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ONC Pushes Public Health Agencies to Improve HIE Integration

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https://ehrintelligence.com/news/onc-pushes-public-health-agencies-to-improve-hie-integration

HIE Integration

The few public health agencies with HIE integration have reported more complete, higher quality data than those without a connection.

An ONC resource on how public health agencies utilize health information exchange (HIE) integration contains best practices and insights using interviews from public health agencies in 16 jurisdictions.

The findings detailed in the report focus on strategies for public health and HIE integration across six categories: leadership, technical, financial, privacy and security, policy, and health IT developers.

ONC partnered with Clinovations Government + Health (CGH) to examine HIE use among public health agencies. These state and community agencies can assist in improving the health of populations through disease prevention activities using data from public health screening and treatment services, laboratories, pharmacies, environmental health monitors, emergency medical services, local public health agencies, and clinical care providers.

Public health agencies function within states and communities and collect data from providers to use for data registries and disease surveillance systems. With an HIE connection, public health agencies can benefit from improved interoperability and reduce redundant connections.

While public health information systems with HIE integration have increased in recent years according to ONC, the practice is not yet widespread. In 2012, a survey from the Association of State and Territorial Health Officials (ASTHO) found 13 state public health agencies received lab results and nine received reportable diseases through HIE organizations.

“This trend occurs as researchers discover instances of higher quality in public health data transmitted from HIE organizations, as compared to clinical information systems,” stated the report. “For example, a 2013 investigation of electronic lab report messages finds data enriched by an HIE organization is more complete, compared to data from clinical systems.”

Public health systems with integrated HIE organizations have also been shown to yield improvements in care coordination and clinical efficiency, according to qualitative research in upstate New York, central Texas, Indiana, and New Mexico.

Still, HIE integration within public health systems is a relatively recent undertaking.

ONC highlighted three factors as contributing to this lack of integration:

  • An existing reporting infrastructure already facilitates public health reporting for health care providers.
  • The HIE organization’s technical solution does not often supply public health agencies with the level of data required for public health functions
  • Limited resources are available to dedicate to HIE infrastructure.

In its report, ONC determined that a combination of flexible, standardized technical solutions, policy enabling standardized public health reporting through HIE organizations and secondary data use, and affordable connectivity solutions offered by health IT developers could address these issues.

Interviewees highlighted a number of objectives driving the need to encourage more HIE integration in this care setting.

Most stated HIE integration could streamline the number of connections and thereby reduce costs for healthcare providers, HIE organizations, and public health agencies sharing information. Additionally, integration could support providers in achieving public health requirements for the EHR incentive programs.

Other interviewees expressed interest in developing a sustainable platform for clinical and public health data exchange for improved analytics and quality measurement.

To achieve these aims, ONC outlined ways public health agencies can overcome barriers to HIE integration — specifically, lack of standardization, gaps in standard use and adoption, lack of aligned messaging standards, and inconsistent data quality pose issues in integration.

Improving standards for public health data exchange is especially necessary.

“EHRs that meet ONC’s Health IT Certification Program requirements support transport protocols such as Direct for transport of Continuity of Care Documents (CCDs),” wrote ONC. “Public health content is standardized at the provider (EHR) and public health level, but the method of transport is not. The HL7 implementation guides and certification standards for public health information exchange do not require any specific transport mechanism, which can vary by state or region.”

Using transport methods such as the Direct standard could assist in improving standardization in public health data exchange.

To help public health agencies more efficiently exchange health data, ONC provided a summary of best practices for HIE use.

“One jurisdiction’s HIE organization respondents describe an increasingly electronic environment as being overall good for the community with the ability to share information across trading partners,” stated ONC.

“However, public health agency respondents caution against the growing electronic gap between public health and health care providers, where health care providers increasingly use health IT with exchange capabilities, but public health agencies do not have comparable technology to participate in exchanges,” the agency advised.

Finally, ONC emphasized the need for collaboration between public health agencies, HIEs, healthcare providers, and health IT developers to work toward bidirectional, standards-based health data exchange.

“Standards alignment must integrate public health information systems and HIE organizations, with transport mechanisms and terminologies meeting all of the public health data requirements,” maintained ONC.

How to turn healthcare’s single-payer threat into a reality

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http://www.modernhealthcare.com/article/20170913/NEWS/170919942

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What’s behind the renewed enthusiasm in the Democratic Party for Sen. Bernie Sanders’ single-payer healthcare bill? The GOP still controls both houses of Congress and the White House. The Affordable Care Act still faces an existential crisis.

Unless something is done in the next few weeks to shore up the exchanges for 2018 and reverse HHS’ mean-spirited efforts to undermine enrollment, the enormous progress made over the past four years—last week the Census Bureau announced the nation’s uninsured rate had dropped sharply over that period to 8.8%—will begin to reverse. For those desperately working to avert the immediate danger, single-payer advocacy is a distraction.

Unfortunately, the logic of contemporary politics made the current push for single-payer inevitable. President Donald Trump and the tea party set the table. They proved that in a populist moment, extreme positions that cater to a sliver of the electorate are a viable path to electoral success.

Expect left-wing challengers supporting single-payer to win numerous Democratic House and Senate primaries next spring. A wave election typical of first-term, off-year elections will lead to a single-payer caucus in the next Congress with as much power as the tea party caucus had after the wave of election of 2010.

Single-payer looms as their threat. If you destroy President Barack Obama’s grand compromise-his eponymous plan relied on private insurers and preserved the employer-based system- the fire next time will get rid of both.

Unlike the tea party, single-payer advocates have history on their side. The U.S. over the last half century has moved inexorably toward universal coverage: Medicare and Medicaid; the Children’s Health Insurance Program; the ACA. It will get there one way or another.

Sanders asked the right question in his op-ed last week in the New York Times. “Do we, as a nation, join the rest of the industrialized world and guarantee comprehensive health care to every person as a human right?”

Polls now report growing support for single-payer health insurance. When asked if the government has the responsibility to guarantee access to healthcare for all Americans, nearly 60% answer yes. In other words, a clear majority of Americans now say yes to Sanders’ question.

It’s not just a human-rights issue. Universal access through universal insurance coverage is a necessary if insufficient component of getting healthcare costs under control. It is also a building block for restoring the nation’s economic competitiveness, especially in areas of the country suffering from a prolonged decline. No region can thrive unless it has a well-educated, healthy workforce.

Industrialized countries diverged in how they achieved universal coverage. Some chose a government-funded, single-payer system. Others chose well-regulated private insurers. Still others chose a combination of the two.

The U.S., because its employers used health benefits to get around World War II’s wage-and-price controls, accidentally chose a mixed system. It was the erosion of the employer-based system that led to Obamacare.

Sanders and his 15 Senate co-sponsors propose to eliminate the employer-based system entirely. He would gradually expand Medicare to cover everyone over four years.

The legislation is silent on how to transfer the $1.1 trillion spent by employers on health insurance to government coffers, necessary to defray the cost of his plan. He doesn’t address how he would counter the tremendous opposition that disrupting the existing system would draw from employers and their workers, including those in many unions.

Sanders decries the lack of progressive think tanks to come up with answers to those and other transition questions. But the problem isn’t the absence of good ideas. It’s the absence of fertile soil in which those ideas can grow.

That will change rapidly if Republicans succeed in repealing Obamacare, or undermine it and send the uninsured rate soaring again. That, and only that, will turn the single-payer threat into the last viable path to universal coverage.

WHY RETURNING TO A PRE-ACA MARKET ISN’T AN OPTION

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http://www.managedhealthcareconnect.com/article/why-returning-pre-aca-market-isn-t-option

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After the recent failed attempts to repeal the Affordable Care Act (ACA), it is anyone’s guess as to what comes next. Tax reform and infrastructure now appear to have moved ahead of health care on the legislative agenda—leaving the ACA largely out of lawmakers’ hands, and the Department of Health and Human Services (HHS) at the helm.

The President has implied that the federal government might halt federal payments to insurance companies meant to provide financial assistance to consumers who qualify for subsidies if they purchase health insurance on the ACA exchange. So far that has not happened. In a recent appearance on ABC’s “This Week” Sunday newsmagazine, HHS Secretary Tom Price, MD, said that he and his team are combing through the specifics of the ACA law, “asking the question, ‘does this help patients or does it harm patients? Does it increase costs or does it decrease costs?’”

There are more than 1400 instances in the law where the HHS Secretary has discretion to make changes, making the HHS the most likely source for any forthcoming health reform.

Republicans generally favor pushing more decision-making down to the states, and offering more choice to consumers. Dr Price has talked up a provision drafted by Senator Ted Cruz (R-Texas) that was included in the Senate’s plan. It would have given consumers the choice to purchase insurance that does not meet the ACA’s standard of the essential health benefits, but instead meets a given State’s definition of which service it deems essential. Coupled with the ability to grant state waivers for changes to the current law, many have suggested this could lead to consumers purchasing plans that do not cover most services.

“Dusting Off” The Old Way

The so-called Consumer Freedom Option is strongly opposed by the nation’s largest health insurers, which seemed to bewilder Secretary Price.

“It’s really perplexing, especially from the insurance companies, because all they have to do is dust off how they did business before Obamacare,” he said during the This Week interview. It is “exactly the kind of process that has been utilized for decades.”

Even though the Cruz provision went down with the rest of the Senate bill in July, it is not unreasonable to wonder if Secretary Price might try to figure out how to offer low-cost “skinny plans.” Or if Congress might do that same if and when health care moves back into the limelight.

This begs two questions:

  1. Can the United States ever go back to the way health insurance worked before the ACA, dusting things off, as Secretary Price suggested?
  2. Can selling insurance inside and outside of the ACA—as the Cruz provision envisioned—work?

Most industry experts offer a resounding “no” to both questions. As we have reported previously, it is difficult to take benefits away once they are given. For that reason, there is consensus that the ACA in some form or fashion is here to stay. There is also near universal agreement that certain parts of the ACA—notably the exchanges—need work. But experts also point out that provisions like Sen Cruz’s, that propose parallel systems where different rules apply, will not improve the exchanges, and indeed will likely hasten the so-called death spiral.

AHIP Objects, Actuaries Agree

In a July letter to Senate leaders, America’s Health Insurance Plans (AHIP) pointed out that even though the Cruz provision calls for a single risk pool, such a pool would be established “in name only. In fact, it creates two systems of insurance for healthy and sick people.”

A paper published this year by the American Academy of Actuaries, reinforces this claim.

“If insurers were able to compete under different issue, rating, or benefit coverage requirements, it could be more difficult to spread risks in the single risk pool…. Changes to market rules, such as increasing flexibility in cost-sharing requirements, could require only adjustments to the risk adjustment program. Other changes, such as loosening or eliminating the essential health benefit requirements, could greatly complicate the design and effectiveness of a risk adjustment program, potentially weakening the ability of the single risk pool to provide protections for those with preexisting conditions.”

Such a system, according to the paper, would effectively create two risk pools, and premiums in the ACA plans would be much higher than in those not subject to ACA regulations, leading to a destabilized ACA market. Moreover, things would get worse if people were allowed to move between plans depending on their health status.

Making the Problems Worse

The experts we spoke with agreed, citing the potential for confusion and flawed benefit design. Additionally, it does not adequately address the ACA exchange problems, and indeed may exacerbate them.

“The Cruz amendment would not likely achieve anything other than allowing young/healthy individuals to purchase cheaper, inadequate coverage at a lower price,” David Marcus, director of employee benefits at the National Railway Labor Conference, explained. “It would generally do nothing to lower premiums for ACA-compliant coverage.”

Gary Owens, MD, president of Gary Owens Associates, a medical management and pharmaceutical consultancy firm, implied that Cruz’s plan is a half-baked solution that most would have a difficult time navigating.

“This seems to just one more attempt to cobble together a solution to address the issue of healthcare access and coverage,” he said. “It would probably create more confusion for consumers about which plan is appropriate for their needs.”

Norm Smith, president of Viewpoint Consulting, Inc, which surveys managed markets decision-makers for the pharmaceutical industry, concurred.

“Many of the people buying these plans would not be able to define what’s covered, and what’s not,” he said. “Plans would be difficult for state insurance commissions to control without standardized benefit design.” He added that ACA plans would be crippled as younger, healthier people leave in favor of non-ACA coverage.

F Randy Vogenberg, PhD, RPh, principal at the Institute for Integrated Healthcare, said that the Cruz approach is a tepid response to what he sees as failure on the ACA exchanges.

“It has no merit because it does not address the need to change from the current exchange products,” he explained.

More Choice or Inadequate Coverage?

Proponents cite the fact that skinny plans give more choice to consumers, and that free-market principles are needed, vs increased government intervention. Mr Smith reminded us that the ACA—which is based on the Romney plan that became law in Massachusetts—already contains free-market components. For that reason, he said that introducing more choice could work in theory. However, in practice, “with the level of medical insurance literacy being so low, I’m not sure most members will understand what they are buying.”

Mr Marcus added that “The marketplace is already designed to have market principals, though the insurance that is available through [it] is limited to certain types of coverage.  Offering more choice means certain people can get cheaper plans, but those cheaper plans are generally inadequate methods of protecting against health costs.”

Dr Owens explained that health reform will take much more than simply going back to the way insurance was sold in the 1990s, or tacking piecemeal amendments onto the ACA one after the other.

“Trying to glue on a piecemeal solution is not the answer,” he said. “Congress needs to drop the partisan approaches, put together a real working group that will take the needed time and use the available expertise to develop a comprehensive plan that takes the ACA to the next level.”

New Consumer Expectations

In the end, a big reason that insurers cannot simply dust off their plans from the past may be due to customer preference. Consumers often feel hamstrung when it comes to buying appropriate, affordable coverage. Yet they possess more power than many believe, as evidenced by the backlash Washington lawmakers have faced at local town hall meetings. This, in large part, led to the downfall of ACA repeal efforts.

The term “pre-existing conditions” is now a part of almost every health consumer’s lexicon, and people do not expect to be shut out of the market or forced to buy an exorbitantly expensive plan just because they have such a condition. The ACA appears to have cemented that mindset.

Dr Owens explained that insurers are more eager to work within the already established system of regulations, as opposed to wading into uncharted regulations.

“I don’t think the insurers want to increase the complexity of the marketplace,” he said.

Mr Smith agreed, adding that there would need to be “an awful lot of explaining before members knew what they were buying.”

“Going back just doesn’t make sense,” Mr Marcus noted. “Insurance carriers have spent huge sums of money developing systems to comply with the ACA. Profits at the largest carriers are the highest they have ever been. Insured individuals now have an expectation for ACA market reforms to be continued, but the concept behind the Cruz amendment would not change that.”

Additionally, the health insurance industry as a whole is probably concerned about payers who would choose to sell substandard plans outside of the ACA exchanges. Consumers would be left “in a bind when they need to access coverage,”  Dr Owens said, which would not reflect well on the industry. — Dean Celia

Why Bernie Sanders’s plan for universal health care is only half right

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https://www.brookings.edu/blog/fixgov/2017/09/13/why-bernie-sanderss-plan-for-universal-health-care-is-only-half-right/?utm_campaign=Brookings%20Brief&utm_source=hs_email&utm_medium=email&utm_content=56298642

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Sen. Bernie Sanders plans to introduce his universal health care bill Wednesday; it is likely to serve as a litmus test for Democrats with presidential aspirations. The legislation is bold and simple, which makes it very appealing. A recent survey by the Pew Research Center found that 60 percent of Americans believe the federal government should ensure health coverage for all Americans.

But Sanders’s bill only gets it half right.

The part that’s right is that every American would automatically get health insurance. If that came to pass, the door would be open to lowering costs while eliminating the highly complex regulations needed to police our current system and the inequitable tax treatment that sustains it.

The part that Sanders gets wrong is that he would turn Medicare into a single-payer system for all, supplanting private insurers.

That approach has lots of problems, not least of which is an enormous price tag. Consider what happened in California earlier this year when the state legislature briefly considered a single-payer bill. An appropriations committee estimated it would cost $400 billion, over twice the state’s annual budget. Such complications make the Sanders bill — and other Medicare for all proposals — virtually impossible to enact.

People also forget that Medicare is a hidebound system. It took Congress more than 40 years to offer a prescription drug benefit, for example. Physicians are paid using an arcane system developed decades ago and that has now ballooned to more than 140,000 procedure codes, all of which is supervised (and gamed) by physicians themselves. Standard private sector cost-saving measures, like competitive bidding for routine services, are rarely used.

There is a better way — called universal catastrophic coverage — which borrows from both progressive and conservative playbooks. It would combine the federal guarantee of insurance for all with the cost-controlling benefits of insurers competing for that business.

From the consumer viewpoint, universal catastrophic coverage would look like this: All Americans not covered by Medicaid and Medicare would be placed in a single, massive risk pool. The government would assume the risk of insuring everyone, using a high-deductible policy that would guarantee that no one would be without care in the event of a health care crisis.

To keep the plan progressive and affordable for all, deductibles would be tied to income. Services that are very effective would be exempt from the deductible and fully covered. This includes many prevention services — like flu shots — but also medications for chronic disease, certain vaccines, and the like.

This would eliminate a host of problems in the current system: no more worries about preexisting conditions, no more losing insurance when changing jobs, no more mandated buy-in, and no more upward spiraling of premiums for those buying policies because healthy people are staying uninsured and not paying their share.

From the point of view of insurers, the new system would look like Medicare’s prescription drug plan, in which they compete for market share by offering different networks, deductibles, premiums, and supplemental coverage.

A version of universal catastrophic coverage that I devised with my colleague, Kip Hagopian, would cost the government about 15 percent less than the Affordable Care Act while insuring 115 million more people, according to a RAND study. Premiums would be about $3,000 annually, about 40 percent less than the ACA silver plans.

This approach borrows from liberal dreams for health care as a right, and from conservative conviction that market forces are the most efficient way to deliver health care and keep costs under control. That is why both sides can support it.

Being bold means asking for big changes. The current system of employer-based insurance would lose its tax-protected status, which currently costs the federal government $236 billion (about the same as the mortgage interest deduction, charitable deductions, and retirement benefit exclusions combined, according to the Tax Policy Center). Those savings would be used to underwrite the new system.

Vested interests will find many reasons to oppose change. But the bottom line is that we can cover everyone if we are smart about it.

The Single Payer Debate

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http://www.rollcall.com/news/politics/sanders-displays-political-clout-single-payer-movement?utm_source=rollcallheadlines&utm_medium=email&utm_campaign=newsletters&utm_source=rollcallheadlines&utm_medium=email&utm_campaign=newsletters

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The seismic shift in support for Sen. Bernie Sanders’ plan to transform the U.S. health care system into a single-payer program indicates the reach the Vermont independent has within the Democratic Party.

At the same time that his onetime presidential foe Hillary Clinton is reminding people of the party’s devastating loss last fall, Sanders is trying to define its future. His bill to enroll every American in Medicare drew 16 co-sponsors, 16 more than when he first introduced similar legislation in 2013.

It has garnered support from possible 2020 Democratic presidential hopefuls — Sens. Cory Booker of New Jersey, Kamala Harris of California, Elizabeth Warren of Massachusetts and Kirsten Gillibrand of New York — as well as Sen. Tammy Baldwin of Wisconsin, an incumbent up for re-election next year in a state narrowly won by President Donald Trump.

It also provided a welcome talking point for Republicans who have long railed against government-run health care. Several GOP senators used Sanders’ legislation as a tool to warn voters of what could come if Republicans are unable to overhaul the health care system.

‘A political crisis’

During a bill introduction Wednesday that felt more like a campaign rally than the standard press conference, Sanders — flanked by co-sponsors — stuck to his standard script of bashing Republicans and special interest groups for doing nothing to address rising health care costs.

“The crisis we are discussing is not really about health care,” he told a crowded room of activists and supporters. “The crisis we are discussing today is a political crisis which speaks to the incredible power of the insurance companies, the drug companies and all those who make billions of dollars off of the current system.”

The politics of “Medicare for all” are divisive. And aside from a short comment about raising taxes across the board, Sanders has yet to outline a clear way to pay for such a system.

There is a divide within the Democratic Party on how to define such a system, and many Senate Democrats have yet to voice their support for Sanders’ plan, including vulnerable incumbents up for re-election such as Sen. Joe Manchin III of West Virginia.

Despite those differences, however, the expanding coalition of Democrats who now back such a proposal is a display of just how Sanders, who gave Clinton a serious challenge for the presidential nomination, continues to influence the national party.

“Sen. Sanders’ presidential campaign was a phenomenon that very few people saw coming. It uncovered a groundswell of progressive activation that the party now rightly wants to tap into as we head into 2018 and 2020,” Connecticut Democratic Sen. Christopher S. Murphy said. “I think that Democrats now feel a little freer to imagine some even bigger and bolder ideas.”

Asked whether the growing support for his legislation is indicative of his influence, Sanders hedged.

“Right now, we are focusing on what the bill is about,” he said. “We’ll talk about the politics of it later.”

A national message?

Several other Democratic senators supported the national party embracing more bold ideas — like Medicare for all — in the fallout from the 2016 election and tied that movement directly to the success of Sanders’ campaign.

“It’s an idea whose time has come. There’s a clear recognition that universal coverage has to be the goal,” Democratic Sen. Richard Blumenthal of Connecticut said. “These principles are now in the public mind, front and center, and that is due, in part, to the prominence that Bernie Sanders gave to them during the campaign.”

A Democratic aide echoed those thoughts and said the shift is indicative of a recognition that the party needs to be bolder and sharper in its proposals.

“I think there will be a lot of support for this bill,” the aide said. “It’ll make the clear contrast between the two parties on health care even more clear.”

While the Sanders proposal has gained more support among members of the Democratic conference, skeptics remain.

“The Sanders bill requires people to give up their insurance. It’s not an option that you buy in. It requires people to give up the insurance,” Sen. Claire McCaskill of Missouri said. “I’ve been down the road of requiring people to do things the government says on insurance and it is a road paved with big rocky boulders.”

Asked whether she correlates the growing support for Medicare for all to Sanders’ popularity among liberals, McCaskill — who is up for re-election in 2018 in a state Trump won easily — said she had not analyzed it from that perspective.

“I just think we’ve got to think this through and not make this some kind of political litmus test,” she told Roll Call.

While other Democratic lawmakers also said they hoped support for the Sanders bill would not be a political benchmark for the party, several openly said endorsing the concept would be crucial for any successful candidate.

“I have trouble seeing how a viable Democratic candidate does not support the idea of single-payer,” Blumenthal said. “This bill is going to drive the national message.”

Bernie-Care barrier?

Some Senate Republicans, who this summer failed in their attempt to repeal and replace the 2010 health care law, are making a last-ditch attempt to overhaul it.

Sens. Bill Cassidy of Louisiana, Lindsey Graham of South Carolina, Ron Johnson of Wisconsin and Dean Heller of Nevada are pushing legislation that would transform the health care system to essentially a large federal block grant to the states based on the size of their individual insurance pool.

Their message to the Republican conference was clear: It’s either our plan or Sanders’ proposal.

“If you want a single-payer health care system, this is your worst nightmare,” Graham said. “Bernie, this ends your dream of a single-payer health care system for America.”

Republican leadership echoed that message.

“We see what the alternative is and hopefully that’ll focus the mind,” Senate Majority Whip John Cornyn said. “Their party is clearly lurched to the left even further, and it’s made it hard for otherwise pretty pragmatic people, like Chuck Schumer, to do deals which he ordinarily would do with Republicans.”

But for Sanders, the failed attempt by the GOP to overhaul the current health care law only bolsters his case.

“To my Republican colleagues, please don’t lecture us on health care,” he said. “You, the Republican Party, have no credibility on the issue of health care.”

GOP Sees Offensive Opening on Health Care for 2018

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http://www.rollcall.com/news/politics/gop-medicare-for-all-strategy?utm_source=rollcallheadlines&utm_medium=email&utm_campaign=newsletters&utm_source=rollcallheadlines&utm_medium=email&utm_campaign=newsletters

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Republicans plan to tie all Democrats to “Medicare for all” proposals.

As more and more Democrats come out in favor of some form of “Medicare for all” legislation, Republican campaign strategists are salivating.

In much the same way the GOP has tried to tie all Democrats to House Minority Leader Nancy Pelosi in attack ads, they’re planning to tie all Democratic incumbents and challengers to different proposals from Vermont independent Bernie Sanders in the Senate and Michigan Rep. John Conyers Jr. in the House, regardless of whether they’ve personally embraced those policies.

“I’m thrilled,” said Corry Bliss, executive director of the Congressional Leadership Fund, the leadership-backed super PAC that plans to spend $100 million to help Republicans keep their House majority in 2018.

“I love their new policy so much that I’m thinking about taking the $50 or so million I was planning on spending on attacking Nancy Pelosi and putting a small portion toward explaining how single-payer hurts the American people,” Bliss said Tuesday.

That strategy isn’t much different from the GOP strategy of the past seven years, when the party has gone after Democrats on the 2010 health care law. But after months of their own health care legislative failures, Republicans think they finally have an offensive opening on health care again.

“It’s first time we’ve been in that position in a long time,” said one GOP campaign strategist, who acknowledged that this year’s health care debate revived the 2010 law.

Attacking all Democrats

The National Republican Congressional Committee was especially vocal on Wednesday, with a digital ad and a slew of press releases trying to pin Sanders’ proposal on Democratic incumbents and challengers.

“Studies reveal that single-payer would cost taxpayers a staggering $32 trillion over the next ten years,” the releases say, all pointing to the same study from the Urban Institute from May 2016.

“Sanders and Pelosi are leading their members down a path with nowhere to turn but left,” NRCC communications director Matt Gorman said in a statement.

In reality, Pelosi has shied away from Medicare for all proposals, trying instead to keep her caucus’ focus on improving the 2010 health care law. Her reticence toward the issue is a fact Republicans sometimes highlight to underscore its unpopularity — as in, “This is such a bad idea, Nancy Pelosi doesn’t even support it.”

But when it comes to messaging against the proposals, Republicans are happy to include Pelosi — a perpetual boogeyman — to help tie the issue around the neck of all Democrats.

California Rep. Scott Peters, a member of the moderate New Democrat Coalition and chairman of the group’s PAC, brushed aside the threats of those kinds of attacks.

“That won’t be a very effective campaign technique. People understand where we are,” he said, walking down the House steps Wednesday afternoon. Peters, an NRCC target in 2018, doesn’t support the Conyers legislation.

But with a majority of House Democrats signing onto it, and many 2020 hopefuls embracing the Sanders plan in the Senate, Republicans see it as nationalized party issue they can apply down ballot to all candidates.

“This is going to help frame the choice next year,” Bliss said. “It will be a huge issue in every single district that we spend in next year.“

One Republican admitted, though, it may be harder to message against a Democratic proposal that doesn’t stand a chance of becoming law anytime soon and doesn’t have a Democratic president behind it.

“I don’t think it will get to the same level as Obamacare did in the 2010 cycle,” the GOP strategist said. “You don’t have the same boogeyman in President Obama and Pelosi.”

Still, Republicans hope the issue will help them by pushing Democratic candidates to the left and sinking nominees in red districts or states won by President Donald Trump last fall.

In Wisconsin, where Trump eked out a win, Sen. Tammy Baldwin has come out in support of Sanders’ legislation. She’s the only senator up for re-election in a state the president won to have signed onto the Sanders’ proposal.

Trump has called for “insurance for everybody,” but Republicans say it’d be very easy to message against a Medicare for all plan to his voters.

“Here’s a socialist idea where everyone gets the same thing,” the GOP strategist said. “That doesn’t play.” It doesn’t fit with what she called the “you deserve more” narrative that Trump pushed to working-class voters during the campaign.

Keeping up the heat

Democrats aren’t backing away from their own offensive attacks on health care, trying to make the GOP-controlled Congress own their repeal-and-replace efforts.

That continued on Wednesday, with the introduction of the Senate Republicans’ latest effort at repealing the 2010 health care law.

“The 2018 election will be a referendum on the toxic GOP health care plan that spikes costs and strips coverage,” said David Bergstein, spokesman for the Democratic Senatorial Campaign Committee.

And they’re skeptical that this week’s attention on the Medicare for all legislation will take away from what a GOP-controlled Congress has been able to do — or not do — on health care this year.

“To have that be their golden ticket out of the nightmare they face right now seems just insane,” one Democratic operative said.