• Wait! Defenders of Medicare have a point

    And I’m not sure Matt Miller articulated defenders of current Medicare’s point properly. I’ll get to that. First, Miller’s main point is that we should keep premium support on the table as an option. I agree, provided we recognize that the precise nature of that support matters and matters a lot. For what types of plans will it be available (public option included?) and how is it set and indexed (will it keep pace with health care costs?)? These are crucial questions.

    Now to Miller’s critique of Medicare defenders.

    [T]he Democratic case on Medicare (as well as the GOP’s case last election) is therefore caught between two claims that can’t both be true: (1) we spend much more on health care than anybody else without better results; and (2) if we cut the growth of this spending to below the rate of GDP growth, we’d have to curtail Americans’ access and quality of care. No matter how often and how loud the interest groups, politicians and other forces of the status quo scream the latter, it cannot be true if the former is a fact.

    Sorry. Wrong. Both (1) and (2) can be true. Let’s take (1) as given. How can (2) still be true? It’s true in the sense that we have no idea how to cut spending and, crucially, spending growth, without harming access to both health protecting and preserving care and unnecessary care.

    Every real-world study I can recall that has examined how broad changes in health care financing play out (by which I mean changes that might actually bend the cost curve, not just shift the level of spending) concludes that, at a minimum, some groups get less of both necessary and unnecessary care. The stylized fact is that half of forgone care was actually valuable care that should have been delivered. That’s a loss in access to care and to the quality of care received. That’s point (2).

    Just because (1) and (2) are both true, despite what Miller says, does not mean we should not make changes to Medicare or that we should stop looking for ways to deliver more necessary, high quality care and less unnecessary care, hopefully saving money by doing so. In that, I think both Miller and I agree.

    • I also wonder where Miller got his numbers claiming that Ryan’s plan would be generous in other countries. Under the Ryan plan, seniors will receive only about 1/3 the value of their premium by 2030 (2035?). I cannot think of another OECD country with decent medical care which costs 1/3 what ours does.

      I wonder what the chances are of getting an amended Ryan plan that would offer a public option to compete with the private plans? Reset the index and we could have a half decent plan.


      • Without going back to the piece, I thought Miller was using the starting value of the subsidy in 2022, not 2030. Given the erosion rate that makes a big difference.

        Agreed on your last paragraph.

    • Exactly,

      The hidden assumption in Matt’s piece is that we can identify and easily cut unnecessary, wasteful or useless spending.

      Given, among other things, that the Republicans are actively campaigning against provisions of the ACA which aim to do exactly that, and that one person’s waste is another’s income, his hidden assumption is very far from obvious.

    • The logical conclusion of those two statements also imply

      Are there any medicare defenders who do not accept that the program needs to be slimmed down and waste trimmed?

      It seems that if there were a lot of medicare defenders who were proposing that we keep the program waste and all, this might be a point, but I don’t seem to know any medicare defenders who aren’t bound by the same problem of eliminating structural waste and harming outcomes unintentionally.

      Medicare defenders: We can maintain the medicare system as it is with some changes to trim waste and cut costs.

      Ryan Budget defenders: Medicare is fundamentally screwed, if we switch to a consumer driven policy, we can change incentives to increase efficiency (I don’t actually buy that).

      Medicare defenders: Don’t listen to him! You can’t cut medicare spending without hurting seniors!

      The criticism needs to have two characteristics:

      1. That it is true.
      2. That it is a unique consequence of the plan.

      In this case, the criticism is universal of all attempts to tackle medicare, so it really isn’t a valid criticism of the Ryan plan.

      So, do you believe that the ACA won’t either leave costs rising unabated or curtail some access? Is there anyone who has proposed a plan for dealing with medicare that won’t curtail access to some degree? While it may be true that you cannot control costs without curtailing some access and care, it is very hypocritical to point that out in a critique of a reform plan, and then defend your own reform plan without acknowledging the same thing (which has been the purpose of the “other countries spend less with better results” meme).