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A number of factors underpin the anti-redistributionist shift in public opinion that I wrote about last week. First, and perhaps most important, is the emergence of significant resistance to downward redistribution among the elderly, a major voting bloc. ... In the zero-sum competition for federal dollars, the cost of major spending programs like the Affordable Care Act has to be made up by spending cuts elsewhere. The Obama administration has reported that the Affordable Care Act will be financed in part by $716 billion in Medicare cuts over 10 years. Somewhat improbably, the administration also contends that cuts of this magnitude will not reduce services to Medicare beneficiaries. (Thomas B. Edsall, 4/22)

The uncomfortable truth (for liberals, at least) is that the ACA case arises from a piece of statutory language that on its face explicitly says that tax subsidies are only available for health insurance purchased on an exchange “established by the state.” Liberals have tried to explain why, correctly interpreted, this language really means “established by the state or the federal government on the state’s behalf.” But their theories seem forced. ... The simplest way for the liberals to win the Obamacare case, King v. Burwell, is to convince [Justice Anthony] Kennedy that the ACA shouldn’t be read literally, as doing so would produce a disastrous and therefore unjust result. (Noah Feldman, 4/22)

Tea Party Senator Ron Johnson has unveiled a new plan to provide temporary help to the millions of people who might lose health coverage if the Supreme Court sides with the King challengers and guts subsidies in three dozen federal-exchange states. Senator Johnson’s fix reportedly has 29 GOP co-sponsors ... and it is fair to assume the eventual GOP post-King contingency plan, if there is any GOP consensus plan, may look something like it. ... The Johnson plan would keep subsidies going ... until September of 2017. ... The idea is to buy time to develop a more comprehensive GOP replacement for Obamacare. As Johnson himself recently put it, this would allow the future of health reform to be litigated in the 2016 presidential race. (Greg Sargent, 4/22)

The Kaiser Family Foundation released a poll Tuesday showing that public opinion is divided on the Affordable Care Act, also known as Obamacare. Forty-three percent of respondents reported that they approve of the health-care law, and 42 percent said they disapprove. That’s a marked improvement from much of the last year. But those of us who believe that the ACA is decent policy that’s working fairly well still need to ask: Why do its polling numbers remain so low? (Stephen Stromberg, 4/22)

On December 17, 2014, Vermont Governor Peter Shumlin publicly ended his administration's 4-year initiative to develop, enact, and implement a single-payer health care system in his state. ... In reality, the Vermont plan was abandoned because of legitimate political considerations. Shumlin was first elected governor in 2010 promising a single-payer system. But in the 2014 election, his Republican opponent campaigned against single payer. Shumlin won the popular vote by a single-percentage-point margin, 46% to 45%, which sent the election to the Democratic-controlled House of Representatives; though the House reelected him easily in January, a clear public mandate for his health care agenda was nowhere in evidence. (John E. McDonough, 4/22)

Gov. Rick Scott and Florida House Republicans are failing our uninsured residents and our hospitals that care for them. They oppose the Senate's plan to accept federal Medicaid expansion money and overhaul the Low Income Pool, which sends hospitals more than $1.5 billion a year in federal, state and local money to treat the uninsured. ... Tell the governor and House Republicans to stop fighting Washington and putting our residents and hospitals at risk. (4/22)

Your humble blogger has been tracking the battle over the Medicaid expansion in Florida, because it’s a really big deal. If the administration can get Governor Rick Scott and state House Republicans to accept the expansion, it could help weaken the blockade against it that conservatives have built in other states, which has slowed down Obamacare’s health coverage expansion after a number of states accepted it last year. Now things are getting truly crazy in Florida. Legislators who oppose the Medicaid expansion are locking reporters out of meetings about the issue. And Republicans who support it are saying this episode is now reflecting badly on the national GOP. (Greg Sargent, 4/22)

The Montana affiliate of the Kochs’ Americans for Prosperity thought it was in a strong position to derail Medicaid expansion in the state, just as AFP activists did in Tennessee in February. ... at this point a year ago, Medicaid expansion in Montana looked like a lost cause, but in early May 2014, [Gov. Steve] Bullock started arranging some “non-publicized” meetings on the issue. The governor saw a possible opportunity to advance the policy, so he started quiet negotiations with state Republicans and private-sector stakeholders. It worked. Assuming the Obama administration signs off on the package, which is likely, Montana will expand health security to tens of thousands of low-income residents, while improving state finances and bolstering state hospitals. (Steve Benen, 4/22)

Let us now praise Newt Gingrich. Yes, Newt Gingrich. There he was, the scourge of Big Government, on the op-ed page of Wednesday’s New York Times calling for a doubling of the National Institutes of Health budget. “It’s irresponsible and shortsighted, not prudent, to let financing for basic research dwindle,” he wrote, noting that government investments in preventing and curing disease could save the government money in direct health-care costs. (E.J. Dionne, 4/22)

The men and women who serve in the military protect both the United States’ security and its values, including political liberty, free enterprise and individual choice. How strange, then, that when their time in uniform ends, we thank them for their service and turn them over to the Department of Veterans Affairs, which epitomizes centralized bureaucracy. (Charles Lane, 4/22)

When the federal government announced last week that youth e-cigarette use tripled in just one year, surpassing the use of traditional cigarettes, the reaction was appropriately strong. “A wake-up call,” said one commentator, echoing others. We agree. But a word that shouldn’t be used to describe it is “surprising.” It’s not. E-cigarettes have so far escaped federal regulation and are being promoted using the same playbook cigarette companies have used to addict generations of teenagers. (David A. Kessler and Matthew L. Myers, 4/23)

Michigan Republican Tim Walberg was a Christian minister before winning election to Congress in 2010 — and he hasn’t entirely changed jobs. In a rare Tuesday-night committee meeting at which House Republicans advanced a bill curtailing reproductive rights, Walberg took the even rarer step of lecturing his colleagues on Scripture. (Dana Milbank, 4/22)

After a second go, and some hasty revision, a controversial bill to end the personal belief exemption for school vaccinations passed through the Senate Education Committee on Wednesday. But it’s far too early for supporters of the bill to raise a celebratory toast. There are plenty of other ways SB 277 by Sens. Richard Pan (D-Sacramento) and Ben Allen (D-Santa Monica) can get held up as it works through the legislative process. (Mariel Garza, 4/22)

Ask most rational people what their No. 1 priority is and, I suspect, they would answer good health. Love, friends, money, freedom, a good education, a productive life — they're all right up there. But none outranks health. So it's pathetic that more legislators aren't fully embracing a bill that essentially would tell parents: Vaccinate your kids against infectious diseases or they won't be allowed in school where they could jeopardize the health of other children. (George Skelton, 4/22)

In most doctor-patient conversations, the doctor leads the way. But when it comes to planning for the end of life, we need a role reversal. The patient — you — may have to take the lead in conducting end-of-life conversations. While this may seem surprising, remember that dying is essentially a social and intimate family event that has become overly medicalized in the past century. (VJ Periyakoil, 4/22)

For the first time, I was present as one of my patients died. I had been working in intensive care all year, and many of the people I’d cared for were dead now. But this patient died with my hand on his forehead. I was with him and saw the monitor the minute his heart quit, its rate dropping from 130 beats a minute to 90, 70, 40, 30, asystole. It was peaceful. He had a do-not-resuscitate order, and the family was expecting it. As far as dying in an intensive care unit goes, it was a good death. (Melissa Beth Behl, 4/22)

The dysfunctional Congress finally appears to be working again as the Founders intended. Lawmakers are negotiating, voting on bills and actually passing legislation. As proof of this, National Journal’s Charlie Cook points to three things: congressional approval of a permanent “doc fix” to prevent cuts to physician reimbursements under Medicare; extension of the Children’s Health Insurance Program; and passage of budget resolutions by the House and Senate. There’s even more evidence. (Karl Rove, 4/22)

Now Congress has scrapped the SGR, replacing it with still-embryonic but promising incentives that could catalyze increased efficiency and greater cost control than the old, flawed formula could ever really have done, in a law that includes many other important provisions. How did such a radical change occur? And why now? The “how” was logrolling — the trading of votes by legislators in order to pass legislation of interest to each of them. Logrolling has become a dirty word, a much-reviled political practice. But the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act (MACRA), negotiated by House leaders John Boehner (R-OH) and Nancy Pelosi (D-CA) and their staffs, is a reminder that old-time political horse trading has much to be said for it. (Henry J. Aaron, 4/22)

In February 2015, Senators Orrin Hatch (R-UT) and Richard Burr (R-NC), along with Representative Fred Upton (R-MI), unveiled the Patient Choice, Affordability, Responsibility, and Empowerment Act (Patient CARE Act). ...it would fundamentally restructure the program. First, the proposal would eliminate all federal funding for the ACA' s expansion of Medicaid eligibility for adults. Second, it would end Medicaid's historical entitlement to comprehensive coverage for low-income children, pregnant women, and families with dependent children, along with the entitlement to long-term care services and support for elderly or disabled Medicaid beneficiaries. For these groups and services, it would replace Medicaid's open-ended financing structure with a block grant that would allocate a fixed sum to each state .... Such a law would be bad news for beneficiaries and for providers, especially those that serve low-income communities, since under such financing terms few, if any, states could maintain existing coverage for affected populations. (Sara Rosenbaum and Timothy Westmoreland, 4/22)

Early in his career, Louis B. St. Petery Jr, MD, a pediatrician in Tallahassee, Florida, attended the funeral of a young patient from his practice who was shot and killed after the child’s sibling found a loaded gun in a bedside drawer. “It should never happen,” said St. Petery .... With that memory not far from mind, St. Petery, like many physicians across the country, routinely asks his patients’ parents whether they have guns in their home. If they do, he advises them to take safety measures .... But whether St. Petery and colleagues across Florida will be able to continue such routine inquiries without fear of being reported to the state medical board now rests in the hands of the US Court of Appeals 11th Circuit. (Bridget M. Kuehn, 4/22)