Could Auto-Enrollment Be the Answer?

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.

6 replies »

  1. Does anyone stop to think where these tax credits are coming from? The way I see it the subsidy is funded by (1) the insurer taxes and (2) tax payer money.

    If everyone eligible is automatically enrolled that just means more of the insurer taxes and taxpayer dollars flow back to the insurance companies in the form of premiums.

    Someone on this website was supporting government salaried doctors so why not use the unused tax credit budget for a salaried doctor at a VA hospital to provide care to those uninsured?

    I’d rather have that then throw my money back to the insurance companies who aren’t improving care and who aren’t controlling costs. Insurance is just a means to protect against bankruptcy; it doesn’t improve health.

  2. I think David Cutler did recommend it, and Obama opposed mandates because he was planning to go with this policy.

  3. This does have good possibilities It certainly seems like an improvement over the tortuous enrollments in the ACA exchanges, along with the tortuous suspense on whether enough healthy persons will enroll.

    Let’s look at two challenges which the Repub’s plan would face.

    #1 is paying for the tax credits.

    Assume that Medicare stays intact. That leaves about 250 million persons to get tax credits.

    100 million are under age 21. I do not know how their tax credit would work.

    So let’s focus on the 150 million adults.

    Say that each of them gets a tax credit of $2500.

    That means $375 billion a year in government spending.

    The only way to raise that kind of cash is make all employer premiums into taxable income. Philosophically that is OK with me but I do wonder if this whole thing balances. What if many employers stop paying for health insurance? The financing disappears.

    #2 is what the tax credit actually buys.

    $2500 a person might be just enough to enroll the opt-out person in a catastrophic health plan.

    I think it would have to a government plan. I cannot imagine a private insurance company wanting to take the risk of enrolling a million totally unknown persons who have been uninsured in many cases for years.
    Also the insurance company would be terrified of what age mix it might get.

    It is not like Republicans to endorse a program that would in effect re-create Medicaid. They may be assuming that the tax credits would be a boon to private insurers.

  4. This sounds like a very wise and simple solution. I would love to hear opinions from some of the experts that follow this blog on whether or not this has merit