Republicans

Kudos to the New England Journal for providing a tidy summary of the latest Republican healthcare reform proposal. Up until now, your correspondent was only vaguely aware of the GOP’s evolution from the political party of “no” to one of “go,” albeit with lots of caveats.

It seems the Senate Republicans no longer want to repeal Obamacare and are OK with keeping many of its more popular reforms. Instead, they’re focusing on undoing selected provisions, such as repealing the minimum benefit, returning some aspects of medical underwriting and resurrecting the “block grants” for Medicaid.

But one of the more interesting wrinkles in the proposal is “auto-enrollment.”

Those of us from the bygone days of “disease management” may recall the debates over the merits of “opt-in” versus “opt out” participation in our programs. The former required persons to actively chose to be entered into nurse coaching, which had the advantage of committing resources to a highly motivated population. The latter approach assumed all patients with a condition were enrolled and, only if they specifically requested it, would they allowed to stop the coaching phone calls. Unfortunately, “opt-out” usually gathered many patients who never answered the phone and were “engaged” in name only.

Well, the Republicans are apparently proposing that states be allowed to “auto-enroll” persons eligible for premium payment support into an insurance plan or Medicaid without their up-front permission, just like the old “opt-out” disease management days. The tax credit would cover the insurance costs, no bills would be issued to the consumer and voilà! the risk pools would expand. Patient choice would be preserved, because persons could always just say no.

Your correspondent was always of fan of opt-in disease management. Not only were patients who wanted to be in the program more amenable to behavior change, it allowed the program to “flex” the nurses that we needed as the program grew in scope. However, when it comes to insurance, yours truly thinks the Republicans may be onto something with their opt-out insurance approach.

Count your correspondent as a fan.

Jaan Sidorov, MD, is a primary care internist and former Medical Director at Geisinger Health Plan with over 20 years experience in primary care, disease management and population-based care coordination. He shares his knowledge and insights at Disease Management Care Blog, where an earlier version of this post first appeared.

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The Republicans have an alternative to Obamacare and they may have given the Democrats a big political gift.

The proposal was unveiled last Monday by Republican Senators Richard Burr, (NC), Tom Coburn (OK), and Orrin Hatch (UT).

The Republican plan targets many of the most unpopular parts of the Affordable Care Act such as expensive mandated benefits and the resulting lack of choice, the individual mandate, the employer mandate, and age-rating disruptions.

My sense is that most independent voters––the ones that matter in an election-year––don’t want Obamacare repealed; they want it fixed.

The problem for Republicans is that they have such a visceral response to the term “Obamacare” that they just can’t bring themselves to fix it. The notion that Obamacare might be fixed and allowed to continue as part of an Obama legacy and as a Democratic accomplishment is something they can’t get past.

So, the only way Republicans can propose an alternative to Obamacare is to first wipe the health insurance reform slate clean and start over.

Continue reading “The Republican Alternative to Obamacare: Their Aversion to Fixing it May Prove to Be a Political Mistake”

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Views on the Affordable Care Act (a.k.a. Obamacare, a.k.a. Health Reform) are mixed. Despite the fact that many people support individual provisions, overall, the measure is unpopular. Why would that be the case?

A revealing Health Affairs interview with Cythnia Morgan, may reveal the answer. Morgan is a fifty-eight-year-old former hotel manager, has been out of work and uninsured for the past three years. Her income is low, but not low enough to quality for Medicaid. She is exactly the type of person the health insurance exchange is supposed to help. So why wouldn’t like someone like her support the Exchanges?

After being told of how the ACA’s health insurance exchanges would work, she stated:

“Oh, God, that would be great—if there’s going to be a plan that’s affordable. But come on now, it’s really hard to believe.”

A Democrat would read this and claim that Mrs. Morgan is ignorant of the provisions and yes, in fact, this is exactly what the ACA will do. Republicans will say that Mrs. Morgan is 100 percent correct. Although the provisions do promise affordable care, she is correct to be skeptical that government can deliver on this promise when private industry could not.

Continue reading “Why Is Obamacare So Unpopular?”

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Last week’s State of the Union speech was notable because the President hardly mentioned the new health care reform law.

Avoiding what is supposed to be the centerpiece domestic accomplishment of President Obama’s first term stuck out like a sore thumb.

He said almost nothing because the Obama team simply doesn’t know what to say.

The fact is the Affordable Care Act (ACA) is generally unpopular, and its best-known provision, the individual mandate, is wildly unpopular.

Two years after passage and, the implementation of the law’s first steps all designed to build support, the public’s opinion of the law is unchanged and not good. The just out January 2012 Kaiser Health Tracking Poll leaves no doubt:

  • Only 37% of those surveyed have a favorable view of the law.
  • 44% have an unfavorable view of the Affordable Care Act.
  • But even some of those who don’t like it don’t like it because it didn’t go far enough—31% of all of those surveyed want to expand the current law while 19% want to keep it in its current form. That’s a total of 50% that want to keep or expand it.
  • 22% want it repealed outright and another 18% want it replaced with a Republican alternative—a total of 40%, fewer than want to expand it or keep it as it is.
  • On the individual mandate, 67% have an unfavorable view of requiring everyone to buy coverage, while 30% have a favorable view of the requirement.
  • While a total of 50% of those surveyed think the law should be kept or expanded, 54% say the Supreme Court should throw the mandate out, while only 17% say they think the mandate should be upheld.

So, let’s summarize. Only 37% have a favorable view of the law and 67% don’t like the mandate. But 50% think the law should be kept as it is or even expanded.  No wonder Obama and his political team can’t figure out how to play this. Continue reading “Repealed, Replaced and Expanded”

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It should now be clear to Republicans they are in trouble over the Ryan Medicare plan.

Yesterday, they lost a seat in a solid Republican New York House district. Their candidate had benefited from lots of money and House leadership attention. The big issue was the Ryan Medicare plan.

All month, Republican Presidential candidates have been walking a tightrope over the Ryan plan–don’t embrace it but don’t criticize it either for fear of offending the base who will drive the primary outcomes next year. You only had to watch the Gingrich implosion to see what happens if you fall off that tightrope.

Next the Senate will take up the Ryan budget. Senate Democrats can’t wait for a vote on it and are making the Ryan Medicare plan the central issue. Already, at least three Senate Republicans have said they will not vote for the House budget over the Medicare issue. Leader McConnell, sensitive to its political vulnerability, has told Senators they are free to vote their conscience on this one. Continue reading “Earth to Republicans: You Are In Big Political Trouble Over the Ryan Medicare Plan”

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Emboldened by their victory in the Midterms, many Republicans are calling for repeal of the Patient Protection and  Affordable Care Act (PPACA). How likely is it that we’ll see changes any time soon?  Probably not very.  More cautious observers are expressing reservations about the prospect of any reversal in the near term.

Paul Ryan, R-Wisconsin, one of the Republican young guns, says, “You can’t fully replace this law until you have a new President and a better Senate. And that’s probably 2013, but that’s before the law fully kicks in on 2014.”

Michael Tanner, a senior fellow at the conservative Cato Institute, is more straightforward,”Repealing Obama care is just not going to happen while Obama is in office.”

In the meantime, expect the following events to play out over the next two years.

1. House Republicans will vote overwhelmingly to repeal Obama care, with modest Democratic support from those elected who opposed Obamacare.

2. Harry Reid, Senate Democratic leader, will refuse to bring the House repeal up for a Senate vote.

3. President Obama will insist, as he already has, that it is foolish to “relitigate” a law which he regards as set in legislative, historic, and ideological concrete.

4. They will call upon Kathleen Sibelius, Secretary of Health and Human Services, to explain why costs have risen sharply since passage and why so many insurers and businesses have dropped coverage.

5. They will summon Doctor Donald Berwick, Administrator for the Centers of Medicare and Medicaid Services, to explain his views and to justify why he should be reseated following his recess appointment.

6. They will seek to repeal the reform the provision calling for submitting of 1099 forms for every $600 of business expenditures – a possible item of compromise.

Continue reading “The Road to Repeal?”

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