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The Affordable Care Act was supposed to simplify Medicaid’s myriad programs across the country to provide a more uniform medical safety net for poor Americans in every state. It hasn’t worked out that way. In fact, Medicaid programs now vary more widely state to state and even within states than they did before. (Margot Sanger-Katz, 1/28)

Conservatives in Washington are increasingly confident that the Supreme Court will rule this summer that the White House has gone beyond its legal authority in implementing the Affordable Care Act. ... It's true that taking away the subsidies now would be disruptive, but the court can't let itself be swayed by that argument. Otherwise, it would be saying that the more people a lawless presidential action affects, the more untouchable it should be. Congress and state legislatures are the proper forums for resolving this problem. Both will be under enormous pressure to do so if the court rules against the IRS and people lose their subsidies. That's why a lot of the commentary about the case as a death knell for Obamacare is overstated. (Ramesh Ponnuru, 1/28)

So what does it take to ruin your reputation around Washington these days? The question comes to mind after learning that one of the capitol’s most corrupt bureaucracies has decided to hire one of its most incompetent contractors—and the answer explains a lot about accountability in government. (1/28)

Several aspects of public opinion on the Affordable Care Act have remained unchanging virtually since its inception: most people don't know what it does or how it affects them personally, but when asked about it in the most general terms they say they're against it. The resulting confusion has been consistently exploited by the law's political opponents, who continue to call for repeal of the whole law, even though that's favored by a minority of Americans. Even fewer think that will happen or that the Republican Party has offered a serious alternative to the law. (Michael Hiltzik, 1/28)

The Barack Obama administration has announced plans to tie 90 percent of all Medicare fee-for-service payments to some sort of quality or value measure by 2018. Sounds exciting! Who wouldn't like to ensure that their doctors are paid for delivering value, rather than just randomly sticking needles into us? Unfortunately ... there is less to this announcement than meets the eye. ... actually doing this, rather than just saying it, turns out to be really hard. (Megan McArdle, 1/28)

Now comes the Congressional Budget Office with a useful reality check, in the form of its annual 10-year fiscal forecast. The report contains one solid piece of news in support of the president’s rosy attitude: The cost of health-care reform, once projected by the CBO to be $710 billion between 2015 and 2019, is now slated at $571 billion, a reduction of 20 percent. To be sure, some of that savings appears to be caused by the refusal of many states to join in the Affordable Care Act’s expansion of Medicaid; but much of it reflects declining health-care inflation, which is the opposite of what the law’s critics predicted. (1/28)

Health and Human Services Secretary Sylvia Mathews Burwell announced a bold initiative Monday aimed at moving half of all Medicare payments away from traditional fee-for-service reimbursement by 2018 and replacing it with incentive-based payments encouraging higher quality and lower costs. The plan also establishes a network to accelerate adoption of payment reforms in the private sector. As the secretary herself suggested, accelerating payment reform is more easily said than done. Time will tell how rapidly changes are adopted, which reimbursement models work best, and payment reform’s overall impact on quality and health spending. Of broader significance than this initiative, potentially, is a shift in Medicare’s role from a bill payer to a more proactive force, with the program using its purchasing power and leverage to drive positive change not only through Medicare but also in the private sector. (Drew Altman, 1/29)

President Obama's new budget is expected to include hundreds of millions of dollars for so-called precision medicine. The initiative, which he introduced last week in his State of the Union address, has bipartisan support and is a bright spot in the otherwise tight funding environment for medical research. Unfortunately, precision medicine is unlikely to make most of us healthier. (Michael J. Joyner, 1/29)

The continuing and spreading outbreak of measles traced originally to visitors to Disneyland and Disney's California Adventure park revives the questions of who should be held responsible, and how they should be made to pay for the injury and illness they've caused. Here's one suggestion, offered Thursday by science writer Alex Berezow in a USA Today op-ed: "Parents who do not vaccinate their children should go to jail." That may be an extreme remedy, but Berezow's notion that non-vaccinating parents should shoulder the responsibility for their actions is widely shared among legal experts and bioethicists. (Michael Hiltzik, 1/28)

Almost 50 rural hospitals have closed their doors since the beginning of 2010, with over half of those closures occurring in the past two years alone, leaving more Americans to trek long distances to obtain health care — sometimes with dire consequences. ... Colorado may soon add to this tally, with Leadville's St. Vincent Hospital facing closure if it does not find a partner, buyer or management relationship together with an infusion of resources. Should St. Vincent close, Leadville will lose its only emergency room and ambulance service, and the county's only nursing home. Leadville's community of 2,600 people would be required to overcome 33 snowy, mountainous miles to reach the nearest hospital in Frisco. (Michael King, 1/28)