The Hill reports that Paul Ryan's budget committee will propose huge Medicare and Medicaid reforms. The Democratic response is gonna be epic. The fight over public opinion for block granting Medicaid is probably winnable, but even that will take some care. Reformers will have to lead with the present broken condition of Medicaid and present the block granting as a way to let states produce better results with less money. The fight over Medicare will be much harder. Almost everyone is a current or prospective stakeholder in Medicare. Defined contribution Medicare (where the government gives a set amount of money and the recipient uses the money to purchase from a range of health care plans) is a policy proposal that is almost entirely unknown to the public. I would be surprised if one in fifty Americans could accurately describe defined contribution health care. If you were to write down a neutral, one sentence description of a defined contribution version of Medicare, I suspect most respondents would not prefer it to the present system. One of the most important facts in this debate is that most people would keep things going as they are - if they could. They would want Medicare to continue to pay at the projected (pre-Obamacare cuts) level and for the resulting burden to not crush the economy. Well that isn't going to happen. There are going to be limits placed on Medicare spending. The only question is whether those limits will be more of the kind centralized, sudden, and dumb cuts we saw in Obamacare, or whether we will have more market-oriented reforms that increase the productivity of the health care sector and let the elderly pay for the services they want rather than the services some bureaucrat wants them to have. A few pieces of advice from an amateur for Paul Ryan:
1. Defined contribution is a terrible way to describe the conservative version of Medicare. So is is voucherizing and privatizing. It should be called patient-centered Medicare for future retirees. It should be conservative patient-centered health care reform that allows the (future) elderly to purchase the services they want vs. bureaucrat-centered Medicare cuts where some agency just says no. It should be innovation, choice and better health care vs. death panels.
2. Medicare reform is a comparative issue. We are really facing tough choices and those who say otherwise are liars who want to cut your health care. There are two major ways of bringing down Medicare spending to a sustainable level. The Democrats will cut your benefits and leave you with no other options. We see that in Obamacare's plan to reduce provider reimbursements. The Obamacare plan is to pay your doctor less, thereby making it harder to get medical care. Multiply this approach across all your medical needs. And the Democrats are doing this to current retirees. Sometimes the government will just tell you no. More often the government will find sneakier ways to deny you care (creating waiting periods or paying at artificially low rates so that a service becomes unavailable.) They will nickel and dime you to death. This is the future under the Democrats and they have already started building it. Republicans need to explain that patient-centered Medicare will force providers to reorganize to provide better care for the elderly at a lower price, and that this is much better than the Democrat plan to give you less care when and how the government says so.
3. Ryan is articulate, energetic and smart, but he can't be everywhere at once. I assume most Republican members of Congress will be hopeless at explaining this issue past a couple of talking points. Some Republican members of Congress are quite old and have lost something off their fastball. Some are hacks who are just there to be there and aren't about to take on a complicated and controversial issue with enormous political downside risk. They will run for cover after the first AARP blast email. Some have real limited government principles but have demonstrated little ability (and perhaps little interest) in communicating to people who haven't already bought into the conservative narrative. Some congressional Republicans fit into more than one of the above categories.
Ryan needs to get together about twenty congressional Republicans to be the voices of the GOP on this issue (and one of them should be Marco Rubio.) They need to know the facts and the arguments inside and out, and have their responses honed to the second. Then they need to go everywhere and explain, explain, explain. Congress won't pass patient-centered Medicare this year or next. This is a public education effort and those most principled and articulate of Republicans need to be ready. They won't get another chance to make a first impression with the public.
Pete's very sobering post below on the difficulties of the coming war over entitlement spending prompts a thought on the comparatively minor skirmish over public employee compensation and union power. If Republicans actually succeed in curtailing... Read More