Obradovich: Your Cliff's Notes guide to the Iowa straw poll

Next weekend in Ames, presidential campaigns will be busy trying to turn straw votes into campaign gold. Just like in the story of Rumpelstiltskin, the magic is in the spinning.

The Iowa Republican straw poll has the power to alter the character of the 2012 presidential race even though it’s only a mock election. Candidates who fare poorly — at least in the eyes of the media — can go from Prince Charming to pumpkin faster than you can say Tommy Thompson. And sometimes the fairest of them all is the candidate who comes in second.

The candidates who are doing the best in media polls are not necessarily the ones who rise to the top in Ames. That fact makes the straw poll hard to predict, and there are a few extra wrinkles this year. The poll’s significance and fairness are always up for discussion as well.

Here’s a Cliff’s Notes summary of the major themes.

The scene: Light on candidates, heavy on media.

In some ways, the poll is likely to be a downsized affair compared to past years. The number of candidates expected to fully participate in the event is down to six, compared to eight in 2007. National poll leader Mitt Romney will be on the ballot but his campaign didn’t buy space or organize a turnout effort. Neither did Jon Huntsman, who is not competing in Iowa, or Newt Gingrich, whose campaign was strapped for cash.

Iowa Republican Party spokesman Casey Mills wouldn’t disclose ticket sales or predict turnout. The reduction in the number of candidates who are driving most of the attendance would suggest lower turnout than the 14,300 who cast votes in 2007. In 1999, the total of votes cast was closer to 24,000.

But the number of media credentials issued — around 700 — has shot up from roughly 450 four years ago. The addition of a televised debate just two days before the straw poll is one reason for the spike in interest. Fox News and the Washington Examiner are co-hosting the debate on Thursday night. So far eight candidates have qualified, according to a news release. The final lineup will be announced on Tuesday.

Mills says he’s been surprised by the number of international media outlets signing up. There also has been an explosion of bloggers and other online media covering the campaign.

The players:

Bachmann: Of the six candidates who bought space at Hilton Coliseum, Minnesota Rep. Michele Bachmann is the favorite in polls of Iowa caucusgoers. The Register’s Iowa Poll in June had her virtually tied with Romney, just as she was formally launching her campaign. She’s drawn enthusiastic crowds on her bus tours, capitalized on her tea party base and has heavily emphasized her roots as a Waterloo, Ia., native. But Republican observers question whether her campaign has matured as quickly as her popularity. The straw poll has long been seen as a test of organizational muscle, a necessary element to turning out voters for next winter’s caucuses. Even if Bachmann’s popularity trumps political craft, it doesn’t pay to be seen as the prohibitive frontrunner. As Romney well knows, journalists yawn at the easy win and reward the candidate who pulls off a surprise.

ACO Fairy Tale Faces a Rumpelstiltskin Moment — Guest Opinion

The ACO fairy tale is drawing perilously close to an unhappy ending.

The government’s long-awaited  draft regulations  on Accountable Care Organizations have brought a dose of ugly reality to a concept that’s always seemed coated with a patina of pixie dust. Unless those regs are substantially changed before the clock strikes Jan. 1, 2012 — the statutory date for ACO implementation –  Cinderella’s  going to turn back into a scullery maid and the horse-drawn carriage transporting her to the Health System Transformation Ball will be revealed as nothing more than four mice and a pumpkin.

The essence of the ACO concept is using financial incentives to reward doctors and hospitals for redesigning care processes to provide “high quality and efficient service delivery,” in the words of the Patient Protection and Affordable Care Act. As  I wrote last fall , ACOs have been the one reform beloved by Republicans and Democrats; doctor groups and insurance companies; policy wonks and profit-seeking capitalists. This unusual unanimity was due in part to a lack of specifics that enabled every stakeholder to gaze upon the ACO and see reflected their very own version of Prince Charming.

Conservatives hail the ACO as marketplace medicine, while liberals focus on organized systems of care replacing fee-for-service chaos. Providers applaud a reform that places them at its center, while health plans know that providers asked to bear financial risk — if an ACO doesn’t measure up, the government won’t pay up — will seek out actuarial experts like them as partners. ACOs also are expected to require the products and services sold by a host of consultants and entrepreneurs.

For medical groups and hospitals considering becoming an ACO, Medicare offers a straightforward risk-reward proposition. Providers must invest considerable resources in building an infrastructure and institutional culture capable of managing and measurably improving the health of a defined group of Medicare beneficiaries. In return, however, ACOs that meet the government’s standards will make much more money than if they clung to the old ways of care delivery.

The central problem with the draft regs, however, is that the risk-reward ratio is highly skewed. The Centers for Medicare & Medicaid Services painstakingly delineates a dizzying litany of hurdles to surmount, from documenting progress on 65 different quality measures to Medicare editing your marketing materials and to government monitors descending upon your offices. Meanwhile, the promised rewards are wrapped in a fuzzy package of impenetrable risk-adjustment algorithms and wait-till-next year financial commitments that sound like a cross between a cell-phone contract and a time-share vacation offer.

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