The part of the Ryan budget proposal calling for an overhaul of Medicare—turning it into a voucher program for seniors to buy private insurance—did not go over well with many Americans. In fact, the outcry from seniors from both political parties was great enough that the House leadership has backed away from their insistence that raising the budget debt limit be dependent on revamping Medicare. But what about Medicaid?

So far, the GOP has not backed down from their plan to “reform” the federal-state program that provides benefits to some 69.5 million poor children and adults as well as the disabled and frail elderly in nursing homes. The Ryan budget proposal calls for cutting federal funding for Medicaid and turning it into a block grant program. It also includes the GOP’s repeal of the Patient Protection and Affordable Care Act which would effectively deep-six the health law’s planned expansion of Medicaid. Together, these provisions would result in federal savings of $1.4 trillion over the 2012 to 2022 period, according to the Congressional Budget Office. Yet the agency concluded that although “states would have additional flexibility to design and manage their Medicaid programs and might achieve greater efficiencies in the delivery of care than they do under current law” they would also be required to reduce enrollment rolls, cut provider reimbursement, slash benefits and increase cost-sharing.

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Today, I stumbled onto a new blog,“Deeper Tweets–Sometimes 140 Isn't Enough.” There, “Medskep” has just reprinted a comment that I made on The Health Care Blog a year ago, turning it into a stand-alone post. At the time, I was responding to an essay by Dr. Nortin Hadler professor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill, and Dr. Robert McNutt, a professor of Medicine at Rush Medical College in Chicago titled “The Evidentiary Basis for a Clearly Meaningful Benefit.”  (Hadler is the author of Worried Sick: A Prescription for Health in an Overtreated America, The Last Well Person, and Stabbed in the Back).

As I re-read my comment, I decided that I would like to share it with HealthBeat readers. But since it is only a response, first let me offer some excerpts from their provocative post :

“We entered the 21st century awash in “evidence” and determined to anchor the practice of medicine [in that evidence]. There is the sense of triumph; in one generation we had displaced the dominance of theory, conviction and hubris at the bedside. The task now is to make certain that evidence serves no agenda other than the best interests of the patient.

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Less than a year after Congress passed the Patient Protection and Affordable Care Act, a newly conservative House voted to repeal it. Aware that such a repeal was purely symbolic and would be blocked by the Senate and vetoed by President Obama, GOP leaders instead promised “death by a million cuts” and have introduced a steady series of bills that de-fund many of the health law’s provisions.

For the GOP, this goal of de-funding the health reform law has been increasingly intertwined with efforts to cut the federal deficit. The most recent conflation was House passage of Rep. Paul Ryan’s (R-WI) budget plan that included privatizing Medicare and turning Medicaid into a block-grant program—ideas that provoked outcry among seniors and others in town hall meetings around the country. Yesterday, Rep. Dave Camp, (R-MI) who is chairman of the powerful Ways and Means Committee, said that in the face of opposition from Democrats, he will not push forward with the Medicare privatization proposal. 

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In San Francisco, the “most costly user of publicly financed emergency health services…a ‘frequent flyer’ in emergency room parlance – is 49, Caucasian, schizophrenic, and addicted,” writes R. Jan Gurley, a board-certified internist who treats many homeless patients in that city and pens a blog titled “Doc Gurley: Posts from an Insane Healthcare System.”

Gurley continues; “He has been listed in at least two concurrent city systems as homeless (either continuously or episodically) for 16.6 years. He’s a frequent caller of ambulances (more than four times a month), a frequent user of detox and sobering center services, and a high utilizer of mental health services (including psych emergency). He is very, very ill.”

He is also costly to the public health care system. According to Gurley, last year the homeless man with this dubious honor “used an estimated $155,453 worth of emergency and urgent services alone (not counting other medical costs)” despite having a legal conservator and being enrolled in the city’s Department of Public Health intensive case management program.

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Below, a guest-post by Harold Pollack on Osama bin Laden’s death.  (Pollack is Helen Ross Professor at the School of Social Service Administration, and faculty chair of the Center for Health Administration Studies at the University of Chicago. He recently joined The Century Foundation as an adjunct fellow focusing on issues of Economics and Inequality. This post originally appeared on the Foundation’s blog, www.tcf.org )

Pollack suggests that bin Laden’s death signals a time for reflection, not celebration.  I totally agree.  I found the televised spectacle of college students, high-fiving and cheering, as if their team had just won a football game, unsettling.  War is not a sport.

 I fully understand why anyone who lost a loved one on 9/11, along with families of soldiers killed in the Middle East, would feel a great sense of relief, as well as a certain grim satisfaction upon hearing that bin Laden had left this planet.  His death will not fill the holes in their hearts, but it is something.

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“I diagnosed ‘abdominal pain’ when the real problem was hunger,” admits Dr. Laura Gottlieb in a wonderfully candid Op-ed that explains why physicians so often fail to recognize poverty as the true cause of what appears to be a physical disease.

“I confused social issues with medical problems in other patients, too. I mislabeled the hopelessness of long-term unemployment as depression, and the poverty that causes patients to miss pills or appointments as noncompliance. In one older patient, I mistook the inability to read for dementia,” writes Gottlieb who is a Robert Wood Johnson Health and Society Scholar at the University of California, Berkeley, and the University of California, San Francisco. 

“My medical training had not prepared me for this ambush of social circumstance,” Gottlieb adds. “Real-life obstacles had an enormous impact on my patients’ lives, but because I had neither the skills nor the resources for treating them, I ignored the social context of disease altogether.” (Many thanks to HealthBeat reader Dr. Rick Lippin, who called my attention to Gottlieb’s superb Op-ed.)

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Here at HealthBeat, we often write about medical technology—the overuse of expensive imaging tests, unscrupulous relationships between doctors and medical device makers and the way these practices inevitably drive up the cost of health care. Our current health care system operates on the “build it and they will come” mentality—from spinal fusion devices to digital mammography to drug-eluting stents, we have seen demand ramp up in direct proportion to supply. Under health reform, this will clearly change as comparative-effectiveness and cost-effectiveness studies inform the government’s scrutiny of new technologies.

So how will this work in practice? An early test case may be the emerging technology of whole genome sequencing, the process of translating and cataloging an individual’s entire genetic code—all 3 billion base pairs that make up the “instructions” for life. Genome sequencing is a key component of “personalized medicine,” the Holy Grail for medical researchers who envision administering treatment that is targeted specifically to individual patients.

A handful of venture-capital-backed companies are developing nimble machines that can now sequence an individual’s genome in just a matter of weeks. This raw information—a kind of biotech version of tea leaves—is then sent to genetics researchers on a hard-drive, along with a list of identified single gene variations that might be involved in a patient’s cancer or other disease. These gene variations could also be harbingers of medical problems he or his family members might face decades from now. Although this is powerful technology offers great promise, right now whole genome sequencing is capable of offering practical help to only a very select group of patients.

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