• Ryan, Wyden, and the health care reform debate

    I have already answered my 10th email of the morning asking me what I think of the Ryan-Wyden plan for Medicare. The short answer is: it hasn’t been fully released yet, and I can’t comment on something until I’ve had the chance to evaluate it fully.

    But here are my gut thoughts based on what I’ve seen so far. I agree that – as described at the moment – this seems like it’s making Medicare more like the ACA in the future, but with a big difference. It sets actuarial minimums, it demands guaranteed issue and community ratings, it sets the subsidies by competitive bidding, and it allows for plan switching. But it’s different than the ACA in that it contains a fee-for-service public option.

    I expect that those who are dyed-in-the-wool single payer supporters will oppose this, as it can be seen as the first step towards dismantling traditional Medicare. I expect that those who are dyed-in-the-wool free marketeers will oppose this because it doesn’t do enough to dismantle traditional Medicare. But everyone else is going to be in a bit of a pickle.

    I’ve often been snarky towards those who think that a single payer system is American as apple pie if you’re 65, but communism if you’re 64 (I’m looking at you, Congress). But if this proposal picks up steam, it will flip things for many people. It will be hard to argue that the ACA is a viable, progressive solution for universal coverage if you’re 64, but free-market-heartlessness if you’re 65. And many who wholeheartedly supported the ACA will find themselves in that position moving forward. After all, this program even has a public option.

    Moreover, with Ryan’s support, many who want to repeal the ACA may soon be in a similar spot. How do you support this plan as a sensible solution for universal healthcare if you’re 65, but believe that it’s tyranny and the end-of-freedom if you’re 64? After all, the ACA doesn’t even have that public option.

    Now, if no other Democrats besides Sen. Wyden and no other Republicans besides Rep. Ryan support this, then they’ve just gone out on a limb, and nothing will change. But Ryan is not the most liberal of Republicans, and Wyden is not the most conservative of Democrats. I think it’s likely that others will sign on. When that happens, the whole dynamic of the discussion could change. That is, if the media is paying attention, and can learn to ask good questions.


    Note from Austin: My post on the Wyden-Ryan plan will appear at noon. Many questions will be answered and many asked.

    • I don’t nessisarily agree that it will be that hard to hold both positions. I think it all depends on the status quo going in and those are very differnet for the above 65 and the below 65. ACA (or Ryan-Wyden) are in the middle between the 2009 status quo for the above and below 65 populations. What would be really interesting is if Democrats tried to get a public option (or even Medicare buy-in option) in ACA as an exchange for doing this work in Ryan-Wyden. That would get us closer to a point where the status quo for both populations are the same.

    • The private plans will cherry pick the lowest cost participants, leading to ever increasing costs for traditional Medicare.

      The result will be higher overall costs for Americans, with possibly lower costs for taxpayers. In other words, high income taxpayers benefit, with everyone else losing.

    • There are differences between the ACA and the Wyden-Ryan plan, though. Of all the complaints about the ACA from Republicans, I’ve never heard anyone say that the exchanges themselves are a bad idea. As someone on that side of the aisle, I support the idea of exchanges. I think it’s a good idea to make insurance plans clearer and comparable. But I don’t support most of the details surrounding them–the individual mandate, forcing companies to insure young adults, guaranteed issue, the free-ness of birth control, the ACA’s rules about businesses paying fees for uninsured employees, the loss ratio rules, IPAB, etc. So I can conceivably disagree with the ACA and support Wyden-Ryan.

    • “It will be hard to argue that the ACA is a viable, progressive solution for universal coverage if you’re 64, but free-market-heartlessness if you’re 65. And many who wholeheartedly supported the ACA will find themselves in that position moving forward. After all, this program even has a public option.”

      Certainly that’s the argument that Paul Ryan will make and that David Gregory will try to nail Democrats with on Meet the Press, but it’s obviously ridiculous. Along with many (most?) familiar with the issue who would’ve preferred a public option, I think that American healthcare will be much improved by the ACA, that universal public insurance would be better, and that universal public care would be ideal. The evidence is simple: a boatload of other countries do this (some with higher poverty and obesity rates and higher costs of living) and it’s cheaper.

      As easy as it is to come up with this argument in favor of their plan, it’s easy to come up with an argument against it. Presumably they’ll claim the plan saves money… the money comes from somewhere: health care subsidies, Medicare, and Medicaid. You pay someone to conduct a hasty study that adds all these numbers up and say that RyWydencare’s going to cut however many hundreds of billions from healthcare over 10 years and kill who knows how many old people and children. That’s the mindless tactic that moved public opinion on the ACA by, what, 20 points or more?

      For what it’s worth, my ideal healthcare law would be three lines long:
      1. Congress sets the total annual appropriation for national healthcare, with some fraction held in escrow each year.
      2. HHS spends this money as it sees fit to regulate insurance, provide insurance, provide care, regulate drug prices, etc.
      3. Regional, age, and economic disparities in care must be minimized as is practical. The courts can enforce this vague rule as they see fit.

      By placing unlimited authority for various aspects of care with the three branches of government, the health care system can both be agile and also responsive to public pressure. Not enough money being spent on healthcare? Vote (D) for Congress. You think market-based solutions will more efficiently spend money? Vote (R) for President. Are folks in Wyoming getting shoddy care? Lobby your representatives to confirm judges more sensitive to urban/rural inequality. Think we were better off before? Vote for representatives that will kill the program. Requiring it to be paid for on an annual basis satisfies any deficit concerns.

      If I had to sell such a plan, I’d do nothing but appeal to nationalism. Come up with two easy-to-understand numbers measuring care cost and care quality, stick with them, and find some Al-Gore-like figure to dedicate their life to saying that the States should be the best country on both scores. Say that all we have to do is copy England and we’d halve our costs and improve our care, but why stop there?

    • I do not agree that the holding the two positions are at odds. I supported the ACA because it is better than the status quo. However, the status quo for Medicare is better than this new proposal IMO.

      Therefore, I oppose the new proposal and support the ACA. It’s really pretty easy.

      I could warm up to the new proposal, but my sticking point is the cap on maximum growth of Medicare spending regardless of whether or not healthcare gets more expensive. Bringing down the cost of Medicare, without bringing down the cost of healthcare in general, is simply a backdoor way of providing less Medicare.

      • Understand, I get that it’s possible to thread the needle. But you’re arguing in a way that few politicians do. They say things like “tyranny” or “universal coverage is achieved” in ways that make doing so nearly impossible. If we had a real press corps.