AHIP is in town (as in San Francisco) and sadly that means I’m juggling the office and conference going. So altough I made the odd party I missed former Minnesota governor Tim Pawlenty (who apparently was paid $30K to speak). However, Politico’s Kate Nocera seems to think he got a bit of a tough reception from the insurer crowd which by and large is going to enjoy the ACA and has set its course on making hay from it. But whether or not repealing ACOs and the experiments with Medicare financing are really going to happen (and they’re not) I was though struck by the final quote about exchanges: ‘And Pawlenty dismissed the importance of the state exchanges the law will create to provide consumer choice. “We already have an exchange: It’s called the free market,” Pawlenty said.’ Pawlenty shows himself to be a complete idiot on the Mark Pauly scale here. (Pauly is the Wharton professor who thinks that the individual insurance market works fine because it’s more or less OK for 80% of the people in it). But doesn’t this remind you of another not-too-bright former Republican governor? Remember who said this in 2007?: “I mean, people have access to health care in America. After all, you just go to an emergency room.” Let’s hope for logic’s sake alone we don’t end up with Pawlenty in the White House, as it could be a repeat of 2001-8 all over again.

Michael Cannon from Cato doesn’t like the idea that we’re going to cover children by putting them into Medicaid. To tell the truth I don’t like it either. He points to a NEJM study that shows–in the no shit, Sherlock department–that Medicaid recipients wait longer for care. My guess is that Michael’s solution is to a) do nothing or b) give Medicaid recipients a fund to pay for their own care–a fund that real life shows us will be cut as soon as budgets get tight (and as has happened nation-wide under S-CHIP). My solution is to put those kids in the same system as everyone else. But the real politics of the US is that–for now–Medicaid expansion is the best we’re getting. As soon as it’s done we should be working to abolish Medicaid by integrating it into a rational single system so that children (and adults) do not get discriminated against in medical care simply because they chose their parents poorly.

Paul Krugman spends time today ripping Paul Ryan once more. Ryan’s plan is to limit government spending way off into the future (starting with people who are now 55) by giving them a flat Medicare voucher and then telling them to try it on for size in the individual insurance market. The joke is that there is a rational way to try to introduce some consumer-choice competition into Medicare. Essentially there are two alternatives to dealing with the mess that is Medicare. One–try to manage Medicare spending both with a global budget (the IPAB) and with specific restrictions on care that’s delivered that’s wasteful or unnecessary (via changes in FFS payment). That’s essentially the route the ACA goes. Two, give recipients a voucher that lets them choose between competing entities that can’t charge more than the value of the voucher and actually are mandated to compete on the correct things (outcomes, service, etc) like they do in Holland and in Alain Enthoven’s theories. That’s rational managed competition under a global budget, and the winners in that would look more like Kaiser and Group Cooperative than today’s insurers. Ryan’s idea is just to subsidize the dysfunctional private marketplace and to repeal the minor restrictions the ACA puts on health insurers while he does it–a sure-fire recipe for disaster.

There is of course another alternative. Just to let Medicare continue to spiral out of control on both costs and the quality of services it provides, and Ryan’s plan basically does that without a safety net