Health Policy Speech Options on the Eve of the State of the Union

It's the eve of Mr. Obama's State of the Union address (or, as the beltway cognoscenti apparently refer to it, "SOTU").

What better way for the Disease Management Care Blog readers to mark this momentous occasion than by pretending that we're in the Oval Office advising the President on the best way forward?

Here are some your options in helping our Chief Executive dispatch the problematic sequester, sustainable growth rate, Medicare and health reform.  Who knows, maybe someone from the White House is paying attention.....

Realizing that the sequester is both a bad deal for Medicare and a trap for the Democratic party, you recommend:

1. compromising,
2. changing the subject back to "evil insurers,"
3. a series of heartland speeches with nodding fawning accountants sharing the stage that explains to the American people the federal budget sequester and why you signed the enabling legislation in the first place,
4. hiring a Kardashian lawyer because he'll know how to arrange a quickie divorce from the sequester deal.

To fix the SGR and prevent a physician flight from Medicare participation, you recommend:

1. compromising,
2. changing the subject to "oil companies,"
3. applying the vast anticipated 2016 savings from the "Medical Home" and ACOs to this year's budget shortfall; if necessary add another zero or two,
4. re-tasking the controversial military drone program to drop freshly minted $100 bills on doctors' offices.

You want mention Marilyn Tavenner, Acting Director for CMS, and ask that she confirmed by the Senate.  To make this happen, you advise the President to:

1. nominate her in the regular course of business and trust the Senate will do the right thing,
2. ask her to change the subject to the White House meme of "corporate jets,"
3. announce she will expand the care management program for FFS Medicare beneficiaries, ignoring, for the moment, that that is the largest insured population in the U.S. without that benefit,
4. fix the Chuck Hagel debacle by changing Ms. Taveneer's nomination to Secretary of Defense

 Knowing that the President risks having his second-term being stymied by a defiant opposition party, you suggest Mr. Obama neutralize them by:

1. reaching out with Lincoln-esque "malice toward none and charity for all."
2. characterizing Republicans as "hateful munchkins"
3. recycling the "previous administration" blame strategy by reminding listeners it was Mr. Bush who kicked off the electronic health record mess in a previous State of the Union address and that its yet-unfulfilled promise is not your fault either.
4. suggesting everyone get out of their closed partisan information loops by regularly reading the Disease Management Care Blog.

Since 2015 promises to be the watershed year for Obamacare, you remind the President to:

1. avoid the subject because everyone's projections are turning out to be wrong
2. decide now between the red pill and the blue pill
3.  announce that his White House advisors know more than any commercial health insurance executive about the underlying actuarial equivalence of an essential health benefit
4. in contrast to the 2010 SOTU, be respectful to the Supreme Court because they saved your Obamacare as*.

The State of the Union is Over. Advice on What's Next for Obamacare

When it comes to assessing or "monetizing" the possibility of a bad future event, the insurance-minded Disease Management Care Blog recalls that a common approach is to multiply the probability of the outcome and its value.  For example, if the chance of a $100,000 house burning down in the next year is 1%, the present value of that risk is .01 x 100,000 or $1000.  That $1000 figure is the starting basis of calculating the cost of homeowner's insurance.

While that logic only goes so far, it can be a useful way to look at other types of risk. For example, instead of confidently proclaiming that the Affordable Care Act "will" or "will not" lead to a deficit, it may be wiser to describe the range of probabilities.  So, depending on future GDP, inflation, disease burden, and other factors, it could be reasonably estimated there is an "X" percent chance it will increase the deficit by "Y" billions of dollars. Multiply that downside risk against the size of the deficit, and Congress and the White House could use that number to discuss the implications for this year's budgeting.

Fat chance of that happening.

With just hours until the State of the Union ("#SOTU") address, it appears our cerebral President won't be thinking that way. Rather, it's more likely that he extol healthcare.gov's repaired functionality, remind listeners that millions of Americans have signed up for insurance, push a "regulatory" agenda and threaten that, so long as he wields the veto pen, "there's no going back."

While the DMCB admires the President's pluck, it still fears that Obamacare could turn out to be his Napoleonic Russian invasion. While he's taken "Moscow" with the passage of the ACA, the countryside is filled with angry partisans, the 2015 elections portend a long cold winter and his supply lines are threatened by botched health insurance data feeds, a dodgy mandate, unintended consequences and costly risk pools.

Once the political theater of SOTU is over, the DMCB suggests that Mr. Obama's advisors should quietly ascertain the likelihood that the ACA gets worse (1%?, 10%?, 25%?) in 2015 and multiply that times the value of the President's legacy.  A realistic appraisal of that number may prompt the President to look at his signature achievement in a new light, gauge the political theatrics for what they are and devote a commensurate level of Oval Office attention to making the law work.