Our guest blogger is Topher Spiro, the Managing Director for Health Policy at the Center for American Progress.

Last week Sen. Ron Wyden (D-OR) and Rep. Paul Ryan (R-WI) released the latest proposal to restructure Medicare by providing “premium support” or vouchers to beneficiaries. The plan, as we’ve noted, is problematic. But it also begs the question: can any design of premium support work?

The answer is: probably not.

No version of premium support can achieve real savings without adverse consequences for beneficiaries. Some versions (like Rep. Paul Ryan’s budget) would impose an arbitrary cap on the amount of the voucher, significantly shifting costs to beneficiaries—regardless of their choice of plan. Other versions would make many of those who wish to remain in traditional Medicare pay sharply higher premiums. For these beneficiaries, the choice of traditional Medicare would be a false one in reality.

What’s more, no version of premium support can fully prevent private health insurance plans from attracting healthier beneficiaries, driving up premiums for those who remain in traditional Medicare. And finally, no version of premium support can create a level playing field between private plans and traditional Medicare. As a result of these two factors, more and more beneficiaries would gradually shift to private plans over time.

These risks are too great. Medicare coverage costs less than comparable private coverage, and Medicare is more successful at containing costs per enrollee than private plans. While diluting traditional Medicare would sacrifice these advantages, premium support would provide little benefit in savings because the Affordable Care Act already created a mechanism to limit the growth in Medicare costs.

Find out more about the flaws that are inherent in Medicare premium support here.

During the ABC News GOP presidential debate earlier this month, Mitt Romney promised to repeal the Affordable Care Act, saying, “If I’m President of the United States, we’re gonna get rid of ObamaCare and return, under our constitution, the 10th Amendment, the responsibility and care of health care to the people in the states.”

But Romney hasn’t always supported eliminating the law in its entirety. For instance, as this video uncovered by Andrew Kaczynski demonstrates, in April 2010 Romney was still carefully contrasting Obamacare with the state reform he signed into law as governor of Massachusetts and promised to maintain some of its provisions. “Some similarities, some differences, and I hope we’re ultimately able to eliminate some of the differences, repeal the bad, and keep the good,” Romney said:

At that point, more than a year before he announced his candidacy for the presidency and just one month after Obama signed health reform into law, Romney was still trying to figure out how best to position himself for the nomination. The view he adopted — however briefly — contrasts sharply with what he’s now telling voters on the stump in Iowa and New Hampshire and undermines his efforts to present himself as consistant in his opposition to the law. For instance, it was during this period, during a conversation with conservative blogger Kavon Nikrad that Romney said that while he disagrees with the federal health care mandate, he does not support its repeal:

“You have stated your intention to spearhead the effort to repeal the ‘worst aspects’ of Obamacare, does this include the repeal of the individual mandate and pre-existing exclusion?”

The Governor’s answer:

“No.”

Gov. Romney went on to explain that he does not wish to repeal these aspects because of the deleterious effect it would have on those with pre-existing conditions in obtaining health insurance.

The argument Romney was hinting at in April 2010 is precisely how the federal government is defending the provision in court: requiring everyone to purchase health care coverage prevents individuals from gaming the system (buying health care only when they fall ill), allows individuals with pre-existing conditions to find insurance, and helps reduce cost shifts throughout the health care system.

ThinkProgress has previously reported that in the years before Newt Gingrich announced his candidacy for president, he publicly called for universal health care reform that included a federal individual mandate, risk pooling mechanisms to lower costs for individuals and small businesses, federal subsidies for lower-income Americans, and government investment in electronic health records and comparative effectiveness research. Gingrich’s proposals put a conservative twist on many of the provisions included in President Obama’s Affordable Care Act and were heavily influenced by the corporate clients who participate in the Center for Health Transformation, which until recently served as a hub for his health care ideas.

On Friday, our former colleague Lee Fang unearthed audio conference calls between Gingrich and his corporate clients from 2010, in which the former House Speaker promised to work with Republicans and the health care industry to maintain favorable portions of the law:

Gingrich also spoke on the calls reminding listeners that health reform could be shaped through committees hearings in 2011 and through the repeal-and-replace period in 2012, when (he suggested) a Republican president would take over. Touting his access to the Republican party, Gingrich said he would be advising the congressional leaders as they took aim at the law.

On one call, Gingrich suggested that his clients — each paying as much as $20,000 in yearly retainer fees — would have a role in crafting policy.

“There are clearly things that we’d like to see continued and we’d like to see legislation passed almost concurrently that will sustain the good parts,” said Gingrich, explaining what would happen if the bill were to be repealed. Showing his savvy at generating business, he added that he would “love the help of all of our members in identifying” which parts of reform should remain law. [...]

Gingrich applauded the “rapidly emerging standard of care” that would come with new Medicare reporting patterns prescribed by the law. “I think that those people who understand it and adapt to it, and learn how to use it faster will have a substantial net advantage,” Gingrich advised.

As Fang notes, “Gingrich’s private description of the Affordable Care Act differs dramatically from what he had said to voters publicly. In interviews over the last two years, he has described President Obama’s program as a ‘centralized healthcare dictatorship’ with provisions that ‘would, in effect, be death panels.’ At Republican debates, he said that if elected, he would literally sign the repeal at his inaugural ceremony.”

Gingrich did also indicate that he supported a provision of the law which allows young adults to stay on their parent’s health policies until age 26, telling a town hall crowd in New Hampshire, “That particular piece there is nothing wrong with. I didn’t say there is anything wrong with that. I’m happy to concede out of 2,800 pages, at least 200 are good.” Recent data found that 2.5 million young adults are insured as a result of the policy.

Medicaid, which is funded jointly by the states and the federal government, provides health coverage to approximately 53 million lower income Americans. The federal government helps fund the program by matching state spending on a per-claim basis and paying a percentage of each state’s Medicaid costs (anywhere between 50 and 75 percent). While both parties are looking for ways to reduce spending on the program, the GOP presidential candidates, along with Mitt Romney, have proposed reducing the federal government’s commitment by block granting its contribution and paying states pre-established grants that are indexed over time. Under such a plan, federal spending would no longer reflect the actual costs of the program, particularly during periods of economic recession when Medicaid rolls swell and costs increase.

“Medicaid alone, by being sent back to the states, and growing the funding by inflation — CPI — plus 1 percent a year, will save a $100 billion,” Romney usually says on the campaign trail. But during a rare yesterday, the former Massachusetts governor took his claim one step further, telling Fox News’ Chris Wallace that reducing the federal government’s payments to the safety-net health care program would not undermine beneficiaries because states would use the reduced funds more efficiently:

ROMNEY: I take the Medicaid dollars, send them back to the states, without the mandates as to how they have to treat –“

WALLACE: “But you’re also cutting the budget by $700 billion dollars.”

ROMNEY: “Well what I’d do is I’d take the money, send it back to the states, and say we’re going to grow that funding at inflation, the CPI, plus one percent. By doing that, you save an enormous amount of money. I happen to believe that states can do a better job caring for their own poor, rooting out the fraud and waste and abuse that exists within –“

WALLACE: “But you don’t think if you cut $700 billion dollars in aid to the states that some people are going to get hurt?

ROMNEY: “In the same way that by cutting welfare spending dramatically, I don’t think we hurt the poor. In the same way I think cutting Medicaid spending by having it go to the states run more efficiently with less fraud, I don’t think will hurt the people that depend on that program for their healthcare.”

Watch it:

It’s an ostentatious claim from a governor who reformed the Massachusetts health care system in order to sustain increased federal funding for Medicaid. And while some states could certainly find less painful cuts to Medicaid, a Congressional Budget Office analysis of Paul Ryan’s very similar block granting scheme found that if federal spending for Medicaid decreased, “states would face significant challenges in achieving sufficient cost savings through efficiencies to mitigate the loss of federal funding.” “To maintain current service levels in the Medicaid program, states would probably need to consider additional changes, such as reducing their spending on other programs or raising additional revenues. Alternatively, states could reduce the size of their Medicaid programs by cutting payment rates for doctors, hospitals or nursing homes; reducing the scope of benefits covered; or limiting eligibility,” the budget office concluded. As a result, enrollees could “face more limited access to care,” higher out-of-pocket costs, and “providers could face more uncompensated care as beneficiaries lost coverage for certain benefits or lost coverage altogether.”

Some Republican governors have spoken out against the proposal and condemned additional federal cuts in general. As Nebraska Gov. Dave Heineman (R) indicated in November, states can swallow small cuts, but larger reductions would result in a “cost-shift to the states.” “We know there is going to be a reduction in the Medicaid program. If it’s a small reduction, states are prepared to share in that, we will do our part,” he said. “If it is a dramatic reduction, then it is significantly going to have an adverse impact on state budgets. And when you look at state budgets, there are three big items: Medicaid, the funding we do for the education of our children in K-12 and higher education. So if you dramatically cut Medicaid, you’re going to force us to make dramatic education cuts for our children, that’s not where we ant to go,” Heineman warned.