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A Better Strategery And Better Chosen Ground

Rich Lowry is wondering whether the Medicare cuts in Paul Ryan's Path to Prosperity will sink the plan.  You can look at the public polling and conclude that restraining Medicare spending is a lost cause, but not so fast:

1.  Reforming Medicare is a comparative issue.  It is (or ought to be - if the Republicans are minimally competent) a choice and not a referendum on one particular approach.  We aren't really arguing about Medicare cuts.  We aren't even arguing about Medicare cuts vs. tax cuts.  President Obama has already cut Medicare by hundreds of billions.  He has now proposed to cut Medicare by over a trillion more.  He has proposed to give a panel of unelected bureaucrats the power to impose service cuts.  So our choice is a market-oriented reform in which seniors would have more options (and maybe more disposable income) and a centralized government system in which the government slams the door in your face when and how the government decides.  Even so, the Republicans could still lose this argument because...

2.  The Republicans still need a better plan.  As Josh Barro wrote, they need more credible funding proposals for Medicare.  Keeping a defined contribution version of Medicare FFS would be good politics and good policy.  As Capretta and Miller pointed out, there will be circumstances where a defined contribution Medicare FFS would offer the best product at the most competitive price. This would also reassure some fraction of the public that Medicare FFS would still be there, but within a system that encourages health care providers to orient themselves to patients rather than bureaucrats and would give patients choices between different provider networks that competed on extent of services (past the government-mandated minimum) and cost.   

Categories > Politics

Discussions - 11 Comments

Insurance companies are for-profit businesses, therefore, they want to expend the least amount of money relative to the amount that they bring in through premiums. Doing otherwise would not maximize their profit, and bring the greatest benefit to their shareholders. Insuring the elderly, where the greatest amount of money is spent on health care issues is a losing bargain for any insurance company.

I have a friend who is about 70 and who has been diagnosed with Pancreatic cancer. Before they can even deal with the cancer (at MD Anderson, no less), they have had to get a raging infection under control. His wife estimates that their personal contribution to his care thus far is close to 6 figures....think of what Medicare is about to pay! What actuary would ever in his or her right mind recommend that a private insurance company pay for this level of care?

Rationing is going to happen no matter what, and it should. Just because we have the technology doesn't mean we should always use it. The question is, who is doing the rationing? A private insurance company where, once you've been denied coverage your pre-existing condition will render you uninsurable for any other insurance company, and where there is no profit benefit from expensive patients, or a system where there is at least some level of social contract, however tenuous?

Personally, I know which one I'd choose, and if you have parents who are elderly, or if you've ever tried to negotiate the insurance maze for minor medical stuff when you have all the cognitive strength of youth or middle age, I think the answer is simple.

George, yes health care is a limited resource, but it matters whether providers have incentives to become more efficient to get customers or just offer whatever services the government will pay for in an environment where consumers rarely see prices. We can get more from our dollars if providers are oriented to getting us to give them money under our control. I'm not sure why, given premium support, you think insuring the elderly is unprofitable (though funding levels matter.) People had similar concerns about Medicare Part D and the program combines savings to the government and choice among private plans with patient satisfaction. At the very worst, under the Capretta-Levin plan you still get Medicare FFS though with fewer resources - in other words you get what you seem to prefer. In a competitive insurance market, you would have choice of what services (over the government guaranteed minimum) you could pay for. If you wanted less coverage for certain higher cost and low success rate procedures you could have more disposable income. If you wanted more coverage, you could pay for coverage of more procedures (most of which you will not need.) I'm not sure why you would prefer a government monopoly provider in which you (unless you were very wealthy in such a government-oriented health care market), there is no appeal from a government refusal of service and decisions are made based on a given moment's economic and political considerations and where there is no legal remedy for breach of contract - because there is no such contract. You are right that it would be easy in one sense, but not in one that I would prefer.

Paul Ryan is a huge Ayn Rand disciple. When she wasn't cashing her own social security checks she was gung-ho on espousing her own true elitism (and fervent atheism - yes, have an extra helping of irony!). The deserving rich should hoard their wealth and altruism is a form of "evil," yada, yada, yada. Familiar stuff these days.

I wonder what Joe the Plumber thinks of Ryan's various policy prescriptions.

Craig, a pointless stream of free association (Joe the Plumber?) without a mention of Palin? Are you feeling okay?

Pete, you're delusional if you think there's an appeal from the insurance companies. Part of this whole fight over health care is because of the deplorable way that insurance companies treat patients who have their policies.

I am, however, curious about what you consider to be an acceptable "government guaranteed minimum" level of coverage...what specifically should be covered under such a plan? Perhaps it would be easier to say which parts of Part A and B should not be considered part of a "government guaranteed minimum."

George, I agree that there are some people who would like to do away with private insurance altogether, though it seems to me that most American with insurance coverage are satisfied with the care they get. And that includes those on Medicare Part D. That was why "this whole fight over health care" did not include doing away with private insurance despite Democratic supermajorities in Congress.

I'm open-minded about how the definition of minimum benefit would end up being under a defined contribution version of Medicare. There is, under any conceivable system, going to be a "core benefit" as Capretta and Miller explain. Defining a core benefit (at whatever rate of cost growth we agree on) and letting plans compete on offering that benefit and other benefits seems more transparent, sensible, and humane than putting people in a one size fits all system and letting a government panel deny treatments based on the political and economic considerations of the moment. Perhaps one particular plan will offer higher cost sharing for physical therapy in return for lower premiums and greater disposable income. This is preferable to my experience with Medicare in which government policy first stimulated an oversupply of physical therapy to the elderly (since it paid bills almost without question and it wasn't like the elderly in question had the option of refusing the therapy and using that money for other purposes - it was either use the service or lose it) and then, after a policy shift produced an undersupply and helped drive multiple nursing homes out of business. It would have been cheaper and better for everybody if the consumers and providers could have found each other. This tack is especially useful in younger and healthier people, but it has its uses for the elderly too.

Pete - when dealing with long-winded nonsense, I don't typically feel the need to offer fully-formed, precisely written thoughts in response.

Suffice it to say that Paul Ryan's open adoration for Ayn Rand is probably a good indicator of why Ryan is out to abolish Medicare (for starters). It could be seen as some kind of altruism.

I'm sure any mention of Ryan's collecting Social Security as a teenager and using it to go to a state-funded public college (which is fine by me, but still hypocrisy on a brain-crushing scale - imagine if Obama had done that! Just guess what the NLT/Tea Party response would be - be honest, if possible) is also, in your realm, just irrelevant "free-association," too.

I hadn't thought of Palin regarding this subject (Ryan's Randian efforts to abolish entitlements), and still don't. I'm guessing she hasn't read any Ayn Rand and her views on Medicare, Medicaid, the deficit, and the budget would make my worst examples of pointless free-association look like (hmmm....what impresses NLTers?) a Jonah Goldberg column.

There was a reason I inquired about Joe The Plumber's take on this matter, but I won't elaborate on that.

Wow, I wonder if he drove on government-owned roads, too. What a hypocrite!

"I don't typically feel the need to offer fully-formed, precisely written thoughts in response."

No you don't. Suffice it to say that a program of redistribution that spends trillions of dollars (which the Ryan Plath To Prosperity does) not "abolish" entitlements and would not be part of any Ayn Rand political program.

Your Social Security point is silly and you ought to spend a moment thinking about the liberal talking points you repeat. Ryan's Path To Prosperity did not offer any Social Security proposals, but the Ryan Roadmap's reforms of Social Security would be more downward redistributive than the present system (smell the Randianism!) The reason you find Ryan's collecting Social Security as a a teenager hypocritical is that you are caught in a web of self-validating delusions. That doesn't mean there aren't nonidiotic reasons to object to Ryan's policy proposals

I'm the anonymous fellow.

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