It will be a tall order for Paul Ryan to match the strong debate performance delivered by his ticket mate, Mitt Romney, last week in Denver. But that’s just what the Republican vice presidential nominee is tasked with doing on Thursday, when he meets the Democratic incumbent veep, Joe Biden, at his first (and only) debate of the 2012 election season.

When Romney selected Ryan to be his running mate, the choice was cheered by conservatives excited to have a champion in the cause to curb government spending and reform entitlement programs. But Ryan has also provided Democrats a big target — a result of his proposal to fundamentally transform the Medicare program. 

Elected to the House in 1998 at age 28, Ryan is doing something unprecedented for a running mate — bringing a detailed policy agenda with him and finding that the presidential candidate who picked him has accepted it and is also running on it. 

It’s likely that the Ryan budget plan and especially its Medicare transformation will be a primary focus of Biden’s attacks on Ryan in the debate. But it’s unlikely that Biden will go as far as a left-of-center group, The Agenda Project, did last year in making the argument against Ryan’s plan. The group’s TV ad featured a Ryan lookalike actor, with “America the Beautiful” playing in the background, pushing an elderly woman off a cliff to her death, as the ad said, “Is America beautiful without Medicare? Ask Paul Ryan and his friends in Congress.” 

Biden will surely be more subtle than that ad, but his argument will be aimed squarely at the crucial demographic in Florida and other states: voters on Medicare or those about to be eligible for the health insurance entitlement. 

When Ryan’s party regained control of the House in the 2010 elections, GOP candidates performed best among voters age 65 and older, nearly 60 percent of whom voted Republican, according to exit polls. 

Reforming health care
Here are the highlights from Ryan’s Medicare proposal:

• His reform would gradually increase the Medicare eligibility age to 67.

• The phased-in increase in eligibility would start in 2023.

• His proposal would do away with Medicare’s open-ended payments for those born in 1958 and later.

• Ryan’s plan would not apply to those now receiving Medicare benefits – but he does favor repeal of the Affordable Care Act (ACA), which would mean that today’s seniors would lose the additional prescription drug benefits that the ACA gave them.

But even though Ryan wants to repeal the ACA, his budget blueprint incorporates various cuts to Medicare that were enacted in the overhaul, saving more than $500 billion over ten years. They’re the same kind of cuts that the Republican ticket has criticized Obama for enacting.

It is no accident that Ryan, the policy wonk who says “I'm kind of a PowerPoint guy,” finds himself in this starring role. He almost seemed destined for it back in 2010, when he played the role of chief antagonist to President Barack Obama at the Blair House health care summit. He was tough on entitlement spending and confronted the president with a six-minute lecture on what was wrong with his health care overhaul.

“This bill does not control costs,” Ryan told the president. “This bill does not reduce deficits. Instead, this bill adds a new health care entitlement at a time when we have no idea how to pay for the entitlements we already have.” 

At that summit, Ryan also made what has become a core argument in Romney’s speeches and one that the GOP presidential nominee deployed in his first debate with Obama last week: The Affordable Care Act “treats Medicare like a piggy bank. It raids a half a trillion dollars out of Medicare, not to shore up Medicare solvency, but to spend on this new government program.” 

Conservative favorite
That six-minute lecture helped make Ryan a hero to GOP base – at a time when the Republican Party was still feeling the sting of Obama’s 2008 victory. 

“There were only two choices on the list of VP candidates who would have excited the base, Paul Ryan and Marco Rubio,” said Republican campaign consultant Jason Roe, who is currently working on GOP House races in Illinois, Arizona and California. “What Ryan has done is he’s brought seriousness about what’s going on in Congress and the issues related to the debt and reforming entitlements.” 

Ryan “brings kind of a sober sensibility to the debate. Some of the things that he has talked about over the last few years are tough medicine. Even if people don’t agree with him, they at least recognize that he’s being honest about the problems and honest about what the solutions are going to look like,” Roe said. 

Before Romney’s strong debate performance last week against Obama, “there were elements of the base that were not yet excited about Romney,” Roe said, and in the period between the GOP convention and that debate victory, Ryan supplied “proxy enthusiasm for the ticket.”

But Democratic strategists say that Ryan’s budget plan provides fodder for them, not only in the presidential race but in congressional races as well. 

A few days after Romney chose Ryan, Alixandria Lapp, the executive director of the Democratic House Majority PAC, said, “From House Majority PAC’s inception (in April 2011), it was clear that the Ryan budget could be the key to Democrats taking back the House majority.” 

House Majority PAC spokesman Andy Stone said Tuesday, “It’s not a state secret that we were going to use Ryan budget attacks against Republican candidates this cycle. They’re incredibly potent –  all the polling has demonstrated that. The fact that Paul Ryan is on the top of the ticket now means that they are that much more effective. And we can see the effect of these hits in lots of districts around the country.”

He cited House Majority PAC TV ads which are being run against first-term Republicans Rep. Daniel Webster in Florida and Rep. Jeff Denham in California, as well as against seven-term Rep. Charlie Bass in New Hampshire.

Sovereign debt crisis warnings
Republicans have been offering proposals for more than 20 years to redesign Medicare, but it’s the reality of sovereign debt crises in European nations that has given a new urgency to the case for entitlement reform. Ryan sounded that theme Monday night at a Pontiac, Mich., fundraiser: “The worst thing that could happen is President Obama gets re-elected and we go down on a path towards a debt crisis.”

But he has been sounding that alarm for well over two years: “You have Portugal, Italy, Greece, Spain with huge debt crises. We should not fool ourselves to think that that could not come here,” Ryan said early in 2010 in an interview with MSNBC’s Chris Matthews.

Differences with Romney 
On Thursday night, Biden might seek to highlight Ryan’s differences with Romney on at least on at least two significant issues, abortion and the 2009 GM/Chrysler bailout.

Romney would allow abortions in cases of rape or incest, or when the mother’s life is in danger. But Ryan’s position is that abortions, even in the case of rape and incest, should be banned.

Ryan also voted for the 2009 GM/Chrysler bailout, which Romney opposed, and as recently as Monday lamented the loss of auto industry jobs. “In the district I represent, we lost two Delphi (parts) plants, we lost a Chrysler engine plant, we lost the GM plant in Janesville where I live. So trust me when I say, we know a very healthy auto economy is healthy for America,” he said.

TOLEDO, OH -- Mitt Romney on Wednesday pointed to the health care reform law he enacted as governor of Massachusetts as proof of his empathy and care for the American people.

In an interview with NBC News, Romney referenced an element of his record he almost never invokes on the campaign trail to answer a question about how he can better connect with Americans and prove he understands the lives and trials of middle class Americans.

"I think throughout this campaign as well, we talked about my record in Massachusetts, don't forget -- I got everybody in my state insured," Romney told NBC's Ron Allen in an interview before his rally here tonight. "One hundred percent of the kids in our state had health insurance. I don't think there's anything that shows more empathy and care about the people of this country than that kind of record."

Romney's health care law in Massachusetts has long been a lightning rod issue for conservatives, who unfavorably compare it to President Barack Obama's own federal law and as a damning reflection on Romney's conservative bonafides.

The former Massachusetts governor also touched on another portion of his biography that he seldom discusses to connect with average Americans: his time as a Mormon pastor.

"I think people have the chance, who watched our Republican convention, to see the lives that I've had a chance to touch during my life, to understand that as I served as a pastor of a congregation with people of all different backgrounds and economic circumstances that I care very deeply about the American people, people of different socio-economic circumstances," Romney told Allen.

Taking the stage for the final rally of his two-day Ohio bus tour moments later, Romney also spoke about the importance of compassion in his speech and said his interactions with Americans from all lots in life have shown him the greatness of America -- and that everyone has challenges of their own.

"You look around, you see everybody, they look happy, and you think everybody else is doing just fine, and you're the only one with problems. But the truth is, most people that you see have some real challenges in their life of one kind or another. I understand that," Romney said. "And I've seen that inside the heart of the American people, despite our challenges, is a conviction that this nation is the greatest nation in the history of the earth."

Slideshow: On the campaign trail

Reuters, Getty Images

In the final push in the 2012 presidential election, candidates Mitt Romney and Barack Obama make their last appeals to voters.

Launch slideshow

NEW ORLEANS -- Republican vice presidential nominee Paul Ryan received boos as he addressed the AARP convention here on Friday -- perhaps his most unfriendly welcome on the 2012 campaign trail.
 
Several members of the “Life@50+” Annual Convention crowd booed loudly as Ryan began remarks proclaiming, “Seniors are threatened by Obamacare.”
 
“The first step to a stronger Medicare is to repeal Obamacare, because it represents the worst of both worlds,” Ryan went on as members continued to shout. “It weakens Medicare for today’s seniors and puts it at risk for the next generation. First, it funnels $716 billion out of Medicare to pay for a new entitlement we didn’t even ask for. Second, it puts 15 unelected bureaucrats in charge of Medicare’s future.”
 
Throughout the Wisconsin congressman’s nearly 30-minute speech, he rarely received applause and instead heard people yell “You lie!” and “No!” to many of his claims of what he and his running mate, Mitt Romney, would do if they make it to the White House.

Bill Haber / AP

Republican vice presidential candidate, Rep. Paul Ryan, R-Wis., appears at the AARP convention in Friday, Sept. 21, 2012.

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The last time Ryan came close to getting this kind of a reception from a crowd was during his very first solo campaign event -- on Aug. 13 -- when he spoke at the Iowa State Fair.

Ryan's speech came immediately after President Barack Obama spoke -- via satellite -- to the same AARP convention, knocking the Romney-Ryan plan to overhaul Medicare.

“I don’t consider this approach bold or particularly courageous,” Obama said, per the Washington Post. “I just think it’s a bad idea. No American should spend their golden years at the mercy of insurance companies.”

The Romney-Ryan plan would transform Medicare by giving future seniors a payment -- Democrats call it a "voucher," Republicans call it "premium support" -- to purchase private insurance or to gain access to traditional Medicare.
 
Yet Ryan countered by giving one of his most in-depth descriptions of the GOP's plans to change Medicare, and he did it as he was joined by his 78-year old mother, Betty, at the conference.
 
“In order to save Medicare for future generations, we propose putting 50 million seniors, not 15 unaccountable bureaucrats, in charge of their own health-care decisions,” he said, drawing some of the only applause of the speech.

On Day 2 of the Democratic National Convention, speakers cherry-picked employment numbers to make President Barack Obama's record on jobs look better than it is and misrepresented Republican proposals on Medicare to cast them in the worst light.

A look at some of the claims from the stage, in speeches preceding former President Bill Clinton's featured address Wednesday night, and how those assertions compare with the facts:

Rep. Nancy Pelosi of California, House Democratic leader: "Democrats will preserve and strengthen Medicare. Republicans will end the Medicare guarantee."

Rep. Steve Israel, D-N.Y., chairman of the Democratic Congressional Campaign Committee: "Paul Ryan wrote the budget that turns Medicare into voucher care and could charge seniors $6,400 more every year, while funding tax breaks for millionaires. Here's their economic plan: if you're a millionaire, you win the lottery. If you're a senior, you lose your Medicare guarantee."

The fact: Both are on shaky ground in declaring that Republicans will end the "Medicare guarantee," and Israel's figure for how much more seniors could pay is outdated. It's actually based on a Congressional Budget Office analysis of the 2011 version of Rep. Paul Ryan's Medicare proposal, different in several important ways from the Republican vice presidential candidate's latest 2012 version.

The latest Ryan plan would offer future retirees the choice of a government program modeled on Medicare or private plans subsidized by government. That's not a proposal to end a Medicare guarantee. The nonpartisan Congressional Budget Office does, though, estimate future retirees would get less from the government under the Ryan plan than if current law continues.  Republican presidential candidate Mitt Romney has endorsed Ryan's Medicare ideas in broad terms while saying the White House agenda will be his own, not his running mate's, if they win.

Ryan's plan only affects people joining the program in 2023 or later. It's expected that private health insurance plans serving seniors would have to guarantee some basic level of benefits, yet to be spelled out. Finally, there's no such thing as a "guaranteed" Medicare benefit for the ages, because Congress can change the laws.

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Pelosi: "Under President Obama, we've gone from losing 800,000 jobs a month to adding 4.5 million private sector jobs over the last 29 months."

Steve Westly, former California state controller and chief financial officer: "President Obama understands that future. He knows that this election is about creating jobs today. That's why he's helped create 4.5 million of them, growing the economy from the middle out, not the top down."

The facts: While that figure has become a White House talking point, it's only part of the story. It's a selective number that refers just to private sector jobs created in the last 29 months, from the trough of the recession through July. Governments — especially state and local ones — have continued shedding jobs. And the claim ignores job losses during Obama's term before the employment picture bottomed out.

The economy lost 8.8 million jobs from the time employment peaked in January 2008 until it hit bottom in February 2010. Between then and this July — the most recent month for which there are figures — just 4 million jobs have been recovered. Never since World War II has the economy been so slow to recover all the jobs lost in a downturn.

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Pedro Pierlusi, non-voting member of the House from Puerto Rico: "The president is a champion of comprehensive immigration reform and is preventing the deportation of thousands of young men and women who were brought here as kids, have played by the rules and have done nothing wrong. Indeed, they are doing everything right by getting an education or serving in the military. But if Mitt Romney gets into office, he has vowed to overturn that action and veto the Dream Act if it ever passes Congress."

The facts: During the Republican primaries, Romney did pledge to veto the DREAM Act, a bill that would provide a path to citizenship for many young illegal immigrants brought to the United States as children. But Romney has not said what he would do with Obama's deferred action policy, which allows many young illegal immigrants to avoid deportation for two years and get a work permit. Romney has only said that he would work to create a "civil but resolute" long-term fix to illegal immigration.

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Cecile Richards, president of Planned Parenthood Federation of America: "When Mitt Romney says he'll get rid of Planned Parenthood, and turn the clock back on a century of progress, it has real consequences for the 3 million patients who depended on Planned Parenthood last year. "

The facts: Romney has proposed to eliminate federal money for Planned Parenthood but not get rid of the organization. Planned Parenthood's budget is roughly $1.1 billion, and it receives about $75 million in federal financing, which cannot be used to pay for abortions.

__—

Pelosi: "Democrats passed health reform to allow Americans the freedom to pursue their passion; to make health care a right, not a privilege."

The facts: Access to health insurance is essentially becoming a right under Obama's health care law, although one that most people will pay for, and that right comes with a mandate to obtain coverage. Those who don't will be penalized. It is true that insurers will no longer be able to deny coverage to people who have been sick or charge them exorbitant rates, once the law takes full effect. 

John Brecher / NBC News

A panel discussion held by Democrats for Life in Charlotte, North Carolina on Tuesday, one of many events organized around the Democratic National Convention.

CHARLOTTE, N.C. – Small, shrinking (at least in its congressional representation), and sometimes forgotten, the wing of the Democratic Party that wants to limit or ban abortions is still trying to assert some influence here at the Democratic convention in Charlotte, N.C.

“We are members of the Democratic Party. We are pro-life and we are proud of our position as pro-life Democrats,” Kristen Day, executive director of Democrats for Life of America, told a group of about 40 people at an event Tuesday.

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“Being pro-life in the Democratic Party can sometimes be a lonely thing,” former Rep. Kathy Dahlkemper of Pennsylvania told the audience, which included a few delegates.“There are factions in our party who want us to go away. There are factions that think that we’re not true Democrats.”

But, she contended, Democrats can’t win seats like the one she held for one term in Erie, Pa., without running anti-abortion candidates. Elected in 2008, Dahlkemper was swept out in 2010 in the 2010 GOP wave, losing to Republican Mike Kelly.

“We will never get to be a majority again unless we have pro-life Democrats,” argued former Michigan Rep. Bart Stupak, who retired in 2010 and is on the board of Democrats for Life.

John Brecher / NBC News

Democrat Bart Stupak, a former US Representative from Michigan, talks to reporters following a panel discussion held by Democrats for Life in Charlotte, North Carolina on Tuesday.

Thirty-five years ago when the Democrats enjoyed a 292-seat majority in the House, there were 125 anti-abortion Democrats – including a young Rep. Al Gore of Tennessee. Now there are only 17 anti-abortion Democrats and districts such as Gore’s are now represented by anti-abortion Republicans.

Asked what his group wanted from the Democratic Party platform, Stupak said, “What it should say is the same thing it said in 1996: that on the abortion issue, we recognize that within in our party there are differences and we respect everyone’s differences, including those who are pro-life. What we want is an acknowledgement that pro-life Democrats exist and are valuable members of our party.”

You would not know they exist from the speakers’ line-up at the convention.

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Given speaking slots Tuesday night: Nancy Keenan, President of the National Abortion Rights Action League and Secretary of Health and Human Services Kathleen Sebelius. Democrats for Life opposes Sebelius’s health insurance mandate because they say it requires companies and insurers to provide contraception coverage to workers, including certain types of “morning after” drugs that Stupak and anti-abortion activists say induce abortions. “The abortifacients are the big issue for me,” said Dahlkemper.

Stupak said that Sebelius’s contraceptive mandate violated both a 2009 law and the executive order which Stupak negotiated with the Obama administration that was designed to ensure that no money in the Affordable Care Act goes to subsidize abortions.

That accord was what allowed Stupak, Dahlkemper and other anti-abortion House Democrats to vote for the Affordable Care Act.

Related: Passion on display during DNC's first night

“I think it’s illegal,” Stupak said of the HHS mandate. But the former Michigan congressman said there’s still hope that Sebelius will relent and find some way to allow people or firms to modify the mandate. “We’re still engaged in discussions with HHS and the White House and we hope the matter will be resolved.”

Alabama delegate Julian McPhillips, an attorney on Montgomery, Ala., said he’d like the Democratic platform to go further than simply acknowledging that anti-abortion Democrats exist: “I wish they would acknowledge that there is real life in womb. This is my biggest problem with being a Democrat, no doubt.”

John Brecher / NBC News

"The only problem with pro-choice is that it's no choice for the one and only life at stake," said Alabama delegate Julian McPhillips, attending a Democrats for Life event in Charlotte, North Carolina on Tuesday, one of many events organized around the Democratic National Convention. He and his wife adopted a one-day-old boy 21 years ago from a mother who McPhillips said had intended to get an abortion until he convinced her to continue the pregnancy and give the baby up for adoption.

Given how marginalized the anti-abortion Democrats are, a natural question is: What is it that keeps them in the Democratic Party?

Dahlkemper answered that Tuesday by noting that she’d voted for the Obama stimulus bill, the Dodd-Frank Wall Street regulation bill, the repeal of the Don’t Ask Don’t Tell policy on gays in the military, and of course the Affordable Care Act – which she argued “will significantly reduce the number of abortions in our country,” because it broadens Medicaid eligibility and provides funding for pregnant women’s care.

Slideshow: Democratic National Convention

“My votes in Congress put to rest any lingering idea that I am not a true Democrat,” she said.

And Democratic anti-abortion activists contend that Mitt Romney would be a worse president on protecting unborn life than Obama has been.

Stephen Schneck of Catholic University in Washington told the gathering that “the number of abortions will skyrocket” if Medicaid spending is cut, which would be one likely outcome of adopting the budget plan of the GOP vice presidential candidate, Wisconsin Rep. Paul Ryan.

“Can a pro-life voter vote for Romney if it means a 6 or 7 or, God forbid, an 8 percent increase in the number of abortions in America?” Schneck asked.

A few hours after Democrats for Life held its panel discussion Tuesday, a larger group of Democrats – roughly ten times as many – showed up at the NASCAR Hall of Fame in Charlotte for a raucous rally in support of abortion rights.

One of those Democrats with a front row seat at that rally, Annette Jurgelski from Hillsborough, N.C., whose husband is a retired doctor, said one reason she favors abortion rights is that when she and her husband moved to North Carolina for his medical training at Duke University, abortion was still illegal.

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“Women came in afterward for treatment, after an illegal abortion,” she recalled. “And in the nine weeks my husband was on that (obstetrical/gynaecological) service, they brought in a 19-year girl and they could not save her. She died after four days on the ward.”

Jurgelski said she knows there are anti-abortion Democrats and wouldn’t mind an official acknowledgement of the diversity of views within the party. But “the problem with the very, very pro-life (movement) – especially the extreme of it – is that in some cases they will sacrifice the life of the mother for the fetus and I think that’s wrong. And I’m glad there are limits over the term in which abortion can be performed.”

But at the moment there seems to be little effort on either side of the abortion divide in the Democratic Party to bring people such as Jurgelski together with those such as Dahlkemper to seek harmony. In Charlotte, each group went to its own events.

TAMPA, Fla. – Among Mitt Romney’s many virtues and accomplishments listed Thursday evening, one of his foremost achievements as governor – enacting sweeping health care reform – was noticeably absent.

Also missing from most of this week’s convention was any mention of the winding-down wars in Iraq and Afghanistan, two of the engagements that had largely defined the Republican Party for much of the past decade.

Two top officials from Romney’s time as governor of Massachusetts, Lt. Gov. Kerry Healey and Workforce Development Secretary Jane Edmonds, offered testimonials on the Republican presidential nominee’s behalf during the final night in Tampa.

Slideshow: Republican National Convention

But neither of them – and, really, none of the other speakers this week – so much as mentioned the landmark health care reform law Romney signed into law during his lone term in office.

The convention included plenty of promises to undo “Obamacare,” the colloquial name for the health care overhaul President Barack Obama pushed through Congress.

Joe Skipper / Reuters

Republican presidential nominee Mitt Romney takes the stage to formally accept the presidential nomination during the final session of the Republican National Convention in Tampa, Florida, August 30, 2012.

"We will champion small businesses, America’s engine of job growth," Romney said in his acceptance speech. “That means reducing taxes on business, not raising them … it means that we must rein in the skyrocketing cost of health care by repealing and replacing Obamacare."

“The president has declared that the debate over government-controlled health care is over,” Republican vice presidential nominee Paul Ryan said in his Wednesday night address. “That will come as news to the millions of Americans who will elect Mitt Romney so we can repeal Obamacare.”

But the convention all but glossed over “Romneycare,” the markedly similar Massachusetts law that Obama has often cited as a model for his own health care law.

Similarly, Romney made no mention of Iraq or Afghanistan, nor did former Secretary of State Condoleezza Rice, a major figure in orchestrating those two wars for the Bush administration.

The only major figure to really make mention of either of the wars was Arizona Sen. John McCain, the 2008 Republican presidential nominee.

"By committing to withdraw from Afghanistan before peace can be achieved and sustained, the president has discouraged our friends and emboldened our enemies, which is why our commanders did not recommend that decision and why they have said it puts our mission at greater risk," McCain said on Wednesday night.

Romney has struggled to distinguish himself from Obama in terms of how he would differently handle the two wars, and the economy is undoubtedly the prime issue of the 2012 election.

But the Massachusetts law has always been a more politically thorny issue for Romney, having almost tripped up the nominee during the primary fight, precisely for those similarities to Obama’s reforms.

“He is the worst Republican in the country to put up against Barack Obama,” former Pennsylvania Sen. Rick Santorum said in March of Romney because of that Massachusetts law.

Bringing up Romney’s health care law would, at a minimum, risk cognitive dissonance on the issue; at worst, its mention could stir an angry reaction from the conservative delegates gathered here in Florida.

But conventions are carefully scripted affairs that often help decipher what message a party will carry into the fall campaign. The Romney campaign made clear this week that the economy, jobs and Medicare will be at the core of this November’s election. But maybe not health care.

Kevin Lamarque / Reuters

President Barack Obama wipes perspiration from his face as he speaks Saturday in a sweltering gym during a campaign stop at Windham High School in Windham, N.H.

WINDHAM, N.H. – Speaking in a hot, crowded gymnasium here, President Barack Obama kicked off a day of campaigning in this key battleground state where he is running neck-and-neck with his challenger, Mitt Romney.

Since Mitt Romney picked Paul Ryan as the GOP vice presidential candidate, the congressman's budget proposals have become the campaign’s most hotly debated issue.  But it’s not the House Budget Committee chairman’s plan to reform Medicare that would affect today’s seniors, that redesign would impact only those who become eligible only in 2032 and later.

Medicaid is where he’d make immediate changes.

Although few of us want to admit it, once we (or our parents) become old and chronically ill, we (or they) will likely end up in a nursing home with care paid for by Medicaid.

Ryan’s proposal in his fiscal year 2013 budget blueprint: convert the federal portion of Medicaid (currently about $270 billion a year) into grants to each state, with payments indexed to the inflation rate and to the growth in state population.

Medicaid spending has been growing at a much faster rate than the inflation rate – from 2007 to 2010, Medicaid outlays grew at an annual average rate of nearly 7 percent, 5 percentage points faster than the inflation rate during that period.

So Ryan’s reform would mean a reduction in future federal Medicaid outlays. His budget blueprint, which the House voted to approve in March but which the Senate voted to reject in May, assumes $810 billion in reduced federal spending on Medicaid from 2013 to 2023 if his block grant ideas were approved.

In the House Budget Committee report accompanying his blueprint, Ryan said under his reform the states “would no longer be shackled by federally determined program requirements and enrollment criteria. Instead, each state would have the freedom and flexibility and to tailor a Medicaid Program that fit the needs of its unique population.”

Ryan head in the opposite direction from the Affordable Care Act, which imposes uniform national eligibility standards for Medicaid.

His proposal plan raises immediate questions:

• What would governors and state legislatures do if they had the freedom to spend the federal Medicaid money they now get?
• How much would states re-allocate away from some Medicaid recipients, for example single mothers with young children, and toward others, for example, elderly people in nursing homes?
• And despite Ryan’s reference to “each state’s unique population,” in most states aren’t the people who’ll rely on Medicaid the same types of people: the poor and the elderly and disabled who need long-term nursing care? So in the end how different would state-run plans really be from the current system?

According to the nonpartisan Congressional Budget Office (CBO), Ryan’s plan might allow states to “improve the efficiency” of Medicaid in delivering health care to low-income people.

Conservative policy experts point to a Florida Medicaid experiment begun under former Gov. Jeb Bush which uses managed care, financial incentives for healthy behavior, and other strategies to hold down costs. According to an analysis by the Heritage Foundation, a conservative think tank, the five-county pilot project has saved Florida up to $118 million annually.

“If Florida’s Reform Pilot experience were replicated nationwide, Medicaid patient satisfaction would soar, health outcomes would improve, and state Medicaid programs could save up to $28.6 billion annually,” the Heritage report said.

Whether similar experiments would work in other states would need to be proven, but one thing is certain: converting Medicaid into a block grant system would push decision making and political bargaining to the state legislatures and governors, rather than having decisions fought it out in Congress and in the glare of national media publicity; it might be harder for advocates for the poor to fight battles state by state for higher Medicaid spending.

A study last year by John Holahan and others for the Kaiser Family Foundation found that block granting Medicaid would likely lead to states reducing eligibility or reducing benefits for those who were eligible. Hospitals would be forced to provide more charity care to the uninsured.

“To avoid enrollment cuts, states would be required to substantially increase their own Medicaid spending to make up for the loss in federal spending,” the report said.

In one scenario, “states would be relatively protective of the aged and disabled” and would cut Medicaid spending on those groups by less than they cut spending on low-income adults and children.

Taking an opposing view is Anthony Keck, director of Health and Human Services for South Carolina and a former adviser to Louisiana Gov. Bobby Jindal.

The current Medicaid design, he said, is awkward and inflexible. Medicaid has “become a patchwork of hundreds and thousands of specific waivers” from federal rules as states seek to tailor their Medicaid spending to their needs. 

Keck said, “Every state is very different and even when you look within every state, every county and almost every zip code has very different health care problems. There are some counties that have lots of doctors, there are other counties that don’t have very many doctors. There are zip codes where the level of STD (sexually transmitted diseases) is five times the level of the zip code right next to it. So in order to focus on health, you’ve got be able to focus very specific strategies for very different realities and different populations.”

He said, “We know very well that there are extreme pockets of deprivation and poor health outcomes in the state. We know where they are. We can geo-code it perfectly. We want to go work where the problems are.” Instead the Affordable Care Act would require the state to pay for lower-middle income healthy people ith incomes up to about $32,000 for a family of four.

He added that in a block grant scenario there must be accountability for how the federal money is spent.

“If the feds are going to send down to us $4 billion a year in Medicaid money, they certainly deserve a return on that (investment) and they deserve to have a say in how it’s spent, but the sad truth is right now we don’t have any contract with the federal government that says, ‘for the money we are sending down, we want you (the state) to lower childhood obesity by 10 percent in the next five years’ ... There’s none of that, so the feds don’t know what they’re buying.”

He added that states such as South Carolina have told the federal government if it would give them more flexibility, then the states would negotiate with federal officials “goals for the programs that everybody can buy into” such as decreasing the incidence of diabetes. “We’ve never said, ‘just send us the money and let us do whatever the heck we want with it.’ We’ve said, ‘Send us the money and let us negotiate robust goals for actually improving health, and if we don’t meet those goals, then we would be open to building in financial penalties.’ ”

He added under current law Medicaid’s only goals are “cover as many people as possible and make sure nobody is stealing the money. That’s just not what this program should be about. It should be about health."

When Sen. Ron Wyden, D-Ore., formed a partnership last December with House Budget Committee Chairman Paul Ryan on a Medicare redesign, some Democrats grumbled in dismay.

Here was a prominent Democrat – a man with more than 30 years of experience in working on issues of concern to seniors and the former director of Oregon Legal Services for the Elderly – sitting on stage at a Bipartisan Policy Center event with Ryan, whom he called “my colleague and genuine friend.”

Susan Walsh / AP

Sen. Ron Wyden, D-Ore., in the past has called for a fundamental restructuring of the Medicare entitlement.

The Oregon Democrat joined the Wisconsin Republican in calling for a fundamental restructuring of the Medicare entitlement.

Sitting next to Ryan at the Bipartisan Policy Center event, Wyden said,  “There’s a window of opportunity here, a chance to change the conversation, lower the decibel level ... and see if we can bring together progressives and conservatives” to create a system in which people on Medicare choose a private-sector health plan or traditional Medicare, if they want.

Wyden said their plan was “a model driven by choices and competition, here with traditional Medicare, and approaches that would come from the private sector, innovation that the private sector offers. We believe it’s going to work ... .”

He added later at that event that their plan “makes some of the old discussion potentially irrelevant.”

If the cost containment built into the Wyden-Ryan plan works, as they think it will, then a device such as the Independent Payment Advisory Board – the outside panel of cost cutters set up by the Affordable Care Act – “almost becomes irrelevant,” Wyden said.

He added, “My hope is – in terms of politics – is that the president and anybody who is a candidate for president would be interested in looking at this.” 

Wasn’t Wyden, some Democrats asked, giving political cover to Ryan, the Republican leader on budget and spending issues? And why was he doing that?

The questions seemed especially pointed, given that only six months earlier, Democrats had successfully used the Ryan budget proposal – including his ideas for redesigning Medicare – as an issue to help defeat Republican Jane Corwin in a special House election in upstate New York.

“Despite Wyden's claims otherwise, the Wyden-Ryan plan ends Medicare as we know it, plain and simple,” said Rep. Pete Stark, D-Calif., last December. “If these two get their way, senior citizens' health coverage will depend on what big insurance offers and what seniors – most of them on modest, fixed incomes – can afford.”

The Wyden-Ryan plan would “undermine rather than strengthen Medicare," White House Press Secretary Jay Carney told a Dec. 15 news conference.

Now that Ryan is Mitt Romney’s running mate, those Democrats might have even more reason to grumble, especially if Romney keeps using Wyden’s collaboration with Ryan as a symbol of courageous bipartisanship, as he did on Monday in Miami.

“One of the things I like about Paul Ryan is he’s demonstrated ... an ability to work across the aisle, to find people who have a common purpose, who may disagree on some issues, but find enough common ground to get things done," Romney said. "For instance him coming together with a plan to save Medicare for future generations – no change to current Medicare beneficiaries or people near retirement, but for future beneficiaries, he and Senator Wyden have come together. This is the kind of bipartisanship we need more of, not less.”

After Romney touted the Wyden-Ryan partnership on Saturday, saying that Ryan had “found a Democrat to co-lead a piece of legislation” to save Medicare, Wyden issued a statement to rebut Romney on this point.

Romney, he said, “is talking nonsense. Bipartisanship requires that you not make up the facts. I did not ‘co-lead a piece of legislation.’ I wrote a policy paper on options for Medicare. Several months after the paper came out I spoke and voted against the Medicare provisions in the Ryan budget. Governor Romney needs to learn you don't protect seniors by makings things up, and his comments today sure won't help promote real bipartisanship.”

Wyden’s sudden prominence in the 2012 campaign makes it all the more important to be clear about exactly what the Oregon Democrat has and has not endorsed.

Wyden did join with Ryan in proposing changes in Medicare that would allow people enrolled in the program to choose from among insurance plans offered by private sector insurers.

As Wyden explained in an op-ed piece for The Huffington Post last March: “Wyden-Ryan doesn't privatize Medicare because Medicare beneficiaries already have the option of enrolling in private health insurance plans. Wyden-Ryan makes those private plans more robust and accountable by forcing them to – for the first time – compete directly with traditional Medicare.”

People in Medicare would get “premium support” payments from the government to help pay the premiums in those privately-run Medicare plans.

Wyden added that “Wyden-Ryan would adjust premium support payments each year to reflect the actual cost of health insurance premiums. In addition, low income seniors, including dual-eligibles (those eligible for both Medicare and Medicaid) will receive additional benefits to cover out of pocket costs – ensuring that seniors have the same choices regardless of income.”

Wyden said private plans might be able to “devise a way to provide the same health benefits as traditional Medicare for less money.” In that case, “a senior might have to pay extra if he or she still wants to enroll in the government option. But if you could get the exact same benefits for less money, why would you want to pay more?”

He emphasized that Wyden-Ryan wasn’t a finished piece of legislation but “simply a policy paper intended to start a conversation” about how Democrats and Republicans could restructure Medicare.

As Wyden noted in his rebuttal of Romney, he opposed Ryan’s budget blueprint when the Senate voted on it on May 16, just as every other Democratic senator and five Republicans, Susan Collins and Olympia Snowe of Maine, Scott Brown of Massachusetts, Rand Paul of Kentucky, and Dean Heller of Nevada, did. (Heller and Brown face competitive re-election battles this November.)

One reason Wyden voted “no” on Ryan’s budget – even though he’d worked with Ryan on Medicare redesign – is that other federal entitlement program that is crucial to the ailing elderly: Medicaid, which covers the cost of nursing home care for elderly and disabled people.

The Ryan budget turned over the federal share of Medicaid payments to the states – “block-granting” in budget lingo – allowing each state to tailor its own Medicaid program to suit its population, but also reducing program outlays.

Wyden complained that Ryan and other Republicans made a mistake in trying to alter Medicaid. “By block-granting Medicaid, they put at risk the most vulnerable seniors, the seniors who need nursing home care that is paid for by Medicaid, and since Medicaid is a Federal-State program, by block-granting it, we put at risk the most vulnerable seniors,” he said on the Senate floor.

Democratic strategists think the same game plan that they used to beat Corwin in that New York special election last year can work against other Republicans this fall – especially those who’re on the record having voted for Ryan’s fiscal year 2013 budget blueprint.

But for some Democrats, Wyden’s willingness to join Ryan in arguing that “a model driven by choices and competition” will work and “makes some of the old discussion potentially irrelevant” – is, at best, a kind of off-message dissonance and at worst a form of heresy.

Supreme Court Justice Antonin Scalia on Sunday renewed his criticism of Chief Justice John Roberts' reasoning in upholding President Barack Obama's 2010 healthcare law and also said the Constitution undoubtedly permits some gun control.

The 76-year-old Scalia - a leading conservative on the court who has served as a justice since 1986 - also was asked whether he would time his retirement in order to let a conservative future president appoint a like-minded jurist.

"I don't know. I haven't decided when to retire," Scalia told the "Fox News Sunday" program. "... My wife doesn't want me hanging around the house - I know that."

"Of course, I would not like to be replaced by someone who immediately sets about undoing everything that I've tried to do for 25 years, 26 years, sure. I mean, I shouldn't have to tell you that. Unless you think I'm a fool."

Roberts, also a conservative, sided with the nine-member court's four liberals in upholding the constitutionality of Obama's healthcare law, considered the Democratic president's signature domestic policy achievement.

Scalia joined in a sharply worded dissent on the day of the June 28 ruling and added to his criticism on Sunday.

A central provision of the law is the "individual mandate" that most Americans obtain health insurance by 2014 or pay a penalty. The ruling found that this penalty "may reasonably be characterized as a tax" and thus would be constitutionally permissible under the power of Congress to impose taxes.

"There is no way to regard this penalty as a tax. ... In order to save the constitutionality, you cannot give the text a meaning it will not bear," Scalia said.

"You don't interpret a penalty to be a pig. It can't be a pig."

Supreme Court justices rarely give media interviews. Scalia is making the rounds to promote "Reading Law: The Interpretation of Legal Texts," a new book he co-wrote.

Scalia brushed off Obama's comments aimed at the court regarding the healthcare law and a campaign finance ruling.

"What can he do to me? Or to any of us?" Scalia said. "We have life tenure and we have it precisely so that we will not be influenced by politics, by threats from anybody."

He was asked "why you push people's buttons every once in a while." Scalia said, "It's fun to push the buttons."

Gun control

Scalia wrote the high court's 2008 ruling that a ban on handguns in the U.S. capital violated the right to bear arms enshrined in the Constitution's Second Amendment.

In light of the July 20 massacre in which a gunman killed 12 moviegoers in Colorado, Scalia was asked whether legislatures could ban the sale of semiautomatic weapons.

He said the 2008 ruling stated that future cases will determine "what limitations upon the right to bear arms are permissible. Some undoubtedly are."

Scalia - a proponent of the idea that the Constitution must be interpreted using the meaning of its text at the time it was written - cited "a tort called affrighting" that existed when the Second Amendment was drafted in the 18th century making it a misdemeanor to carry "a really horrible weapon just to scare people like a head ax."

"So yes, there are some limitations that can be imposed," he said. "I mean, obviously, the amendment does not apply to arms that cannot be hand-carried. It's to 'keep and bear' (arms). So, it doesn't apply to cannons. But I suppose there are handheld rocket launchers that can bring down airplanes that will have to be ... decided."

Regarding the death penalty, Scalia said opponents want it struck under the ban on cruel and unusual punishment included in the Eighth Amendment of the Constitution.

"But it's absolutely clear that the American people never voted to proscribe the death penalty," he said. "They adopted a cruel and unusual punishment clause at the time when every state had the death penalty and every state continued to have it. Nobody thought that the Eighth Amendment prohibited it."

Scalia also took issue with decades-old Supreme Court precedent, saying the Constitution does not provide Americans with a right to privacy, despite a landmark 1965 ruling finding that it does. That ruling helped pave the way for the court's 1973 ruling legalizing abortion.

"There is no right to privacy - no generalized right to privacy," Scalia said. "No one ever thought that the American people ever voted to prohibit limitations on abortion. I mean, there is nothing in the Constitution that says that."

Scalia also was asked about his past criticism of rulings by Supreme Court colleagues in which he called them "folly" and "sheer applesauce."

"I don't know that I'm cantankerous," he said. "I express myself vividly." 

The Congressional Budget Office said Tuesday that due to the Supreme Court’s June 28 decision on the 2010 health care overhaul, the law will cost $84 billion less over 10 years than CBO had previously estimated.

But CBO said 3 million more people will be left uninsured compared to its previous estimate of the number of uninsured in 2022 – that’s because at least some states are expected to forgo the Medicaid expansion that had been mandated by Affordable Care Act (ACA).

“Fewer people will be covered by the Medicaid program, more people will obtain health insurance through the newly established exchanges, and more people will be uninsured,” the CBO said in its report Tuesday.

The law – as upheld and limited by the Supreme Court – will leave 30 million nonelderly U.S. residents uninsured by 2022, the end of the budget forecasting window.

Before the Supreme Court’s decision, the CBO had estimated the number of uninsured in 2022 would be 27 million.

The CBO issued its new estimate based on its assessment of the effects of the Supreme Court’s ruling, which upheld much of the ACA but also said the federal government couldn’t coerce states into acceding to the law’s expansion in the number of people eligible for Medicaid coverage.

The court ruled that the federal government couldn’t penalize states by withholding all their federal Medicaid funds if they chose to not participate in the expansion, which is set to take place in 2014.

If some governors and legislatures opt out of the expansion, about 3 million people who would’ve been covered by the expansion will be eligible for more expensive taxpayer subsidies in the new health insurance exchanges set up by the law.

Some governors – such as Govs. Rick Scott of Florida and Rick Perry of Texas – have said their states would not participate in the Medicaid expansion, but it’s still too soon to know which states will adopt the program and which ones won’t.

The CBO said Tuesday “the reductions in spending from lower Medicaid enrollment are expected to more than offset the increase in costs from greater participation in the exchanges.”

That will be true, it said, “despite the fact that the government’s average additional costs per person in the exchanges will be greater than its average savings per person for those who, as a result of the Court’s ruling, will not enroll in Medicaid.”

It explained that the number of additional people entering the exchanges as a result of the Supreme Court ruling will be “only about half the number who will not be obtaining Medicaid coverage, many of whom will be ineligible to participate in the exchanges.”

The CBO emphasized the uncertainty in its projections. It said, “How flexible executive branch agencies will be regarding the choices that states will have — particularly states’ options for pursuing partial (Medicaid) expansions — is unclear. Hence, what states will be able to do and what they will decide to do are both highly uncertain.”

Two weeks ago in previewing the CBO’s new estimate, former CBO chief Doug Holtz-Eakin, now president of a conservative advocacy group American Action Forum, pointed out that since expansion does not take place until 2014 governors and state legislatures have time to weigh the costs and benefits of the Medicaid expansion. “It’s a far from obvious decision. They should take their time and do the calculus carefully,” he said.

Under the ACA, the federal taxpayers will pay 100 percent of the cost of covering the people made eligible for Medicaid for the first two years and then will pay 90 percent of the costs for the newly eligible until 2020, at which point the normal federal matching formula would apply. That matching formula varies depending on per capita incomes of people in each state -- so poorer states such as Arkansas have more of their Medicaid costs paid for by the federal taxpayers than richer states such as Connecticut do. The minimum federal match is 50 percent.

Early in 2010, the CBO had estimated that the entire ACA would cause a net reduction in federal deficits of $143 billion over the 2010-2019 period. It estimated that the additional cost of providing insurance to 32 million more Americans would be more than offset by cost savings imposed on Medicare and the tax increases in the law.

That CBO estimate was crucial since it gave some congressional Democrats in competitive districts and states the political cover they needed to vote for final passage of the bill.