-Low, Cassell, and Alistair MacDonald. “U.K. Health System, Maligned in U.S., Draws Praise at Home.” The Wall Street Journal 15 Aug. 2009. Burns, John F. “British Threat Reports Says Flu Pandemic Would Have Most Widespread Impact.” The New York Times 9 Aug. 2008. Castle, Stephen. “European Plan Would Expand Health Care Access Within the Bloc. The New York Times 3 July 2008. Cooper, Michael, and Julie Bosman and Kevin Sack. “Parsing McCain on the Democrats‟ Health Plans.” The New York Times 3 May 2008. Dewan, Shaila. “Regarding Tamiflu, Doctors and Patients Face Question of When to Act.” The New York Times 7 Nov. 2009. Grady, Denise, and Pam Kent. “Shortage of Sperm Donors in Britain Prompts Calls for Change.” The New York Times 12 Nov. 2008. Harris, Gardiner. “British Balance Benefit Vs. Cost of Latest Drugs.” The New York Times 3 Dec. 2008. Lyall, Sarah. “BBC Host Admits Killing Ailing Partner.” The New York Times 18 Feb. 2010. Lyall, Sarah. “Britons Fault Health Service, Until Someone Else Does.” The New York Times 21 Aug. 2009.  77 Lyall, Sarah. “Those Who Pay for Private Care Are Testing Britain‟s Public Health System.” The New York Times 21 Feb. 2008. Lyall, Sarah. “Top English Prosecutor Officers Guidelines to Clarify Law About Assisted Suicide.” The New York Times 24 Sept. 2009. McKay, Betsy. “Swine-Flu Wave Poses Threat to Hospital ICUs, Studies AWarn.” The Wall Street Journal 13 Oct. 2009. McNeil, Donald G. Jr. “Machine for Breathing Troubles May Aid in Swine Flu Care, Researchers Say.” The New York Times 16 Sept. 2009. McNeil, Donald G. Jr. “Official Endorses Workplace Clinics for Vaccine Distribution.” The New York Times 7 Nov. 2009. Pear, Robert. “Warring Sides on Health Care Carry Their Fight to TV and Radio Ads.” The New York Times 28 May 2009. Rabin, Roni Caryn. “Benefits of Mammogram Under Debate in Britain.” The New York Times 31 Mar. 2009. Rubin, Rita. “Drugs sales may not benefit ads directed to patients; Study finds little effect on rates of prescription.” USA Today 2 Sept. 2008. Rundle, Rhonda L. “Europeans Take Beauty Trip to U.S. – Plastic Surgeons See Rise in Overseas Clients Amid Weak Dollar.” The Wall Street Journal 8 July 2008. Schmidt, Michael S., and Katie Thomas, Dan Van Natta Jr., Ian Austen, and David Waldstein. “Warring Sides on Health Care Carry Their Fight to TV and Radio Ads.” The New York Times 16 Dec. 2009. Stinson, Jeffrey. “Stem cell bill rekindles British abortion debate; Reducing 24-week limit among changes proposed.” USA Today 3 Apr. 2008.  78 Werdigier, Julia. “Combining Grocery Shopping With Doctors‟ Appointments.” The New York Times 3 Mar. 2008. Werdigier, Julia. “In Britain, a Debate Over Home Care for Elderly People.” The New York Times 10 Mar. 2010. Whalen, Jeanne. “Flu Pandemic Spurs Queries About Vaccine.” The Wall Street Journal 15 June 2009. Whalen, Jeanne. “Glaxo Seeks Guidance From Health Systems.” The Wall Street Journal 7 July 2008. Whalen, Jeanne. “U.K. Plans Massive Swine-Flu Vaccination – Argentina‟s Health Ministry Reports More Deaths, Exceeding Mexico‟s Toll.” The Wall Street Journal 15 July 2009. Whalen, Jeanne. “U.K. to Clarify Assisted-Suicide Prosecutions.” The Wall Street Journal 13 Sept. 2009.  

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