Yesterday, on “CNBC’s Morning Joe,” Paul Ryan claimed Alice Rivlin, Clinton’s OMB director, as an ally: “Alice Rivlin and I designed these Medicare and Medicaid reforms” he announced.  “Alice Rivlin is a proud Democrat at the Brookings institution. These entitlement reforms are based off of those models that she and I worked on together.”

I have followed Rivlin’s career since her days in the Clinton administration, and always admired her intelligence, honesty and integrity. To say that I was dismayed to hear that she had teamed up with Ryan to endorse his plan to end Medicare is an understatement.

But last night, Politico.com’s Meredith Shiner reported that in an interview with POLITICO, Rivlin revealed that she has told Ryan that she “cannot support the final version of the [Medicare] measure” that he has been advocating .

“We talked fairly recently and I said, ‘You know, I can’t support the version that you have in the budget,” Rivlin told POLITICO. “I don’t actually support the form in which he put it in the budget.”

When informed that Ryan had used her name to advocate his plan, Rivlin replied: “That’s not quite fair. We had worked together but the version that’s in the budget resolution is not one that I would subscribe to.”

She went on to explain that a plan that she would back would “let seniors have the choice between keeping their current form of Medicare or choosing to enter the [private insurance pool that Ryan calls for.] “I prefer keeping the old version as a choice,” Rivlin said.

POLITICO reported that “The other main difference is in the rate of growth in subsidies for beneficiaries entering the new exchange system: “In the Ryan version, he has lowered the rate of growth and I don’t think that’s defensible,” Rivlin declared. “It pushed too much of the cost onto the beneficiaries.” 

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The “Path to Prosperity” budget proposed by House Budget Committee Chairman Paul Ryan (R-WI), includes a plan to revamp Medicaid —which currently provides federal funding to states on an "as-needed" basis to help cover the health care costs of the poor and disabled—into a block grant program. This one initiative alone, according to the budget bill’s supporters, would save $750 billion over ten years.

There is little in Ryan’s budget proposal to support just where these savings will come from, but it’s easy to imagine that state caps on Medicaid enrollment, cuts in covered benefits and lowered physician reimbursement, along with an increase in co-pays for beneficiaries will all play an essential role.

Currently, the federal government contributes an average of 57% toward state Medicaid programs ( this ranges from 50-70% depending on a state’s federal matching rate.) There is no cap or ceiling on how much federal funding is available for the health care costs and long term care services provided through Medicaid, nationwide or for any particular state. The Congressional Budget Office predicts that the program will cover 69.5 million Americans this year, including nearly one in three children, with the recession driving many previously middle-income kids into Medicaid and CHIP. Under the Accountable Care Act, in 2014 Medicaid will undergo a significant expansion to include all the non-elderly who live at or below 133% of the poverty line, including some 16 million previously uninsured Americans.

Under the Ryan budget proposal, the health reform law would be repealed—and with it would go the federal funding that would finance some 96% of the cost of this expansion. Block grants require that the federal government pay each state either a fixed dollar amount or cap payments at a specific level, with the state responsible for all Medicaid costs that exceed the cap. If Medicaid costs rise due to increases in enrollment, economic recessions, or even health epidemics like HIV/AIDS, the federal share would remain the same.

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At last, someone is announcing a Health Information Technology (HIT) initiative that opens the door to efficient, secure IT systems that will be able to talk to each other nationwide. At some point in the not-too-distant future, if you live in Pennsylvania and are in a terrible car accident in California, a Kaiser hospital on the West Coast will be able to tap into your medical records at Geisinger and capture information about your medical history, allergies to certain medications, and other critical information in less than a minute.

Already, thanks to the steps that Kaiser Permanente in California has taken, if you live in the San Diego area, are admitted to a Veterans Administration (VA) hospital, and visit your Kaiser physician when you are discharged, with your permission, he can view your VA records, finding all of the information he needs about results from tests done at the VA hospital, what drugs VA doctors prescribed, and recommendations for follow-up treatment.

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Below, a Kaiser Health News column by John E McDonough, a professor at the Harvard School of  Public Health and a former staff member at the U.S. Senate Committee on Health, Education, Labor and Pensions. I agree with McDonough: health care reform is happening, and it is “energizing the U.S. heealth care system–driving the most vibrant reform atmosphere ever.”

As reform becomes a reality, it becomes harder to repeal. This makes the debate in Washington become less and less relevant. The only major threat to reform: the possibility that a anti-reform president will be elected in 2012.  But by then, so many pieces of reform will be in place that it will be very difficult to eliminate benefits that are helping American families.

I disagree only one point: #7.  I’m afraid we’re in the middle of a double-dip recession. On the other hand, a weak economy makes it all the more apparent that we need health care reform.

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Representative Paul Ryan (R. Wisconsin) thinks he has found a solution to Medicare inflation. 

The cost of Medicare has been spiraling for years, thanks to the climbing cost of virtually every product and service in our health care system.  In other sectors of the economy, competition brings prices down. But when it comes to healthcare, each year, we pay more for virtually every test and treatment. Meanwhile, doctors and hospitals do more. Inpatients stays are shorter than they once were, but as Dartmouth’s Dr. Elliot Fisher puts it “more happens to you while you’re there.” 

Now, finally, we have health reform legislation that is designed to rein in costs by changing how we pay for care, and how that care is delivered.  Rather than rewarding providers for “volume” by paying fee-for-service, Medicare will be rewarding them for “value” in the form of better outcomes at a lower price. The Affordable Care AcT realigns financial incentives, reducing payments to hospitals with the highest rates of errors and infections, while paying bonuses to physicians who create medical homes than manage to keep chronically ill patients out of the ER–and out of the hospital. Hospitals and doctors who collaborate to create accountable care organizations will be able to share in the savings if they squeeze some of the waste out of the system and provide, safer, better-coordinated care. Many communities already have shown how this can be done. 

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Summary: Last week, Medicare made the decision to commit to paying $93,000 per patient to cover Provenge, a cancer drug that promises to give the average patient suffering from end-stage prostate cancer  an extra four months–though it doesn’t appear to affect the progress of the disease. 
 For Wall Street investors who had put their money on the Dendreon, the drug’s manufacturer, this represents an enormous win. Cancer researchers also may have reason to cheer:  Provenge could mark a small step forward, opening another door in the long quest to find a cure using a patient’s own immune cells. But it is not at all clear that the government should be paying for the treatment outside of controlled trials. For today’s patients, the danger is that Medicare coverage will give them false hope. After all if the government is willing to pay $93,000, thieir must be a chance that Provenge will save lives, right? Wrong. 

The drug offers absolutely no promise of cure; at best it may extend life for a few months–or lengthen the process of dying, depending on your point of view.  Meanwhile tax-payers and other Medicare recipients are the losers. If Medicare is paying for yet another $100,000 cancer drug that offers only a marginal benefit, it will have that much less to spend on other, more effective, if less exciting treatments.  Finally the decision sets yet another expensive precedent, raising the odds that in the not-so-distant future everyone will have to pay higher Medicare taxes.  At some point, Medicare must just say “No” to drug manufacturers–and begin negotiating for lower prices. 
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Long-time readers may remember Provenge, the cancer drug I wrote about in 2007.  In March of that year an   FDA advisory panel voted 13 to 4 to recommend approval of Provenge. The next day, shares of Dendreon, the drug’s sponsor, doubled. But shareholders did not celebrate for long. Two of the dissenting votes were cast by the panel’s two prostate cancer specialists: Sloan-Kettering’s Howard Scher and the University of Michigan’s Maha Hussain. And they did not just vote “no”—following the hearing, both wrote to the FDA arguing that Dendreon offered no solid evidence that Provenge slow the progression of the disease.

The FDA listened. And it told the company it wouldn’t approve the drug until it had more data. That is when the two oncologists began receiving threatening e-mails, phone calls, and letters. Many were anonymous.

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Below, excerpts from a piece by Joanne Kenen that originally appeared in Health Affairs. 

Kenen is a health care journalist and author who spent more than a decade covering health policy on Capitol Hill. Here, she delves into the stopgap insurance plans that the federal government designed to cover patients suffering from pre-existing conditions while they wait for the final phase of the Affordable Care Act to roll out in 2014.  (Following Kenen’s post, you’ll find my comment on what I see as the core of the problem.)                          
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Conservatives Snipe at Preexisting Condition Insurance Plans
By Joanne Kenen
 “The Affordable Care Act is barely a year old, and its earliest initiatives are already coming under intense scrutiny . . . . Near the top of the list is the so-called Preexisting Condition Insurance Plans, the stopgap program created under the law to cover millions of uninsured people with preexisting medical conditions.  So far, enrollment in the eight-month-old program has fallen far short of expectations: Just 12,000 people had signed up as of February 2011. Now health reform critics are citing the program’s failings as indicative of a disaster to come: 

“’If the feds can’t manage this little project,’ wrote Indiana Gov. Mitch Daniels in a typical swipe in the Wall Street Journal, ‘What should we expect if they attempt it on a scale hundreds of times larger and more complex?”

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