Newt Gingrich — who introduced his own block grant proposal in 1995 — endorsed the Republican effort to reduce federal Medicaid expenditures by transferring more of the responsibility for the program to the states, telling Rep. Michael Burgess’ (R-TX) Congressional Health Care Caucus, “there is zero doubt in my mind that the Lyndon Johnson experiment of a nationally managed bureaucracy for the poor is a total failure. ” During a question an answer session following the speech, Gingrich was asked by CNN reporter Peter Hamby how he would respond to criticism that block grants would lead states to “throw people off the books.” The former speaker conceded that some would, saying “I think different states will do different things”:

GINGRICH: Well, I think different states would have different solutions and different states will do different things. Different states will organize care in different ways. But I find it fascinating that there are people in Washington DC, who believe that their depth of care is greater than the people in those states and they somehow should trust a bureaucrat in Washington who has never been in Idaho or North Dakota or Arizona to be more concerned about the health of people in those states than a company who lives down the street, is part of the process, and actually sees it on a daily basis. And I think different states will do different things.

Watch it:

As the Congressional Budget Office has predicted in analyzing a block-grant proposal offered by Rep. Paul Ryan (R-WI), some of those “different things” include providing “less extensive coverage” to their beneficiaries. In fact, an analysis of Gingrich’s 1995 block grant proposal concluded that 48 states would have experienced a reduction in federal dollars, while federal Medicaid spending would have fallen by 15 percent in FY 2002 — less than Gingrich predicted at the time. But, if this loss of federal funding “had been absorbed through eligibility restrictions, then more than 6 million people would have lost Medicaid coverage in 2002,” the study found. It added that “the states could have responded to these reductions in federal funding by increasing their own spending in order to maintain services for their Medicaid enrollees. However, the amount required to do so would have been equivalent to a 40 percent increase in the $40 billion shortfall that was estimated for 2002.”

Gingrich’s suggestion that “Washington bureaucrats” believe that they know more about a state’s health care program than local residents is also misleading, since Medicaid is a jointly funded program by the states and the federal government. In today’s Concord Monitor, Jim Roche, who is also the president of New Hampshire’s Business and Industry Association, and is “part of the process” wrote an editorial arguing that reducing spending on Medicaid would actually shift costs to businesses.

House Republicans are preparing to unveil their much-anticipated budget next Tuesday and early reports suggest that the party is ready to embrace Rep. Paul Ryan’s (R-WI) Roadmap proposal, which would slash billions of dollars out of the Medicare and Medicaid programs and transfer the risk and burden of health insurance from the federal government to the individuals and the states.

“Ryan’s budget will propose that the federal share of Medicaid be converted into a block grant,” the Hill’s Erik Wasson reports. “This would save the federal government money because the share of costs would be converted to a fixed dollar amount that rises according to inflation, rather than automatically to match healthcare costs.” Politico reports that the cuts could total up to $1 trillion over 10 years:

HUDDLE THEFT: MEDICAID CUTS OF $1 TRILLION- PULSE’s cousin, Huddle’s Jon Allen, is reporting that the House GOP’s fiscal 2012 budget will likely contain Medicaid cuts of about $1 trillion over 10 years, according to GOP insiders. Medicare cuts are also certain to be assumed by the budget, though the figures for that are still more in flux. Medicaid would generally be changed to cut overall federal dollars while giving greater flexibility to states to spend the money they get.

To put this number into some perspective, the current Medicaid baseline is about $4 trillion over the next 10 years, so Republicans are proposing cutting Medicaid by one-quarter with changes that would repeal the Medicaid expansion found in the Affordable Care Act (saving about $438 billion) and giving states fixed block grants that are below projected federal expenditures. As a result, states would either have to make up the difference by increasing spending for the program or “provide less extensive coverage” to their beneficiaries. An analysis of the consequences of a block grant proposal from 1995 found that giving states a fixed amount of funds would have reduced national federal Medicaid funding for FY 2002 by 15 percent and could have led some 6 million Americans to lose their health coverage.

Keep in mind that Medicaid pays for 40 percent of all births and that children comprise half its beneficiaries. But the real cost drivers are older Americans. Medicaid provides financing for 60 percent of nursing-home residents and pays 43 percent of America’s long-term care bill. Ryan’s reform would stick states with the bill and would likely leave many of the most vulnerable without coverage.

Republicans, who attacked the AARP for their support of the Affordable Care Act, are lashing out against the organization for allegedly profiting from the law and are hauling representatives of the group to testify before a Congressional committee tomorrow. In a report released yesterday by the House Ways and Means Committee, the GOP accuses AARP of profiting from the law’s cuts to Medicare Advantage, arguing that reductions in the program would “lead seniors to seek supplemental insurance, including Medigap, which AARP endorses and which, the congressmen said, would provide AARP with a bigger take than Medicare Advantage plans it endorses.” Republicans claim that AARP stands to gain $1 billion in fees from the Medicaid Advantage reductions.

But the GOP hasn’t always been so down on the organization. In fact, in 2003, when AARP endorsed the Republican-backed Medicare Part D prescription drug benefit, Republicans praised the organization without accusing it of potentially profiting from the effort:

REP. PETE SESSIONS (R-TX): “What is surprising to hear the Democrat Party lambaste AARP. The AARP is that organization for senior citizens all across the country who I think has made a very wise and careful decision to look at his prescription drug plan and have clearly said GOP is right on the policy and right on what will give long-term success to this nation.” [2003]

REP. BILL THOMAS (R-CA): “[I]f we are trying to destroy Medicare, why is the American Association of Retired People supporting this proposal? Why is the AARP in favor of this bill?…AARP has chosen to be with seniors, and they have chosen to be with us.” [2003]

REP. JOE WILSON (R-SC): “Additionally, I’m happy to be here because of the support of the AARP of the plan which is before us at this time. I’m a member of the AARP and I’m proud of their promotion of the best health plan that they feel can be produced and that’s the bill before of us this week.” [11/21/2003]

REP. PHIL GRINGEY (R-GA): “Thirty-five million senior members of AARP, 330,000 physician members of American Medical Association who are providing care to hundreds of millions of Americans and 40 million Medicare beneficiaries…Mr. Speaker with so many for prescription drug and Medicare modernization benefit for our beloved seniors who could be against it and why?” [11/21/2003]

In fact, the Republican’s own report reveals that AARP began began selling Medicare Part D drug plans after 2003 and saw its revenues nearly triple. The organization maintains that it keeps its insurance subsidiary’s activities separate from its nonprofit work.

ThinkProgress intern Kevin Donohue contributed significant research for this post.

In 2009, Rhode Island accepted a block grant from the Bush administration that capped the amount of federal Medicaid funding it could receive for five years, in return for increased flexibility over the program. Now, as Republicans in Congress look to lower federal Medicaid expenditures, they’re pointing to the state as an example of what block grants can accomplish.

During a February 15th Senate Finance Committee hearing, Sen. Tom Coburn (R-OK) announced that the 2009 block grant has lowered health care spending and suggested that its success could be duplicated elsewhere. “Well, my question for you is if Rhode Island can save 15.8 percent, why don’t we just block grant every State and let them, and take the rules off and let them do these strategies that you’re outlining rather than spending money in Washington telling them what to do,” Coburn asked Secretary of Health and Human Services Kathleen Sebelius, who was testifying before the committee.

The answer to Coburn’s question is simple: if every state received a Rhode Island-type grant, Medicaid expenditures would increase dramatically. That’s because the Bush administration established a cap that was “above what the federal government otherwise was expected to spend” and gave Rhode Island additional federal Medicaid funding to help pay for services it had previously self-financed.

Most states won’t be so lucky. A recent block grant proposal introduced by Rep. Paul Ryan (R-WI) and Alice Rivlin would reduce federal Medicaid spending by $180 billion and establish caps below what the government would otherwise spend. States would receive an annual federal appropriation that would be less than current projected growth of the program and would be forced to, as the CBO put it in examining the Ryan/Rivlin Medicaid proposal, “provide less extensive coverage, or to pay a larger share of the program’s total costs, than would be the case under current law.” The proposal, in other words, shifts a greater burden of funding Medicaid to the states, which would either have to spend more on their Medicaid programs or cut services and eligibility.

Rhode Island’s alleged cost savings, meanwhile, are partly the the result of the Recovery Act and lower than expected enrollment, not block grant funding. From a recent Center on Policy and Budget Priorities (CBPP) report:

The state has received $400 million in additional federal Medicaid funds as a consequence, a level that will reach about $470 million by June 30, when this temporary federal aid ends. These additional federal matching funds — not any savings attributable to the waiver — are the reason that Rhode Island’s state-funded Medicaid expenditures declined in 2009. Rhode Island would have benefited from these savings whether it had a global waiver or not. [...] Rhode Island’s Medicaid expenditures grew more slowly than other states before as well as after the global waiver went into effect, because enrollment in the program has not increased. In the five years preceding the start of the global waiver, combined federal and state spending on Rhode Island’s Medicaid program grew at an average annual rate of only 2.2 percent… In federal fiscal year 2009, which includes the first three quarters that the waiver was in effect, Rhode Island’s spending increased by 3.3 percent over the prior year.

An analysis of how states would have fared under a previous GOP block grant proposal from 1995 concluded that the one-year reduction in federal funding under the block grant would have been so great, that it would have “exceeded federal Medicaid spending on prescription drugs or home and community-based services and would have equaled half of all Medicaid spending on nursing homes.” As a result, “more than 6 million people would have lost Medicaid coverage in 2002″ if states did not make up the difference.

Rep. Michele Bachmann (R-MN) and a small group of conservative House lawmakers are pushing House Republicans to go after all of the mandatory spending in the Affordable Care Act, claiming that Democrats snuck in $105 billion in hidden mandatory spending into the health care law. “This is something that wasn’t known,” Bachmann said on Meet The Press earlier this month. “This money was broken up, hidden in various parts of the bill.”

I’ve argued that this spending had been widely publicized during the health care debate and this morning, Congressional Budget Office Director Douglas Elmendorf admitted that the information was, in fact, widely known:

REP. FRANK PALLONE (D-NJ): We considered a bill that would repeal funding for section 1311, the health insurance exchange planning and establishment grants. Did you know about that funding stream?

ELMENDORF: Yes, Congressman.

PALLONE: Okay, so it wasn’t hidden. What about section 4002, the prevention and public health fund. Did you know about that?

ELMENDORF: Yes, Congressman.

PALLONE: So that wasn’t hidden either. And what about funding for school based health centers? Did you know about that?

ELMENDORF: Yes, Congressman.

Watch it:

Bachmann is still fundraising off the “discovery,” however. “As I continue to fight against President Obama’s far-left agenda in Washington, the liberal left has stepped up their attacks against me,” Bachmann wrote in a March 29th email to constituents. “But, despite these attacks I am committed to…repealing Obamacare, and exposing government corruption like the $105 billion the Democrats appropriated toward funding Obamacare. This was a complete circumvention of the legislative process and I am working stop your tax dollars from being spent on an unconstitutional law.” “That’s why any amount you can donate to my campaign today – up to the $2,500 legal limit – is appreciated,” she added.

The Hill’s Jason Millman is reporting that Joel Ario, who oversees the exchanges for the Department of Health and Human Services, is trying to calm fears that employers would seek to dump their workers into the exchanges once they become operational in 2014. Many conservatives and some employer groups are arguing that the government may be underestimating the shift, but Ario is taking the tact of arguing that if the exchanges provide more efficient coverage, so be it:

“They’ll continue to provide it, and we may wind up with an employer-based system for a long time because exchanges may not develop,” Ario said.

However, if the exchanges prove to be a source for better and cheaper coverage, then employers will be incentivized to scrap their health plans.

“If it plays out the exchanges work pretty well, then the employer can say ‘This is a great thing. I can now dump my people into the exchange and it would be good for them, good for me,’ ” Ario continued.

This sounds right, but it’s worth noting that some economists are predicting that the actual shift will be quite mild, since “firms would need to compensate the workers from whom they remove a current benefit.” In fact, a survey of 2,800 businesses conducted by Mercer in 2010 found that employers are “not likely” to stop providing health insurance coverage out of a reluctance of losing control over a key employee benefit. Massachusetts — which has a much more robust employer requirement than the ACA — actually experienced an increase in employer coverage after reform.

After the first 10 years, the Congressional Budget Office estimates that “the number of people obtaining coverage through their employer would be about 3 million lower in 2019 under the legislation.” Actuaries at CMS estimated that just 1.4 million would move out of employer coverage.

Brett Coughlin of Politico Pro is reporting that House Republicans are reportedly divided about the political wisdom of including Rep. Paul Ryan’s (R-WI) proposal to transform Medicare into a voucher program for future retirees in next week’s GOP budget, fearing that voting to significantly alter the program (and potentially alienate senior voters) makes no political sense if the proposal will go nowhere in the Senate:

Rep. Paul Ryan of Wisconsin, the Budget Committee chairman, and House Majority Leader Eric Cantor are on the deficit-cutting side of the debate. Ways and Means Committee Chairman Dave Camp of Michigan and House Speaker John Boehner are on the other side of the debate, weighing if voting to carve up the Medicare program — only to see it die in the Senate — is worth the political hit, a senior Senate Republican aide and House Republican chief of staff tell POLITICO. [...]

“I see and appreciate where Chairman Ryan — and Majority Leader Cantor — are coming from on this. I also recall the ugly politics in 1995 and 1996,” the Senate Republican aide said. “The challenge is a group of conservative freshmen in the House who are really concerned about the deficit, but who have never had to face a negative reelection campaign.”…Privately, however, Camp is saying — according to the GOP staffers — that he doesn’t see the wisdom in voting on a plan to dismantle Medicare in the House, only to see it die in the Senate.

Coughlin notes that the internal divisions could jeopardize the GOP’s ability to present a unified budget and alienate seniors who have come to depend on the Medicare program. And for good reason. Under Ryan’s plan, new Medicare enrollees would receive an annual voucher they could use to purchase health insurance beginning in 2021. The voucher — which does not keep up with health care costs — would initially be worth an average of $5,900 (in 2010 dollars) and increase to an average of $11,000 in 2010 dollars once all age-groups are phased in.

Seniors, in other words, would pay more. According to this report from CAP, under current law, people with Medicare coverage can expect to pay $2,730 per year ($228 a month) in 2021 for total Part B and Part D premiums. Under Rep. Ryan’s proposal, conversely, new “Medicare enrollees will pay an average of $3,579 for equivalent coverage—a 31 percent increase in their premium for this year.” (See the chart here). As the Congressional Budget has pointed out, “Voucher recipients would probably have to purchase less extensive coverage or pay higher premiums than they would under current law…the federal government would pay [less] for enrollees on a per capita basis, relative to the projections under current law” and “future beneficiaries would probably face higher premiums in the private market for a package of benefits similar to that currently provided by Medicare.”

Republicans have long tried to distance themselves from Ryan’s proposal. Last February, then House Minority Leader John Boehner (R-OH) described the plan as “his,” saying “I know the Democrats are trying to say that it’s the Republican leadership. But they know that’s not the case.” Ryan has even admitted that the proposal has not attracted substantial Republican support. “While I am proud to have 13 House Republicans co-sponsor the legislation, and have been overwhelmed by the support outside the Beltway,” he claimed, “my plan is not the Republican Party’s platform and was never intended to be.”

Jonathan Cohn offers some insight into Gov. Mitch Daniel’s (R-IN) much touted Medicaid reform program (The Healthy Indiana Plan), which Republicans are presenting as the anti-Obamacare success. Cohn explains that the plan — while built on the conservative philosophy that people would use less care if they had more skin in the came — pairs a high deductible health care plan with a health savings account (standard conservative fare) but also includes some rather progressive elements that are also part of the Affordable Care Act:

In some respects, though, the program is not as conservative as its reputation suggests. For one thing, Healthy Indiana applies cost-sharing with discretion. The monthly contributions into the Power Accounts [ vary between 2 percent and 5 percent of income, with the poorer recipients paying a smaller share than the richer ones. And that’s only for people who have incomes. About one-third of the program’s beneficiaries pay nothing at all. The state also regulates the insurers that participate in Healthy Indiana, requiring that they cover preventative care free of charge. These are the sorts of features favored by liberals, most of whom agree there should be some “skin in the game” but worry about placing excessive burdens on the poor and chronically ill.

Still, Healthy Indiana would not meet most liberals’ expectations — because it doesn’t really qualify as adequate insurance. The program doesn’t require coverage of vision, dental or even maternity care. It also has lifetime caps on benefits, the kind that the very sickest patients inevitably reach. “The track record of Healthy Indiana to date does not show that it is a truly affordable, accessible program for all uninsured adults in Indiana,” says Roos, noting that even token financial contributions can be a real hardship.

That last part about adequate coverage is really key because Medicaid spends most of its money on low-income disabled and elderly population who need chronic care and can’t afford to pay for it. Daniels’ approach — like the general conservative principle about high deductible coverage — won’t work for this population and Republicans in the state seem to be exploring ways to bolster the coverage provisions.

So it’s certainly not perfect, but it’s some kind of a start that offers us an important glimpse of how the GOP’s “skin in the game” health care theories operate in practice.

The Hill’s Jason Millman reports that in an effort to undermine the implementation of the Affordable Care Act, Republicans are now questioning whether Secretary of Health and Human Services Kathleen Sebelius has the authority to temporarily exempt limited benefit plans — so called mini-meds — from some of the requirements of the new law:

Republicans have been increasingly critical of waivers granted by the Obama administration to organizations that cannot meet a new mandate to provide at least $750,000 in coverage in 2011. They say the waivers, granted for just the annual limits requirement, are indicative of problems in the law. [...]

But House Republicans with oversight powers say the massive overhaul doesn’t explicitly grant the administration power to provide waivers.

“The entire waivers process is predicated on the ability of the secretary to grant waivers in the first place,” said Rep. Trey Gowdy (R-S.C.), chairman of the House Oversight Health subcommittee. “However, this seemingly fundamental step — the statutory basis for waiving compliance with the law — appears to have been wholly neglected by the plain language of the statute.”

It seems to me that the Secretary’s authority for regulating “annual limits” can be found in Section 2711 of the Affordable Care Act (pg. 33 in this PDF), which states: “a health insurance issuer offering group or individual health insurance coverage may only establish a restricted annual limit on the dollar value of benefits… as determined by the Secretary.” “[T]the Secretary shall ensure that access to needed services is made available with a minimal impact on premiums,” the law says. In other words, it would seem that Sebelius has the authority to determine what constitutes a “restricted annual limit” that can still be imposed before 2014.

And while progressives generally aren’t too crazy about allowing mini med plans — subprime insurance offered to lower wage employees — to skirt important consumer protections, the administration believes that it has to waive certain requirements for specific plans to ensure that individuals are not denied access to needed services or face significantly increased premiums before they have more coverage options in 2014.

The irony here is that conservatives — who have long argued that ACA represents a one-size-fits all approach to health policy — are trying to deny HHS the flexibility to ensure that some plans and beneficiaries aren’t adversely affected by the law’s requirements. (The very requirements they rally against). And, they’re arguing that by taking advantage of all of the provisions in the ACA — including the flexibility it offers — the Secretary is somehow demonstrating that the law is defective.

Under today’s Medicaid program, the federal government pays a fixed percentage of each state’s Medicaid costs (anywhere between 50 and 75 percent, depending on need) and requires states to maintain certain eligibility and benefit standards. Govenors that develop a more innovative approach to paying for health care services may receive a waiver from some of the program’s requirements to pursue other alternatives. Republicans — unhappy with many of the federal strings attached to the federal dollars — have long sought to reform this funding arrangement by transforming the matching-fund structure into a block grant system, under which states would receive set “block” of money to do with it as they wished (within certain constraints).

Last month, GOP governors attending the National Governors Association’s winter meeting pressed President Obama on the idea and according to the Wall Street Journal’s Corey Boles and Janet Hook, Congressional Republicans will likely unveil their own block grant proposal when they reveal their budget next week:

Rep. Mick Mulvaney (R., S.C.) told constituents at a town hall meeting in Lancaster on Thursday that the committee soon would unveil a budget resolution for fiscal 2012 that recommends revamping Medicaid to allow states more latitude in spending federal money.

“We’re getting ready to offer people the first real, substantive discussion on a major entitlement—Medicaid—in my lifetime,” the congressman said.

What Mulvaney describes as “more latitude” and greater state flexibility is really a gigantic cost shift from the federal government to the states. Under their proposal, states would receive an annual federal appropriation that would be less than current projected growth of the program, forcing state governments to make up the difference by increasing spending or (more realistically) capping enrollment, cutting eligibility, limiting mandatory benefits and lowering provider reimbursements.

As the CBO put it in examining Rep. Paul Ryan’s (R-WI) Medicaid block grant proposal: “reducing federal payments for Medicaid relative to currently projected amounts would probably require states to provide less extensive coverage, or to pay a larger share of the program’s total costs, than would be the case under current law.”

It’s the kind of policy that would place Medicaid’s 53 million beneficiaries — the great majority of whom are elderly and disabled — in great danger of losing their coverage and jeopardizing the success of health care reform, which relies on the Medicaid program to expand coverage to some 17 million Americans. And that of course, may be the very goal of proposing it.

Sen. Ben Nelson (D-NE) — who will likely face a tough re-election bid in 2012 — isn’t ready to endorse a specific alternative to the politically unpopular individual mandate, despite asking the Government Accountability Office (GAO) to study alternatives to the provision. In a press release commenting on the release of that analysis, Nelson said the report “identifies options to consider” but cautioned that the mandate is “necessary to maintain the ban on pre‑existing conditions” and keep costs down:

“The GAO report makes it clear that if the individual mandate is struck down by the Supreme Court, insured Americans will again have to pay both their costs and also pay the costs for the uninsured, which totaled $57 billion in 2008,” said Senator Nelson. “Nebraska families and businesses can’t afford to pay to insure their families and pay the costs of the uninsured, too.

“Without the individual mandate or a successful alternative, the number of uninsured is certain to grow and Nebraskans, as well as all Americans, will pay a hidden tax for their health care of $57 billion each year,” said Nelson. “Washington can consider the GAO’s findings to ensure that everyone pay their fair share, to ban pre-existing conditions and to increase coverage.

“Washington needs to explore the GAO report’s alternatives and others to see if there is a successful way to improve health reform.”

The report itself offers nine alternatives to the mandate without estimating how many people would likely be covered under each option:

- Modify open enrollment periods and impose late enrollment penalties.

- Expand employers’ roles in auto-enrolling and facilitating employees’ health insurance enrollment.

- Conduct a public education and outreach campaign.

- Provide broad access to personalized assistance for health coverage enrollment.

- Impose a tax to pay for uncompensated care.

- Allow greater variation in premium rates based on enrollee age.

- Condition the receipt of certain government services upon proof of health insurance coverage.

- Use health insurance agents and brokers differently.

- Require or encourage credit rating agencies to use health insurance status as a factor in determining credit ratings.

The mandate is designed to encourage individuals who wouldn’t normally purchase insurance coverage to enroll and expand the size of the health care risk pool, thus spreading the costs and risks of insurance across a larger population (and helping bringing down health care costs) This kind of policy has almost eliminated uninsurance in Massachusetts where, 98 percent of residents now have health insurance and is expected to insure 32 million Americans by 2019 as part of the Affordable Care Act.

But limited real-world experience with the alternatives offered above (some of which, like the public campaign, can work in conjunction with the mandate) has made it difficult to estimate how many people would be covered under a different proposal. Last month, MIT’s Jonathan Gruber — who was interviewed for the GAO report — published a paper modeling the auto enrollment and the late enrollment penalties and found that both would fall short of the ACA’s goals. He found that auto enrollment would reach 24 million uninsured — since “only about one-third of the uninsured are actually offered employer-sponsored insurance in which they can be auto-enrolled” — while the late enrollment penalty option would fare even worse, enrolling just 21 million Americans. The GAO details the complexities of each option.

Vulnerable Democrats are understandably interested in seeking viable alternatives, but in doing so they should be mindful of the fact that alternative solutions could reverse the progress made in current law. In talking about these policies they also risk buying into the GOP’s premise that there is something inherently wrong or terribly coercive about asking able individuals to take personal responsibility for their health care expenses. Instead of playing defense, they should be reminding the public of the long history of Republican support for the idea.

As we previously reported, the Vermont legislature, led by Gov. Peter Shumlin (D), has been considering a proposal to establish some sort of single payer health care system, where a single public insurer provides health insurance to all state residents, similar to the Medicare system for American seniors.

Last night, the Vermont House of Representatives debated and approved by a 92-49 a bill that would create a single payer system in the state. Shumlin praised the move as making Vermont the first state where “health care will be a right and not a privilege“:

After hours of debate, the Vermont House of Representatives approved a bill that would create a single-payer health care system in Vermont. It passed 92-49. In a meeting right after the vote, the house speaker, the governor and others who worked on the bill called it a historic moment for Vermont.

“Become the first state in the country to make the first substantive step to deliver a health care system where health care will be a right and not a privilege,” said Gov. Peter Shumlin.

The “bill outlines a four-year timeline leading to establishment of the statewide, publicly funded system. It begins by setting up the Green Mountain Care Board on July 1 with a budget of $1.2 million to begin planning the new system. It then creates a health insurance marketplace — or ‘exchange,’ of the sort required by last year’s federal health care legislation. And it then calls for converting the exchange to the Green Mountain Care system.”

Now that it has passed the House of Representatives, it will move on to the Senate, where it is expected to pass. A bigger hurdle Vermont faces is obtaining a waiver from the federal health care reform act and finding a way around federal ERISA laws — which “pre-empt states from enacting legislation if it is ‘related to’ employee benefit plans — that insurers could use to sue the state. The health reform law currently offers a waiver to states who meet certain standards by 2017; Rep. Peter Welch (D-VT) has introduced an amendment that would move the waiver date up to 2014 — an idea that President Obama has endorsed.

This week, 200 doctors from 39 states including the District of Columbia signed an open letter saying they would seriously consider moving to the state to practice medicine if it enacted a single payer system. “The idea of having one set of rules, one form for billing, and knowing that all patients are covered – that would be wonderful,” said Scott Graham, a Kentucky family physician who signed the letter.

Republicans don’t spend too much time talking about alternatives to the Affordable Care Act, but if they do, they often argue that rather than having the government define a standard package of health care benefits that all insurers must provide, Americans should have the option of purchasing catastrophic coverage (high-deductible “consumer-driven” health care plans) and tax-advantaged health savings accounts. Such plans require consumers to pay $1,000 or more per person for health care before their coverage kicks in, but charge lower monthly premiums and allow policyholders to stow away dollars for medical emergencies.

Here is Sen. John Barrasso (R-WY) advancing the proposal to Obama during the White House health care summit, who in turn argues that catastrophic plans wouldn’t make sense for the vast majority of Americans:

BARRASSO: And, Mr. President, when you say, with catastrophic plans, they don’t go for care until later, I say sometimes the people with catastrophic plans are the people that are best consumers of health care, in using — the way they use their health care dollars. [..]

OBAMA: Would you be satisfied if every member of Congress just had catastrophic care? Do you think we’d be better health care purchasers?

I mean, do you think — is that a change that we should make?

BARRASSO: Yes, I think — I think, actually, we would. We’d really focus on it. You’d have more, as you’d say, skin in the game… [...]

OBAMA: Would you feel the same way if you were making $40,000 or you had — that was your income? [...] [M]embers of Congress are in the top income brackets of the country, and health savings accounts I think can be a useful tool, but every study has shown that the people who use them are folks who’ve got a lot of disposable income. And the people that we’re talking about don’t.

The other problem is that catastrophic-only plans generally appeal to a younger and healthier population and may even discourage those individuals from seeking preventive services, even, as it turns out, when that care is free. A new study of 36,000 families enrolled in high-deductible plans finds that health spending was 14 percent less in the first year than for families with lower deductibles, but — and this is a big one — these families were much less likely to invest in preventive care that could stave off more expensive chronic conditions. This may be because they have more “skin” in the game as Barrasso put it, or because they simply don’t understand the coverage benefits. Applicant were also “typically younger and healthier and lived in areas with higher percentages of college graduates”:

But the percentage of young children receiving vaccinations dropped as much as 8.5 percent in the first year their families were covered by the high-deductible plans, while vaccination rates for children in standard plans rose slightly. And use of cancer screenings was two to three percentage points lower among families with high deductibles.

It’s worth noting that the existing legislation already gives younger individuals the option of enrolling in high deductible plans that cover less services at cheaper rates. Insurers will also be able to price their policies based on age and charge young people rates that are three-times lower than what older (and presumably sicker) applicants will be paying.

But some conservatives have proposed going even further, suggesting that insurers should be allowed to design catastrophic plans outside of the requirements of the law (which mandates policies to provide a set of essential benefits) and the exchanges. You can see how this wouldn’t work. If younger people have an incentive to enroll in cheaper high-deductible coverage, the exchanges will be left with sicker individuals who need comprehensive coverage and use it frequently. Without healthy individuals to offset the costs of this care, premiums will have to increase, pushing out everyone but the sickest and neediest applicants. As a result, the exchanges will become cost prohibitive for most Americans.

Meanwhile, the younger people who are enrolled in the cheaper high deductible policies will find their coverage inadequate once they — as we all inevitably are — fall ill and may be even more likely to do so if they forgo preventive care.

Yesterday, the Republicans on the Energy and Commerce Committee issued a press release (and this analysis) in which they claimed to have discovered “a $5 billion bailout fund for state governments, Fortune 500 companies, and Hollywood unions”:

So what is this mysterious $5 billion bailout? Known as the Early Retiree Reinsurance Program, it provides federal dollars to employers and unions that provide health coverage to early retirees. Like many provisions and accounting gimmicks in the health care law, it has largely escaped public scrutiny because of the sheer volume of programs and spending crammed into the law without scrutiny or Congressional oversight.

“Escaped public scrutiny” is an exaggeration to say the least. The program was so secretive that it was extensively covered by the press and regularly touted by Democrats as an example of how the Affordable Care Act would help businesses struggling with growing health care spending and prevent companies from dropping early retiree coverage (seniors 55-64 years old who are not yet eligible for Medicare) before the exchanges begin in 2014. Consider:

- NYT headline: Bristling at Health Plan to Cover Early Retirees [9/9/2009]

- NYT: “Reinsurance program for early retirees Both the House and Senate bills would provide federal financing for a new reinsurance program to encourage employers to maintain health benefits for employees and early retirees age 55 to 64.” [12/28/2009]

- The Hill headline: “HHS begins accepting applications for early retiree reinsurance program” [6/29/2010]

- Rep. Carolyn Maloney (D-NY)’s fact sheet: “The Early Retiree Reinsurance Program provides much-needed financial relief for employers, unions and state and local governments so retirees can get quality, affordable insurance. [2010]

Many different businesses and state governments have benefited from the provision, including the Koch brothers, who applied for federal funding despite spending millions of dollars trying to repeal reform. The provision also resembles one passed by Republicans in 2003, which gave subsidies to employers who offered drug coverage to their retirees before the Medicare Part D program went into effect in 2006. As the New York Times explained, the goal then was the same as it is with the early retiree grants today, “to discourage those employers from terminating those programs, which would have saddled the government and seniors with higher costs.”

Some states have adopted similar programs. In 2010, for instance, Minnesota Gov. Tim Pawlenty (R-MN) extended early retirement benefits to state workers.

Greg Sargent is giving Mitt Romney the benefit of the doubt on his support for state-based health care reform, pointing to this quote from a 2007 speech that seems to suggest that Romney has always argued for a state-by-state solution:

A one-size-fits-all national healthcare system is bound to fail. It ignores the very dramatic differences between states and it relies on a Washington bureaucracy to manage. You think about this, I do not want the guys that ran the Katrina clean up running our healthcare system. So in my view, healthcare reform has to take a federalist approach … We let states decide how they craft their own program. States are able to craft programs to match their unique needs and of course we let states remain as the laboratories of innovation. And by the way, I like the plan we came up with in Massachusetts. I wouldn’t be surprised if other states say, `I like that way, I’m going to copy it.’ And I’d be proud if they did. Some states will find they’ve got better answers than what we came up with, and if they do, hats off to them.

Putting aside Romney’s 2009 comments that Massachusetts reform should serve as a “model” for extending coverage to the nation (which Greg reported on yesterday and I’ve written about here, here, and here), I think the more troubling aspect of this quote isn’t Romney’s position, but the false implication that the Affordable Care Act is a “one-size-fits all national health care system” that does not recognize “very dramatic differences” between the states. In other words, even if Romney has been consistent in his stance, his characterization of the law is self-serving and dead wrong.

In reality, while the ACA lays out a certain framework stats have to follow — there is no question about that — it still provides governors with a great deal of flexibility in how they implement reform, allowing each state an opportunity to develop a somewhat unique solution. Even the waivers HHS is granting to some states (but mostly businesses) is an acknowledgment of the fact that states have what Romney describes as “unique needs.” As Tim Jost recently observed on the Health Affairs blog:

The states, for example, have the option of either implementing the health insurance exchanges themselves or allowing the federal government to do so. States may establish their own risk adjustment programs, preexisting condition high risk pools, and excessive premium increase review programs or leave these tasks to the federal government.

The states also have the option of either enforcing the ACA’s basic insurance regulatory reforms (the ban on rescissions, the requirement of coverage for adult children and of preventive services without cost-sharing, and others), or letting the federal government do it. If a state chooses to implement the law itself, moreover, it generally has a great deal of flexibility in the approach it takes to implementation, as we are witnessing currently in the widely varying approaches the states are taking to establishing their exchanges. [...]

The greatest flexibility, however, is provided by section 1332. This provision authorizes the Departments of Health and Human Services and Treasury to waive key provisions of the ACA and to provide block grants in the amount that the federal government would otherwise have spent in a state on ACA tax credits to states that develop their own innovative proposals for reforming health care. Regulations to implement this provision were proposed on March 10, 2011.

So the more honest position would be to drop the pretense of ACA rigidity and propose different ways to allow states even greater flexibility, if that’s what Romney believes would solve the health care crisis. But those kinds of solutions would require actual policy proposals that don’t lend themselves to the candidate’s one-liner zingers and soundbites.

In his editorial yesterday claiming that the his daughter Carey would have been unable to receive a life-saving heart operation under the Affordable Care Act, Sen. Ron Johnson (R-WI) argued that the new law stifles medical innovation and would jeopardize new medical breakthroughs :

I can’t help but reflect on a medical miracle made possible by the American health-care system. The procedure that saved her, and has given her a chance at a full life, was available because America has a free-market system that has advanced medicine at a phenomenal pace. [...]

The plain truth is that the American system is better at rewarding innovation and responding to consumer needs. But the history of government-led care is there for all to see. Are we doomed to repeat it?

America has certainly had its share of medical breakthroughs, but the procedure Johnson’s daughter received may not have been developed in the United States but rather in Brazil or France — nations that now benefit from some form of universal coverage.

According to CAP Senior Fellow (and resident biochemist) Dr. Lesley Russell, it is most likely that the surgery Carey had was first performed and reported in Brazil in 1975, where doctors described their version of the procedure as “the first successful report of total correction of transposition of the great vessels at the arterial level.” Alternatively, Johnson’s daughter may have had what’s known as The LeCompte procedure, which was developed in France in 1981.

Unfortunately for Johnson, both country’s systems seem far more government-centered than the Affordable Care Act. While Brazil’s system has evolved over time, France — which is often thought to have the best system in the world — has compulsory health insurance. Care is distributed through large occupation-based funds—alliances of professional groups—that are overseen by the government (it sets reimbursement fees with physicians and establishes premiums) and financed through taxes and general government revenues.

The GOP’s instance on repealing the entire health care law would, among other things, eliminate dependent coverage for children on their parent’s plan, re-open the Medicare Part D doughnut hole and increase taxes on small businesses currently receiving tax creditits for providing health insurance coverage to their workers. Today, McClatchy Newspaper’s James Rosen reports that the Republicans’ efforts to put political ideology ahead of good policy is also jeopardizing the development of money-saving medical technology:

Dr. David Cull, a prominent vascular surgeon in Greenville, had invented a small valve system that, if it works, could spare 300,000 dialysis patients across the country enormous suffering and save U.S. taxpayers billions of dollars.

But Cull’s hometown senator, Jim DeMint, would not write a letter supporting the surgeon’s application for a federal grant under the landmark health care bill that President Barack Obama signed into law a year ago today. [...] Backing a grant application under the law — even for a constituent who lives in the same Upstate town as DeMint — would leave the senator open to charges of hypocrisy, staffers say.

Cull received the $249,479 grant without DeMint’s support and believes that his device could eliminate the need for dialysis patients to “undergo 10 to 12 operations over a lifetime to treat complications from the stents.” “Such surgeries cost taxpayers a fifth — $15,000 — of the $75,000 a year the federal program pays per person with acute kidney failure.” “This is money … very well spent,” Cull said. “If our valve doesn’t work, the government will have lost $250,000. If it does work, they will have saved a gazillion dollars.”

For DeMint — who regularly criticizes the Affordable Care Act for failing to lower health care costs and rails against “wasteful spending” — to oppose a measure that could save Medicare millions of dollars is at best dishonest and at worst hypocritical. Republicans who maintain that ‘Obamacare’ will ration care and slow the development of life-saving medical devices shouldn’t undercut private innovation that could improve the livelihoods of millions of Americans. That would, in their words, “death panel” the sickest among us.

During a speech at the Center for American Progress Action Fund this morning, Rep. Anthony Weiner (D-NY) predicted that the current make-up of the Supreme Court makes it more likely than not that the individual health insurance mandate will be found unconstitutional and said that such a ruling could build support for bringing back the public health insurance option:

WEINER: If they strike down the mandate, big deal. Big deal! … We pretty much see the direction the Supreme Court is going, although I think that it would be folly to strike it down, I believe this is clearly under the province of the commerce clause, it’s a relatively small number of people. And by the way, the solution if the mandate is struck down is not that the bill falls like a house of cards…the solution is going to be offering something that everyone agrees is constitutional and that’s the public option in the exchange.

Watch it:

As Austin Frakt put it, the mandate may be the price for maintaining a “private” solution to the health care crisis and the health insurers — the biggest opponents of the public –know it. As Mike Tuffin, executive VP of America’s Health Insurance Plans (the insurance lobby) pointed out in July of 2010, “Health care reform is not over. This is the only the end of the beginning,” Mr. Tuffin said. “Whether we like it or not, the bill was passed. Now we must be reliable and effective implementation partners. We need to stay engaged. The single-payer and public-option supporters have not given up,” he warned.

Also, if one were to review the arc of GOP criticisms against the law, the opposition to the individual mandate — at least from Congressional Republicans — did not develop until after the public option had been effectively taken off the table. Recall that while Sen. Orrin Hatch (R-UT) and former Senators Judd Gregg (R-NH) and Bob Bennett (R-UT) all previously supported the requirement, Sen. Chuck Grassley (R-IA) — who played a key role in the bipartisan negotiations within the so-called gang of six — favored the requirement as late as August 2009. Before that time, the crux of the opposition focused on the public option. As it stood on its last leg in the fall of 2009, Republicans developed a new allergy to requiring people to take responsibility for their eventual health care costs. So, the GOP may have created this conundrum and now they’re making the most of it.

Likely Republican presidential candidate Mitt Romney (R-MA) wasted no time denouncing the Affordable Care Act today, the one year anniversary of its signing. The former Massachusetts governor — who signed and still supports a state-based plan that requires individuals to purchase coverage — wrote in the National Review this morning that if elected president, he would work to do-away with the entire law:

“If I were president, on Day One I would issue an executive order paving the way for Obamacare waivers to all 50 states. The executive order would direct the Secretary of Health and Human Services and all relevant federal officials to return the maximum possible authority to the states to innovate and design health-care solutions that work best for them.”

Romney’s proposed action is bold, but it’s also impractical. The executive branch and the Department of Health and Human Services (HHS) don’t have the authority to grant such broad waivers. According to the law, HHS (together with the IRS) have waiver authority, but only if the states meet very specific requirements. Neither have blanket waiver authority, which would have to come from Congress.

The law does offer states a great deal of flexibility, however, allowing governors to implement the health insurance exchanges themselves or letting “the federal government to do so.” “States may establish their own risk adjustment programs, preexisting condition high risk pools, and excessive premium increase review programs” and receive block grants to construct a “basic health program” that would serve a segment of the Medicaid-eligible population. States can also enter into interstate compacts for the sale of health insurance across state lines and by 2017, the federal government may grant waivers for key provisions and provide states with block grants to develop “their own innovative proposals for reforming health care” (so long as the state provides comprehensive and cost-effective coverage).

Sen. Ron Johnson (R-WI) has an op-ed in today’s Wall Street Journal suggesting that his daughter Carey may have died from a heart condition were she treated under the Affordable Care Act. The piece reads like a hit piece from the summer of 2009, when Sen. Chuck Grassley (R-IA) was suggesting that the Affordable Care Act would pull the plug on grandma and Reps. Steve King (R-IA), Louie Gohmert (R-TX) and Virginia Foxx (R-NC) were arguing that reform would literally kill Americans.

A year out, these kinds of arguments sound absurd, and so Johnson is now touting what TPM’s Brian Beutler calls a “retroactive twist on the ‘death panels’ hoax.” From Johnson’s op-ed:

I don’t even want to think what might have happened if she had been born at a time and place where government defined the limits for most insurance policies and set precedents on what would be covered. Would the life-saving procedures that saved her have been deemed cost-effective by policy makers deciding where to spend increasingly scarce tax dollars? [...]

Take cancer as one example. Compared to the U.S., breast cancer mortality is 9% higher in Canada (according to the government statistics of each country), 52% higher in Germany and 88% higher in the United Kingdom (according to studies published in Lancet Oncology). Prostate cancer mortality is 604% higher in Britain. [...]

The plain truth is that the American system is better at rewarding innovation and responding to consumer needs. But the history of government-led care is there for all to see. Are we doomed to repeat it?

Beutler correctly points out that the ‘government will death panel Americans’ meme has by now been thoroughly debunked — the “limits for most insurance companies” that Johnson is referring to are actually coverage minimums that states can expand upon — and notes that Carey or a child in her position could have benefited from the law’s new regulations that already prohibit insurers from discriminating against children with pre-existing conditions and eliminated lifetime and annual caps that often leave families with thousands in medical bills. Had her parents not received employer-based coverage, she could have found insurance in the temporary high-risk insurance pools that 12,400 Americans are now enrolled in and in 2014, her parents could buy a comprehensive family plan through a state-based exchange.

Johnson’s indictment of universal health systems around the world is equally pernicious. The United States does boast some of the best acute care in the world, but as Jonathan Cohn points out, “it’s hard to read the data as indictment of universal health care when the U.S. survival rate on other ailments isn’t so superior.” For example, “The Swedes are more likely than Americans to survive a diagnosis of cervical, ovarian, or skin cancer; the French are more likely to survive stomach cancer, Hodgkins disease, and non-Hodgkins lymphoma. Aussies, Brits, and Canadians do better on liver and kidney transplants.”

Countries with universal care also have better quality, access, efficiency, equity, and live healthier lives. And while health spending in the United States increased at more than twice the rate of countries like Canada, Australia, Italy, U.K., Austria, Belgium, France, Germany, Sweden, Switzerland, Netherlands, and Japan, America 50th out of 223 nations in life expectancy, with an average life span of 78.37 years, according to estimates from the CIA World Factbook. The United States is also “ranked 29th in the world in infant mortality, tied with Poland and Slovakia.” And so, Johnson gets it wrong. The ACA wouldn’t have killed Johnson’s daughter, but thousands of other uninsured babies would have died without it.