ThinkProgress filed this report from Oak Creek, Wisconsin.

Rep. Paul Ryan (R-WI) has been telling constituents here in Wisconsin that the GOP’s budget would not change Medicare for Americans over the age of 55, going so far as to say, “in our budget we propose not doing any further cuts to Medicare.” “Our point is, let’s not mess with the current program — and yes it grows fast and it’s costing a lot — but we can cash flow it, if we reform it for the next generation going forward.” Ryan went on to say that his “big concern” was that President Obama’s health care law would cut reimbursement rates for existing Medicare providers and push doctors out of the program:

RYAN: Rick Foster — who’s the guy, the chief actuary of Medicare, I talk to him all the time about this. His concern is — this is the chief actuary of Medicare — that if the IPAB goes through, which is in law, it’s just going to cause more providers to just drop Medicare. It’s just going to cause more and more providers not to take Medicare patients.

Watch it:

But earlier this month, Ryan himself admitted that the GOP budget keeps many of the health care law’s reductions to Medicare — thus opening himself up to criticism that the Ryan budget would also force providers out of business. “We retain the Medicare savings,” Ryan said during an April 6th speech at the American Enterprise Institute.

Providers went along with the reductions in the health care law because they would have received 32 million new customers from the coverage expansion provisions and are now complaining about some of the cuts in Ryan’s budget. “The coverage expansions are rescinded, but the cuts remain,” American Hospital Association President and CEO Rich Umbendstock told The Hill shortly after the GOP budget was released. “The two were coupled in healthcare reform… It’s unacceptable if just the cuts stand.”

Michael McRaith

Incoming Federal Insurance Office director Michael T. McRaith sat down with Kaiser Health News last month to discuss how insurers are using the interim period between passage of the Affordable Care Act and when most of the insurance regulations are enacted in 2014 to increase profits and force the sickest (and costliest) beneficiaries off their rolls:

In this transition period to 2014, insurers are increasingly aggressive with their underwriting, meaning they are increasingly aggressive in denying coverage, limiting coverage or denying or limiting any one claim.

They are using the absence of rate regulation to price out existing policyholders. That is designed to lead to the accumulation of capital, so that by 2014, when insurers have to cover everyone, they’ll be starting from a point of extreme financial strength. [...]

Q: Are you hearing anecdotal stories from consumers?

We sure are. People in the pre-Medicare age have a lot of trouble receiving individual and family coverage. Historically someone in that group would receive an offer of coverage with exclusions. Now we’re finding that person is not receiving an offer.

We’re also hearing from small employers whose premiums are increasing 30 percent to 40 percent. In one case a small business of personal trainers, where the average age was 31 — five of them in a high-deductible plan, and no one in the group met the high deductible — their premiums were increased by 35 percent.

It’s hard to see what the Affordable Care Act does about all of this and it only goes to show that Congress will need to pass additional legislation to control health care premiums (Sen. Dianne Feinstein (D-CA) has a bill that could help do just that). Insurers, meanwhile, attribute the rising premiums to the relatively small costs of the initial benefits of reform, even as they continue to spend more of the premium dollar on profits. A sampling of yesterday’s headlines demonstrates just how well they’re doing:

- HUMANA: “Humana’s shares jumped as much as 7 percent after the company said on Tuesday that first-quarter earnings would be well above its previous forecast, raised its full-year profit outlook and increased its stock buyback plans.”

- BC/BS of Delaware: “As Blue Cross Blue Shield of Delaware pursues a merger it says is necessary to afford capital improvements, it has socked away almost three times more money in reserves than is required by its national association to guard against unexpected events. And its $173 million in reserves are 10 times what state regulators require.”

The point on large reserves is also worth highlighting. Insurers typically try to minimize their profits by arguing that they only make up 4 percent of national health expenditures, but the BC/BS example demonstrates that they have a certain level of discretion in how much they can stow away in a reserve, thereby lowering their “official” earnings. This, by the way, is the industry that Paul Ryan thinks should be in charge of providing health care to our seniors.

Peter Suderman sums up the conservative argument for why Romneycare has failed:

So insurance coverage has increased, but largely thanks to tax-funded subsidization. Yet that’s created problems too: As more people got coverage, the system has struggled to keep up with increased demand for services. Uncompensated care, frequently cited as the justification for ObamaCare’s mandate, has remained expensive as emergency rooms have been flooded. And we’re not even getting into the cost overruns.

All this basically boils down to the claim that increasing coverage results in higher demand for providers and necessitates more stringent cost controls. This is a very valid reality, one that is leading Massachusetts lawmakers, providers, and insurers to continue tweaking the health care system.

But nobody in the Bay State is proposing repealing the expansion in coverage, as conservatives are suggesting. Rather, the legislature is now exploring different delivery system reforms and means of addressing provider shortages to accommodate all of the additional patients. Tossing residents off their insurance coverage may free up providers, but it won’t do much to lower the growth in health care costs or diminish the amount spent on uncompensated or emergency room care. If anything, it would only deepen those problem.

So rather than overstating the problems in Massachusetts — the state has spent nearly $300 million less on uncompensated care since 2006, for instance — and pretending that there is some perfect conservative alternative that would magically heal the system, the state is now looking for ways to realistically address the challenges of reform. Conservatives would be more useful if they proposed actual solutions to these problems.

Tony Carrk and Nicole Cafarella have put out a new report demonstrating why the GOP’s main selling point for the Ryan budget — namely that Americans over 55 years of age will receive the same kind of coverage as members of Congress — is so totally and completely wrong. The basic difference is that the vouchers that seniors would receive in 2022 under Ryan’s plan are pegged to inflation and don’t keep up with actual health care costs. The federal government’s contribution to the Federal Employees Health Benefits Plan (FEHBP) are a weighted average of actual premiums charged in any given year and reflect the growth in health care spending.

Carrk and Cafarella modeled what would happen if members of Congress received a Ryan-type voucher and discovered that they “would have had to pay an additional $3,330.36” for a family plan and $1,555 more for individual coverage:

Seniors would obviously also pay more under the Ryan plan than if they remained in traditional fee-for-service Medicare. The Congressional Budget Office analysis of the Ryan plan has concluded that “[T]he beneficiary’s share in 2030 would be 68 percent under the proposal” but only “25 percent” under current law.

Since the GOP has endorsed Rep. Paul Ryan’s (R-WI) plan to completely privatize Medicare by 2022, some Republicans have abandoned their claim that the Affordable Care Act would lead to single payer government health care and begun arguing that Ryan’s reforms are very similar to the exchange structure in the ACA. “It’s exactly like Obamacare,” said NRSC chairman Sen. John Cornyn (R-TX) in the Capitol several weeks ago. “It is. It’s exactly like it. Which strikes me as bizarre that you’re seeing so much pushback [from Democrats].” TPM’s Brian Beutler points out that House Speaker John Boehner (R-OH) is now making the same argument:

According to Speaker John Boehner, the House Republican budget, which passed on April 15, “transforms Medicare into a plan that’s very similar to the President’s own healthcare bill.”

That’s from an interview with ABC’s Jon Karl. Boehner joins Sen. John Cornyn (R-TX) as one of the few high-profile elected Republicans who will admit that the GOP’s Medicare privatization plan is similar in many key respects to the health care law they have spent the last two years demonizing.

But this isn’t quite right. The Ryan plan — particularly the new Medicare exchange of private plans that becomes operational in 2022 — may structurally resemble the exchanges established by the Affordable Care Act in 2014, but in Obama’s plan the subsidy would not depreciate over time and the exchanges themselves will likely provide more choice and be better regulated than anything the free-market obsessed GOP is envisioning. For instance, Ryan has already said that Americans under 55 will no longer have the choice of enrolling in traditional fee-for-service Medicare and has not yet indicated if — like the ACA — seniors in rural districts will have a guaranteed choice of insurers.

The biggest difference between Ryan’s framework and Obama’s plan is that Ryan would take away coverage and increase costs, while Obama would expand insurance rates and lower personal spending. Under the Affordable Care Act, individuals and families who can’t find affordable insurance in the existing individual market — because they have some chronic condition that insurers don’t think would be very profitable — would finally have a stable source of comprehensive insurance, receive subsidies to help make it more affordable and see limits on annual out-of-pocket spending. Obama also institutes some key delivery reforms to help bring down the overall costs of care.

Ryan, on the other hand, would take seniors out of a single-payer health care system that keeps administrative costs at around two percent and force them to purchase those same benefits, at a higher price, from private insurers with significantly higher administrative spending. Seniors will, as the Congressional Budget Office put it, “spend more for health care,” particularly as their $8,000 voucher fails to keep up with health care costs (even if it is adjusted for income and health status, seniors would still receive less value than the existing Medicare system).

So while it’s a hoot to see the Republicans finally endorsing the Affordable Care Act — they should stop comparing it to the Ryan plan and quit trying to repeal it.

Jonathan Cohn continues his “5 Scary Things About The Republican House Budget You Haven’t Heard” with this piece examining the consequences of raising the Medicare eligibilty age from 65 to 67. Cohn argues that so-called younger seniors will have to maintain their employer-sponsored coverage longer, increasing the costs for the employer and raising premiums:

The change would happen gradually, with the eligibility age rising two months every year, starting in 2022. And, in the grand scheme of things, it’s not like that many people are between the ages of 65 and 67 anyway. But think for a second about who those people are–and the insurance options they’d have available to them without Medicare.

Remember, the House Republican budget would also repeal the Affordable Care Act. That would leave insurance companies free to charge higher premiums, restrict benefits, or deny coverage altogether to individual applicants who have pre-existing conditions. Given the relatively high incidence of conditions like hypertension, arthritis, and vision problems among older Americans, it’s safe to assume many seniors would have trouble finding affordable coverage–if, indeed, they could find coverage at all.

To be sure, pre-existing conditions wouldn’t affect older Americans who could get coverage from large employers, either as current workers or younger retirees. That’s how most “younger seniors” get insurance now. But the addition of so many 65- and 66-year-olds to employer insurance plans would raise benefits costs for businesses and, eventually, their workers.

But nine percent of of seniors between 65 and 66 years of age will find themselves uninsured — they will have a hard time finding coverage in a market which tries to maximize profit by insuring only the healthiest Americans — while another 11 percent would be underinsured, a 2009 study found. This, it’s worth pointing out, would also increase the costs for the Medicare program because the newly eligible population would be entering the program with more chronic conditions and would need to use more care. In fact, a recent study found that “chronically ill people turning age 65 who were previously uninsured had lower spending than insured people prior to Medicare. Yet once on Medicare, these uninsured Americans spent 50 percent more than previously insured Medicare beneficiaries who also had chronic disease.” It’s higher costs all around.

Sarah Palin may have been the first Republican to argue that her son Trig would be harmed by the Affordable Care Act, but potential presidential candidate Rick Santorum (R-PA) is not far behind, telling reporters in Iowa yesterday that his daughter Bella — who was born with a genetic abnormality — wouldn’t survive in a country with “socialized medicine”:

“I look at how society with socialized medicine treats children like Bella, and children like Bella don’t survive,” Santorum told The Des Moines Register Monday, the first leg of a three-day swing through Iowa. “Children like Bella are not given the treatment that other children are given.”

Santorum said the new health care law, championed by President Barack Obama, will mean disabled people are denied care more often, and repealing it is the best way to address mounting national debt.

He said that disabled children are denied care today.

“It’s not like this isn’t happening now,” he said. “But it will happen more under a much more budgetarily-driven health care system.”

Putting Santorum’s willingness to use his child to underscore a partisan point aside, his claims about the health law are almost too ridiculous to be taken seriously. But here it is: the law actually prevents insurance carriers from denying coverage to individuals with pre-existing conditions (and disabilities), prohibits health plans from putting a lifetime dollar limit on benefits and offers new options for long-term care. This why groups like the American Association of People with Disabilities, National Organization For Rare Disorders, and The Arc of the United States not only support the law, but have gone filed an amicus brief in its defense.

The law already prevents insurers from limiting or denying benefits to children, meaning that Bella would be able to find insurance coverage if Santorum loses his job after sufficiently embarrassing himself on the campaign trail.

Since the GOP has endorsed Rep. Paul Ryan’s (R-WI) plan to completely privatize Medicare, some Republicans have abandoned their claim that the Affordable Care Act would lead to single payer government health care and begun arguing that Ryan’s reforms are very similar to the exchange structure in the ACA. “It’s exactly like Obamacare,” said NRSC chairman Sen. John Cornyn (R-TX) in the Capitol several weeks ago. “It is. It’s exactly like it. Which strikes me as bizarre that you’re seeing so much pushback [from Democrats].”

This afternoon, during an appearance on ‘Point of View,’ Gohmert attempted to balance these two completely contradictory arguments by arguing that the ACA would lead to more private competition and a government takeover simultaneously:

GOHMERT: But with regard to Medicare, it actually does what Obamacare does, but it does so far more efficiently. It gives patients far more control and that is it gives money in order to provide what’s needed to buy private health insurance. That would be far better than having the government takeover the health insurance business which is what we’ve been told what we’re all about here with Obamacare.

Listen here:

While there are certain structural similarities between the ACA and Ryan proposals, the GOP budget would move seniors from a comprehensive system into one that is decidedly less efficient and more costly. As the Congressional Budget Office (CBO) has pointed out in its analysis of the Ryan proposal, “a typical beneficiary would spend more for health care….[because] private plans would cost more than traditional Medicare because of the net effect of differences in payment rates for providers, administrative costs, and utilization of health care services.”

Likely presidential candidate Rick Santorum (R-PA) tried to shore-up his conservative credentials yesterday by telling Fox News Sunday’s Chris Wallace that he should have voted against the Medicare prescription drug bill in 2003 because the measure was not paid for. “I would say that that was a mistake,” Santorum said. “We did two things that were wrong in the bill. Number one we made it universal…number two, we should have paid for it.”

But Santorum praised the measure as recently as February 2011, when, during an appearance on Fox News, he called the law “a good allocation of money” and even went so far as to defend Republicans for creating the now infamous Medicare doughnut hole of coverage:

SANTORUM: They got an expansion of the Medicare Prescription Drug Program, but that program was designed to do two things: take care of seniors who were poor and needed drug coverage and those who are high users of prescription drugs. It did both. It left a little hole in the middle for those, who frankly could afford to do it. And that was a good allocation of money.

Watch it:

Little may be in the eye of the beholder. Under the Medicare Modernization Act of 2003, enrollees enter the doughnut hole when their total drug spending equals $2,830 and receive no Medicare coverage until they reach $6,440 in total drug spending. Almost three and half million, or 26 percent, of Medicare Part D enrollees reached this coverage gap in 2007 and those who couldn’t afford to pay for their medications stopped taking medicines altogether.

Santorum’s positions may be a bit all over the map, but they all point in one direction: less benefits for seniors. He is now running on a platform that says: fewer seniors should benefit from prescription drug coverage and that today’s Medicare program should be radically restructured so that seniors have to buy coverage from a private health insurer.

Last week, Mississippi Governor and potential presidential candidate Haley Barbour (R) — who vigorously opposes expanding the state’s Medicaid program — tried to minimize his state’s health care access crisis by arguing, “There’s nobody in Mississippi who does not have access to health care.” Barbour maintained that hospitals and doctors routinely provide charitable care and said that residents without reliable access to health insurance received care from clinics.

Barbour may be technically correct — the 1986 Emergency Medical Treatment and Active Labor Act requires hospitals to treat emergency conditions — but as Aaron Carroll and Austin Frakt of the Incidental Economist point out, the emergency room is not a good place for patients with chronic conditions:

Over 25 million people in the United States have diabetes, requiring regular access to medication to stay alive. They can’t get insulin in an emergency room. They can’t get needed eye exams or kidney function tests in the emergency room. They can’t get a checkup in the emergency room. But once they go into hypoglycemic shock or once their feet become gangrenous, then they can get examined and treated. Does that sound like access to health care?

About 20 million people in the United States have asthma. They can’t get their prescription refills in an emergency room. They can’t get the equipment then need, like nebulizers or inhalers or spacers in an emergency room. They also can’t get checkups in an emergency room. Once they have an attack so bad that they could die they can get examined and treated, but that’s not access to health care.

Over 200,000 women were diagnosed with breast cancer in 2010. Not a single one of them could get a mammogram in an emergency room. Over 140,000 people were diagnosed with colorectal cancer in 2010. Not a single one of them could get a colonoscopy in the emergency room.

Nearly one in 100 children have Autism, and not a single one of them can get any treatment at all in the emergency room. More than 5 million children have attention deficit hyperactivity disorder (ADHD), and not a single one of them can get any treatment at all in the emergency room. Around ten percent of all children may qualify for interventions for developmental delay, but few get them, and not a single one of them get them from an emergency department.

Americans often think of health care as acute care — you have a condition that requires emergency surgery, so you go into one of the country’s state-of-the-art health centers and undergo the needed procedure. Most of health care is far more simple. It’s not about complex surgery or fancy technology: it’s about keeping patients healthy, managing their chronic conditions so they don’t worsen, and preventing them from needing that surgery in the first place.

You can’t find that kind of care in an emergency room, particularly when the availability of good emergency room care is in decline. In 2006, 119 million visits were made to ERs, up from 90 million in 1996. At the same time, the number of hospital ERs dropped to fewer than 4,600, from nearly 4,900, causing wait times to also increase.

CMS Head Don Berwick

Republicans have spent the lat two years going after CMS head Don Berwick for allegedly trying to ration care and establish some sort of centralized health care system, but now the man the GOP has labeled Obama’s ‘Health Rationing Czar‘ is telling Politico’s Jennifer Haberkorn that Rep. Paul Ryan’s (R-WI) proposals to voucherize the Medicare program and block grant Medicaid would withhold care from people:

“It is paradoxical really that with all this talk of rationing, the proposal we hear about how to fix American health care is to take it away from people. That’s from the very people who are crying rationing,” Don Berwick, the administrator of CMS, said in a wide-ranging interview with POLITICO. “If you look at the proposed withdrawals of support to Medicare beneficiaries and Medicaid, it’s withholding care from the people who need the care. You tell me what that is?” [...]

“When I read proposals for reform that say, ‘Sorry kid, you’re on your own,’ that’s the not the country I want to be in,” he said. “And I don’t think that’s the country the public wants to be in.”

In particular, he said the idea of block-granting Medicaid — an idea endorsed by most of the likely Republican presidential nominees — has short-term attraction as governors deal with crushing budgets but is “unsound” in the long-term.

“Block grants are throwing the states out on their own,” Berwick said. “If we block grant and the next immense influenza epidemic arrives or a major recession comes back, what do we say? ‘Sorry states, you’re on your own?’”

It’s worth noting that the Affordable Care Act also cuts Medicare, but those savings would slow the growth in the program by removing approximately $500 billion from future spending over the next 10 years. It eliminates overpayments to private insurers and slowly phases-in payment adjustments that encourage providers to deliver care more efficiently. The law also gives Berwick and his agency greater discretion to experiment with alternative payment systems — so that providers are compensated for delivering care more efficiently, rather than just ordering more tests — and establishes an innovation center for payment reform.

In other words, the ACA eliminates the inefficiencies in the health care system without sacrificing guaranteed benefits. Ryan, on the other hand, keeps a lot of the waste in the system and simply cuts the federal contribution to Medicare, passing on more of the cost of coverage to seniors without looking at ways to make the program more efficient. He would force Americans under 55 years of age into less efficient private coverage and would then leave it up to those insurers to deny treatment and benefits.

Gov. Scott Walker (R-WI) is no fan of President Obama’s Affordable Care Act. Upon taking office, Walker “authorized Republican state Attorney General J.B. Van Hollen to join a multi-state lawsuit attempting to overturn it” and replaced his predecessor’s “Office of Health Care Reform” with his own “Office of Free Market Health Care” and tasked it with exploring “all opportunities and alternative approaches that would free Wisconsin” from creating a health insurance exchange.

Walker has now launched a website for the Office “seeking stakeholder input on the design of a potential Wisconsin Health Insurance Exchange.” But click on the “Health Insurance Exchange” tab and you might see the unexpected: Walker touting the federal grant dollars his state has accepted from the very health care law he sees as unconstitutional and is working to oppose:

Walker isn’t the only Republican who is trying to undermine the law while accepting some of its funding. While a number of states are now sending back their federal grants, many continue to accept dollars from Washington even as they complain that the funding is usurping state sovereignty.

As more Republicans continue to distance themselves from Rep. Paul Ryan’s (R-WI) plan to voucherize the Medicare program, likely presidential candidate Newt Gingrich posted a Facebook message on Wednesday suggesting that he too would stop short of Ryan’s proposal to force Americans currently under 55 years of age into private coverage beginning in 2022:

On entitlement reforms, Paul Ryan has offer his “Path to Prosperity” budget plan which stands in stark contrast to the 2012 budget proposed by the White House earlier this year. [...]

One option is for Congress to move towards a 21st Century personal Medicare system that would allow seniors to choose, on a voluntary basis, a more personal system with greater options for better care.

His language is vague, but it sounds like Gingrich is suggesting that seniors should have a choice of staying in traditional fee-for-service Medicare or opting for private coverage from the new Medicare Exchange. Under the Ryan plan, beginning in 2022, new retirees would have to enroll in a private plan, while those currently over 55 could leave traditional Medicare and opt into the private Medicare exchange. That kind of movement could lead to adverse selection against traditional Medicare and increase costs for beneficiaries in that program.

Gingrich’s modification would likely have the same effect. Seniors would now have a choice between traditional and private coverage, but private insurers — driven by a fiduciary responsibility to increase returns for their investors — would design policies that attract a healthier segment of the Medicare population by either advertising certain health benefits (like gym memberships) or under promoting others (like cancer treatment) that would enlist sicker applicants. As a result, healthier beneficiaries would gravitate towards those private plans, increasing the costs for sicker individuals who need a broad range of services. According to researchers at the Kaiser Family Foundation, this would “result in a large erosion of the Medicare fee-for-service program,” despite government attempts at adjusting for risk selection. Seniors would experience higher costs, even as their voucher continues to depreciate.

During last night’s heated town hall, Rep. Lou Barletta (R-PA) took a principled stance against employing harsh rhetoric to “scare” seniors about the future of Medicare. Describing Paul Ryan’s plan for Medicare, Barletta said, “So whatever you hear, that seniors are going to lose their benefits, I’m telling you right now, it’s an outright lie“:

BARLETTA: This plan does nothing to affect anyone 55 years and older and I honesty, when we start doing things to scare senior citizens, when politicians do that to get elected, I believe they need to find a different occupation. Because if this is what you need to do to get yourself elected and to keep that job, I don’t believe you deserve that job.

But in his campaign against then-Rep. Paul Kanjorski (D-PA), Barletta relied on the very same kind of fear mongering rhetoric he now condemns to scare seniors about the cuts to Medicare in the Affordable Care Act. “[T]here are 165 provisions relating to Medicare in the healthcare reform law. These changes aren’t just going to affect future generations – they’re going to affect today’s senior citizens and near-seniors,” Barletta’s campaign website states. “Paul Kanjorski voted FOR this healthcare bill. He voted to cut Medicare by $500 billion, and he voted for all of the changes that will dramatically worsen the health care that seniors receive.” Barletta even used this catchy ad to attack Kanjorski, arguing that seniors would have to “dig deeper” into their pockets to purchase coverage. Watch it:

In reality, the health law does not cut the current Medicare budget, but slows growth in the program by removing approximately $500 billion from future spending over the next 10 years. The changes help stabilize the program by eliminating overpayments and slowly phasing in payment adjustments that encourage providers to deliver quality care more efficiently. As a result the law extends the life of the Medicare trust fund by 12 years and allows seniors to retain all of their guaranteed Medicare benefits.

Yesterday, Scott Keyes reported that Rep. Paul Ryan’s (R-WI) effort to sell his budget proposal was not going over well with conservative constituents in his district. During a town hall meeting in Milton, attendees booed Ryan for rejecting the notion that the top income earners should be taxed more.

Last night, Rep. Lou Barletta (R-PA) received a similarly hostile reception from constituents during a public forum in Carbon County, as he tried to (incorrectly) reassure the group that Ryan’s budget would not affect the Medicare benefits of those over the age of 55. “This plan does not do nothing to affect anyone 55 years or older,” he said. “When we start doing things that scare senior citizens, like politicians do that to get elected, I believe they need to find a different occupation.” But before Barletta could continue, 64-year-old Linda Christman raised her hand and argued that those under 55 would see an erosion of benefits. The exchange became heated as other constituents began yelling for the woman to “sit down“:

CHRISTMAN: “Excuse me, I’d like to get something off my chest. And that is, you seem to think that because I’m not affected I won’t care if my niece, my grandson, my child is affected. I do care. And what you’re doing with this Ryan budget is you’re taking Medicare and you’re changing it from a guaranteed health care system to one that is a voucher system where you throw seniors on the mercy of for-profit insurance companies. [...]

BARLETTA: “Well, I won’t destroy Medicare, Medicare is going to be destroyed by itself. You’re….”

CHRISTMAN: “I have a great way for you…”

CROWD: “Let him talk….Sit down!…Let him talk! SIT DOWN!”

MAN: “I agree with her. And you know what? Why don’t you tell me to sit down?!”

CROWD: SIT DOWN!

MAN: “She’s an American citizen….Why don’t you show some manners and shut your mouth and let her talk…Why don’t you grow up and stop acting like a bunch of little boys?”

Listen:

Under the Ryan plan, Americans under 55 would have to purchase coverage from an exchange of private insurers, which would receive a government voucher that depreciates over time. As the Congressional Budget Office (CBO) has pointed out in its analysis of the Ryan proposal, “a typical beneficiary would spend more for health care….[because] private plans would cost more than traditional Medicare because of the net effect of differences in payment rates for providers, administrative costs, and utilization of health care services.” “Second, the government’s contribution would grow more slowly than health care costs, leaving more for beneficiaries to pay.”

Seniors over 55 could also see changes in their traditional Medicare plans after 2022. Since those currently over 55 would be able to enroll in private coverage, insurers would have an incentive to lure away the healthiest beneficiaries (creating what’s known as a death spiral) and health care providers could abandon traditional Medicare patients for the higher reimbursement rates of private insurers.

David Gorn reports that The California Health Benefits Exchange board met for the first time yesterday, “the initial big step toward implementing the first reform-prompted insurance exchange in the nation.” In October, California became the first state to establish health care exchanges under the Affordable Care Act, following a Massachusetts’ approach of allowing the Exchange to bargain with insurance companies on behalf of consumers.

At yesterday’s meeting, the all-volunteer board selected an interim chair of the exchange board, an interim administrative director, and appointed a search and recruitment committee to find an executive director. Board members also stressed the importance of ensuring that the Exchange serve as an active purchaser of health insurance, emphasizing the need for “choice, value, and service.” The Exchange will be able to negotiate prices for a large volume of individuals and secure the kind of group discounts that large employers now enjoy. Like the exchanges operating in Massachusetts, California will have the authority to exclude inefficient insurers from the market and require issuers to meet certain minimum standards.

“The success of the Exchange will depend in large part on it’s ability to build on California’s history as an active purchaser in other areas of health and importing that experience to the exchange,” Peter Harbage — a health policy expert who attended the meeting — told me, stressing that California is in fact the only state that selectively contracts with hospitals through its Medicaid program. Harbage estimates that this kind of bargaining has saved the sate approximately $15 billion since 1982. “The exchange is a chance to build on that history and find ways to create an even more effective purchaser,” he said.

Progressives see California’s Exchange as model for the nation, but whether other states will adopt the active purchaser structure will likely depend more on political ideology than past models of success. While blue states may follow California’s lead, red states will most certainly prefer the approach championed by Utah, where consumers can compare a wide variety of health plans sold by any insurers that want to participate. Health advocates have dubbed Utah’s exchanges a “flee market,” in which customers are overwhelmed by a myriad of options — many of which provide inefficient or poor quality coverage. It “would be like telling your grocery store they have to offer every single kind of bread baked by every single bakery,” Jon Kingsdale, the former director of the Massachusetts Connector Authority has said. “The Exchanges would be nothing more than an automated Yellow Pages.”

With the overwhelming majority of Americans saying they oppose Rep. Paul Ryan’s (R-WI) budget, Steve Benen has a good post reminding us that it was just last year “when Republicans decided that opinion polls are the single most important factor policymakers should consider, especially when dealing with controversial changes to the status quo.” Here they were arguing that President Obama should drop reform because the American people oppose it:

- SEN. JOHN CORNYN (R-TX): “The American people don’t want this bill, but our Democrat friends seem determined to jam it down their throat regardless, and I think there are going to be some very serious consequences.”

- SEN. LAMAR ALEXANDER (R-TN): “The American people thoroughly reject it. So, if [President Obama] is listening to the American people, they’ve said no to his bill.”

- SEN. JOHN MCCAIN (R-AZ): “The American people are very smart. That’s why two thirds of them want either stop or start over.”

- REP. ERIC CANTOR (R-VA): “What we are trying to do is find out why the president wants to continue to ignore the American people.”

Now they’re ignoring public opinion that’s far harsher than the opposition to the Affordable Care Act:

- 80 percent oppose cuts to Medicare or Medicaid, including 73 percent of Republicans and 75 percent of Independents. [McClatchy-Marist poll]

- 68 percent of Americans say the proposed GOP cuts unfairly favor some groups more than others. And seven in ten also believe the Republican budget will affect their families. [CNN]

- 65 percent oppose turning Medicare into a voucher program and if they’re told that the cost of private insurance for seniors will increase, 84 percent of Americans oppose the plan. [Washington Post/ABC News poll]

Recall that after the election, Senate Minority Leader Mitch McConnell (R-KY) outlined his party’s priorities in the aftermath of a strong showing in the midterm elections. “Republicans have a plan for following through on the wishes of the American people,” he said in a speech titled “Listening To The People Who Sent Us Here.” It starts with gratitude and a certain humility for the task we’ve been handed. It means sticking ever more closely to the conservative principles that got us here. It means learning the lessons of history. And, above all, it means listening to the people who sent us here. If we do all this, we will finish the job.”

As the GOP steps up its attacks against the Independent Payment Advisory Board (IPAB) — a 15 panel commission that would make recommendations for lowering Medicare spending to Congress — Matt Yglesias suggests that the very same Republicans who argue the IPAB would ration care are “the very same members of congress who voted this month to privatize Medicare in 2022 and enact draconian cuts throughout the 2020s and 2030s are here in town right now defending health care providers’ right to charge the government high prices for services that don’t work.” But now, some Democrats are also distancing themselves from the IPAB, arguing that the board’s structure — its cuts would go into effect unless Congress acts — usurps Congressional authority. Jonathan Cohn has those details:

But now some Democrats are joining the calls for repeal, as Jennifer Haberkorn first reported in Politico last week and as Robert Pear notes today in the New York Times. The IPAB was never particularly popular with more liberal House Democrats, who didn’t want to cede power over Medicare to another authority. But, at least for the moment, opposition is coming from a different part of the caucus. The Democrat leading the charge against the IPAB right now, for example, is Allyson Schwartz, a self-proclaimed New Democrat who represents the northeastern Philadelphia and the nearby suburbs.

Why does Schwartz want to get rid of IPAB? In a letter announcing her intentions, Schwartz said it was undemocratic to hand over that authority to a commission. And that’s a legitimate (if, in my view, unpersuasive) argument.

So Republicans are claiming that the board will ration — even kill — seniors, while Democrats are suggesting that Congress can do a better in controlling health care spending. I would argue that both are wrong. As to the GOP’s argument, the board kicks in if health care spending increases beyond a specific threshold and is specifically prohibited from rationing. The IPAB’s recommendations cannot “include any recommendation to ration health care, raise revenues or Medicare beneficiary premiums…increase Medicare beneficiary cost- sharing (including deductibles, coinsurance, and co- payments), or otherwise restrict benefits or modify eligibility criteria,” Section 3403 (page 409) of the Affordable Care Act stipulates.

As to the Democratic criticism, I would argue that it’s far better to have representatives of the various stakeholders in health care — drug companies, hospitals, doctors, patients — (all of whom are nominated by the president and confirmed by the Senate) making these decisions in a transparent, public, and accountable manner and then submitting their plan to Congress for a vote, than resting the cost-cutting powers in the hands of politicians and lobbyists who will undoubtedly reach their decisions without any kind of public input.

The Boston Globe’s Christopher Rowland looks at why Mississippi Governor and potential presidential candidate Haley Barbour (R) is so vigorously opposed to expanding the state’s Medicaid program, which could result in “new Medicaid benefits flowing to 300,000 to 400,000 Mississippi residents.” In a phone interview with the paper, Barbour made it clear that he doesn’t believe that the state — which has an 18 percent uninsurance rate, 28 percent poverty rate and suffers from very high instances of obesity and chronic diseases — is experiencing a health access problem. Residents just need to eat better and exercise, he maintains:

“There’s nobody in Mississippi who does not have access to health care.” … Hospitals and doctors in the state routinely provide charitable care, he said. Residents also can get care from clinics such as the one by the side of Route 49 in Yazoo City, as well as larger and better-equipped community clinics scattered around the state. And Barbour pointed to his efforts in the Mississippi Legislature, unsuccessful so far, to win passage of a voluntary insurance exchange where small businesses and individuals could shop for insurance at discount rates. [...]

“Most of the health disparities in Mississippi are not because of the inability to get access or afford health care,’’ said Barbour. “They are because of diet, alcohol, because of drugs, the very high incidence of illegitimacy that leads to high incidence of low-birth weight children.

“I grew up in a society where if it wasn’t fried you were asking, ‘Why not?’ If it was good you would make it even better with a lot of sugar and butter on it.’’

He added that substance-abuse prevention and encouraging healthier diets do not require a massive expansion of Medicaid.

An ounce of prevention is worth a pound of cure, but expanding access to coverage would actually improve access to preventive services and help tackle the high instances of chronic conditions in the states. In fact, the health law actually provides enhanced Federal Medicaid matching funds to States that offer evidence-based prevention services.

What baffles providers in the state is why Barbour is turning down a deal under which the federal government — because of the expansion to Medicaid under the Affordable Care Act — “will pick up 100 percent of the cost of the Medicaid expansion from 2014 to 2016 and 90 percent of the cost after 2020.” It’s true that the state will have to spend extra dollars to cover the expanded population, but those services are worth paying for in a state where many people “earn too much to qualify for Medicaid but not nearly enough to purchase private insurance” and go without needed medical care. Barbour estimates that the state’s share of expanding the Medicaid eligibility umbrella, “while starting at zero, could climb to as much as $237 million a year by 2020 — when the state would have to start picking up 10 percent of the cost.” That’s a good investment — a tiny share of the total price tag — and well worth it for the benefit of expanding access to care for hundreds of thousands of residents and reducing the heavy costs of uncompensated care that hospitals and doctors now have to provide.

In fact, it’s far more sensible than the current system in which every resident of Mississippi has access to care in the emergency room. Barbour is right on that point, but he can’t possibly think that having uninsured individuals flock to the emergency room for something that could have been handled in a primary care setting or addressed through preventive care is a smart or efficient use of taxpayer dollars.

At least two Republicans are on record condemning the Medicare reforms in Rep. Paul Ryan’s (R-WI) proposal and now former Wisconsin Governor and Health and Human Services Secretary Tommy Thompson is also weighing in against the GOP’s plan to voucherize the program. In an op-ed for the Huffington Post, Thompson writes that while encouraging seniors to have “more skin in the game” should be part of the dialogue, policy makers need to focus on changing the incentives in the system to encourage providers to deliver care more efficiently rather than simply cutting the program:

The good news is that we don’t have to wait to begin to realign physician incentives. The Affordable Care Act gives great discretion to the CMS Administrator to experiment with alternative payment systems. CMS has created an “innovation center” and is looking for ideas. I believe the administration should use its discretion to begin to experiment with capitated payment, where one fee is paid for a patient episode of care, regardless of how many procedures are performed. [...] House Budget Chairman Paul Ryan (R-WI) is leading an important conversation about how to develop a system that would encourage consumers to put some skin in the game. [...]

Simply cutting Medicare isn’t the answer by any means. Instead, let’s focus on the most effective fiscal path forward with the least amount of impact on millions of seniors, their families and our broader economy. In other words, reform Medicare, don’t cut it.

Ryan has taken a lot of heat for failing to find health care savings from within the health care system and instead slashing the federal contribution to the program and shifting the extra costs onto seniors. The Congressional Research Service (CRS) reports that it’s unclear if Ryan budget would protect the parts of the law that Thompson is trumpeting, those “that would test various patient care models including accountable care organizations,” but Republicans have previously voted to repeal those provisions.

This isn’t the first time Thompson — who Sen. John McCain (R-AZ) has dubbed “the smartest guy on health care” — has broken with traditional GOP orthodoxy. In November 2010, Thompson said Republicans shouldn’t repeal the entire Affordable Care Act. “When it’s all said and done, you’re not going to be able to repeal health care because President Obama is not going to sign it,” he said. “[T]he overall health care is going to have take a wait-and-see attitude before all the rules are done and drafted.”