The Problem with the Ryan Plan
The bottom line is that the problem with the Ryan Plan is the Ryan Plan.
To follow on to Doug Mataconis’ post this morning about declining public support for the Ryan Plan, I can suggest one basic reason why it is trending downward: people are starting to learn more about it.
That support is eroding is not surprising when we consider that initial support was built on the following three pillars:
One pillar was the true believer, a group made up of persons ideologically predisposed to like any program that contains such concepts as vouchers, market forces, and block grants (not to mention tax cuts). I know, because not only is this the obvious constituency but also because there would have been a time that I would have reacted in an automatically positive fashion to all of these buzzwords (I have, however, grown skeptical of their magic over the years in this policy area).
The second pillar was hope. A lot of people were initially hopeful that the Ryan Plan was a truly serious policy prescription that could deal with our most pressing long-term fiscal problem, i.e., Medicare. Of course, the irony that people who made a lot of fun of all things hopey-changey would be so vested in hope-based policy ideas should not be lost. An example: I heard an interview with a fellow from the Cato Institute this morning talking about how consumer choice with put downward pressure on prices and said a series of other very serious (and hopeful) about how the Ryan Plan would fix health care costs. However, there are two rather significant problems with this approach. First, the notion that health care/health insurance is the same as any other product is flawed due to the essential nature of the product (health and a better life). Second, this is especially so for senior citizens, when health care because even more essential for quality of life, and where the odds that one will need extensive care increases substantially. (I would note that pillar two remains strong with the pillar one folks, but is eroding with the general public).
The third pillar was courage.* We were told by almost anyone who spoke of the Plan (including the dreaded liberal media) that Ryan’s Plan was “courageous” (or some other superlative). As such, it is hardly surprising that initial responses to the Plan were largely positive. And, I will state, that Ryan does deserve some credit for making an actual policy proposal and I would encourage more attempts in that realm. Fundamentally, it was always going to be the case that the Plan was going to start out at the apex of its popularity and then decline from there. Why? Because the initial press was a combo of hope and courage, with promises of saving to boot. What’s not to like about that? Answer: the actual details of the Plan.
Now, pillar one remains in place.
Pillars two and three, however, are taking serious hits because people are starting to learn more about the Plan’s contents.
There are legitimate questions that call the Plan into question from a policy perspective and there are two key ones. First, the Plan substantially restructures Medicare and changes it from a clearly defined, guaranteed benefit to a more nebulous program. Yes, seniors would be guaranteed a voucher, but they are on their own from there. Second, apart from hope (back to that word) that market forces and state-run (via block grants) programs will lower costs, the Plan does not directly address the health care cost question, which is at the heart of the need to reform Medicare in the first place.
So, in other words, the Plan does not promise the same level of benefit that the current program does and it fails to deal with the cost issue.
Is there any surprise, then, that the Plan’s approval numbers are falling?
And, btw, have I mentioned lately that Medicare is a wildly popular program, amongst Democrats and Republicans? That might be part of the Plan’s trouble as well.
——
*And I mean neither a certain cowardly dog nor Dan Rather’s sign-off.
“Second, apart from hope (back to that word) that market forces and state-run (via block grants) programs will lower costs, the Plan does not directly address the health care cost question, which is at the heart of the need to reform Medicare in the first place.”
So the problem is that it doesn’t force rationing? Yeah, people are probably all ticked that there’s no rationing instead of being swayed by the lies the media and the left are telling them about “cutting” Medicare, “ending” Medicare, “trashing” Medicare, “destroying” Medicare, and granny out in the snow scenarios. You’re right, they’re mad that his plan doesn’t force rationing and actually cut Medicare like Obama’s plans.
Oh, and seniors support his plan more than other groups, so tossing in the bit about people liking Medicare is pretty much another red herring.
So, just adopting the hope and change mantra is a better option?
It seems we are always counselled about the need to be practical and accept what is politically possible, even if it leads us over a cliff. I saw another post that now 51% of the public doesn’t pay income taxes. Is there any wonder why the requests for free stuff just keep growing, as does the number of bastards lining up to promise them they can have it forever? Can we call it the budget deficit and the national debt the tyranny of the majority now?
My problem with the Ryan plan, such as it is, is that it still doesn’t go far enough fast enough to restore fiscal sanity. I guess that makes me one of those true believers or idealogues, though I find your casual dismissal of free market initiatives as magical thinking disappointing, but it does help to explain the change in your thinking over the past year or so.
I am a big fan of markets as a general proposition.
However, the question becomes: does market logic work here? Hoping that it will is insufficient.
First, as much as we might not want it to be the case, the empirical evidence shows that countries with more government involvement in health care actually provide quality care more cheaply. We have to at least deal with that fact.
Second, health care decisions are not made in terms of basic market forces. See here for a nice discussion. Moreover, as a parent you know full well that decisions about one’s children’s health is not simply a cost/benefit analysis (nor is it with an elderly parent).
I will also note that you have bought into the magical thinking that health care is not a product or service just like everything else we buy and sell in life, exempting it from competition, market forces, and the invisible hand by governmental fiat, which gives you a convenient “no true Scotsmen” approach to any solutions that don’t promise more care for less money every year as far as the eye can see. Now, that’s some magical thinking.
Dr. Taylor, I apologize for for being tedious and tendentious, but I can’t help but state once again that the perfect remains the enemy of the good and all the criticism I see of anything like the Ryan plan seems to focus only on it’s not being perfect. Perhaps I am being unfair in grouping you in with this kind of thinking which permeates the airwaves and comment threads.
Probably the stupidest thing I will read all year. The Ryan plan does force rationing. It rations health care by cost. If you can not afford it, you won’t get it (as things are now in this country). The lie that health care is not rationed in this country needs to die.
Gee Charles, someone posted that 51% of the public does not pay income tax? Well by all means, let’s just accept that as a fact and base national policy on it.
I think you fully misunderstand the issue here. There are many things in life that do not conform to markets. Human rights, for example, public goods for another.
Think, for example, what our system of roads would be like if we used only market forces to determine their construction and design.
As mentioned above, of course it rations. Not just on cost, but also at a rude age cut-off.
(yes, I am on the wrong side of it.)
I thing Charles’ angst is ultimately amusing.
The game in Ryan’s plan, to simply cut health care(*), and then taxes, didn’t fly.
* – not just a cut in spending, but a cut in care.
1-) I always said that the problem of Medicare is precisely the *lack* of rationing, not that will be rationated in the future.
2-) The problem with the Ryan Plan is that the problem in the US is not that the health insurance in the US is expensive. The problem is that health care costs are expensive; In Brazil, I see low wage workers paying medical bills out their pockets. That´s unthinkable in the US.
Like Obamacare, Ryan´s Plan does not deal with that.
3-) A subsidized(Or voucherized) market is not a free market.
4-) The problem of Ryan is that like his former Boss he learned the wrong lesson from the Laffer Curve.
Andre’s on to something. Open immigration and recognize foreign medical degrees, and our costs would fall. But I guess we are somewhat conflicted. We want doctors and nurses to be rewarded, and we want low costs.
I am sitting in a hospital waiting room at the moment, my 78 year mother is having surgery today. Spending time like this with her like this, it is quite clear to me just how poorly equipped she is to deal with the whole thing. People give her papers and ask if she understands them. It’s clear to m e that she does not. She says she knows where she needs to go, but she is obviously somewhat confused and disoriented.
Now my mom is a bright woman, but she is almost 80, she has cancer, and she is scared. And the GOP plan for people in her position is to hand them a voucher and say “best of luck granny”.
The only thing I can figure is that conservatives simply lack the imagination to understand that, barring early death, they and everyone they love will one day be old, sick venerable, and eventually helpless. One can only hope that Americas elderly will have the foresight to raise a lot of chickens, thus ensuring adequate health care for themselves…
@anjin-san:
Your situation hits very much at the core of the problem.
And I hope that your mother’s surgery goes well.
Steven Taylor, I appreciate that you’re an open-minded, reality-based conservative, unlike many closed-minded free-market ideologues commenting here.
Good luck to your mother, anjin-san. You nailed it: a lot of people have a severe lack of empathy and compassion. I think in a lot of cases they’re deluding themselves and covering up simple selfishness with a belief in a magical free market that will somehow make things okay for everyone.
charles austin, the UK does an excellent job of containing medical costs. The per capita medical bill in Great Britain is 41% of ours, the infant mortality rate is lower than ours, and the life expectancy at birth is greater than ours depite the fact that the Brits are almost as obese as we are and smoke a lot more. So if all you’re concerned about is containing costs, you should be demanding that the VA be expanded so that it provides medical care for everybody, not just veterans. If, instead, you prefer that physicians continue in private practice, you should demand a single payer system by having Medicare cover people of all ages. The health statistics in single payer countries are as good as Great Britain’s and the costs are only a little higher. Or if you don’t like a government agency providing your health insurance, you should favor the “sickness society” approach introduced by Otto Bismarck and now employed widely in western Europe.
I think your primary interest is in keeping government small and taxes low, without regard to the consequences. If I’m wrong, I apologize. If I’m right, you should stop pretending that you care about the cost of medical care.
One obvious problem I see with the Ryan plan is what happens when 2022 arrives? Does he expect the future politicians will make the changes that he apparently won’t make now?
Brings new meaning to “better dead than red” doesn’t it?
.
Obviously you haven’t looked very far, as that is hardly the only criticism of this plan…
Then there’s the slowly dawning realization that folks 65 and older, with the attendant ravages of age, would find it, and I don’t want to be overly harsh here, goddamned fvcking difficult to find an insurance company that would take them on. Age, in case some youngsters are not aware, is the preeminent preexisting condition.
Steven & Reid… thanks, the prognosis is good, due to excellent care leading to early detection. Sitting here in this fine hospital, with an outstanding surgical team getting ready to go to work, I am acutely aware that millions upon millions of my fellow citizens in the richest country in the history of the world are not so fortunate.
Best wishes for a speedy and easy recovery to your mother, anjin.
I read somewhere that almost 1/3 of medical costs are paperwork related.
I’m always amazed when I see big racks of hard copy medical records stored in a doctor’s office instead of everything being stored electronically.
Falze,
Sell your BS someplace where people don’t have functioning brains, like Wizbang.
1). name an insurance company that wants to insure seniors. you probably cannot. i can’t believe ryan did not review this and get some sort of buy-in or endorsement from insurance groups. i’m sure they would have told him he’s barking up the wrong tree. maybe they did and he didn’t care.
2). if it’s such a great idea why wait ten years? why wouldn’t you implement the path to prosperity right now? don’t we want to be prosperous as soon as possible? the number of seniors in medicare will, by attrition, get smaller over time so, ipso facto, the power of medicare to hold the line on costs will be reduced. the idea that a dwindling number of elderly will not see their benefits cut in the interim is just another fallacy in a plan full of fallacies.
This plan is not brave, it is not serious. it is fundamentally unworkable. so what would happen, should it be implemented is that we will continue to run up deficits for ten years so that the rich can have tax cuts (to lets face it – historically/ridiculously low levels) and then future congresses when faced with an unworkable voucher program will be forced to back away from abolishing medicare.
and on top of all of what i just wrote…the plan doesn’t even touch the pentagon. calling this a serious plan is just stupid.
Speaking of red herrings….
Today’s seniors wouldn’t be affected by the Ryan Plan — they would still get Medicare Classic. So of course they support it more than people who actually have to take the pain.
TGChicago…
Although I am sure you are correct about what seniors are thinking…the idea that todays seniors wouldn’t be affected by the Ryan plan is absolute bunk. (See my post immediately above yours.) As each year of the ten years tick by the pool of seniors in Medicare will be reduced by attrition. As the pool gets smaller the ability of Medicare to limit costs will get weaker. Today many doctors don’t want to deal with Medicare, but do because the pool of patients is so large. Reduce that number and the motivation to treat them reduces as well. Most experts agree that benefits for todays participants in Medicare will be reduced over the ten year span if Ryans plan is implemented.
anjin…my best wishes for your mom.
If the Ryan Plan is so great, the GOP should use it as the centerpiece of the election campaign next year…we’ll see what it does for Republicans…
@norm:
Good point. Thanks.
I think I understand what Steven is getting at in his remarks about Medicare but I think I would phrase it a little differently. There is no market in healthcare and we don’t want one because there is no way to create a market in healthcare that’s consistent with decent standards of public health.
In bickering back and forth about ways and means we shouldn’t lose track of the essential point: there is no plan on the table (including the ACA) under which “Medicare as we know it” is maintained. Costs are rising too fast relative to GDP to maintain it.
I honestly don’t believe there is any way to reform our healthcare system in a way that’s consistent with decent standards of public health without price controls. However, we shouldn’t have blinders on about that. We know very well what the effects of price controls are. That’s why we need to remove the supply bottlenecks in healthcare at the same time as we impose the cost controls.
That will completely up end our healthcare system. A consequence of not putting controls in place 30 years ago.
This is the crux of the problem, yes.
On a slightly different note, Charles, I’m guessing that the “No-True Scottsman” is a reference to Adam Smith — if so seeing him invoked so close to a reference to an “invisible hand” would lead me to suggest that you actually need to reread your Smith as the entire “Invisible Hand” idea, as most people talk about it today, is far more a production of Milton Friedman than anything that Smith actually believed in.
anin-san — not just anybody, here’s the link.
Dr. Taylor — huh? I don’t buy human rights, or roads for that matter. I do buy my prescriptions, and services such as doctor appointments, for which pharmacies and doctors respectively compete for my custom.
anjin-san and Dr. Taylor — wow, guess I haven’t learned anything from my experiences with my Alzheimer’s sticken mother-in-law we’ve been caring for almost 25 years now. It’s hard being Simon Legree all the time, dontchaknow? But please, explain to me how this is different than from each according to his ability, to each according to his need.
stan — Sorry, I’ve lived in the UK under the NHS and want nothing to do with it. And that was before they had the budget problems they have today.
john personna — I’m sick to death of the cherry picked statistics like lower infant mortality and the like. People here are freer, and that means that some of them make bad choices. That’s really unfortunate, but I think your proposed cure is worse than the disease.
Dr. Schuler — so there were no decent standards of public health until 30 years ago?
mattb — FWIW, The Theory of Moral Sentiments is on my nightstand right now. And anyway, what’s wrong with Milton Friedman?
There is rationing in health care today, just like there was in the past and there always will be. The only question is whether it is done by free markets, through some combination of free markets and regulatory control as we more or less have today, or we ditch the free market aspects all together and let the bureaucrats start generating five year plans with the attendant hypocrisy, corruption, and terrible results they are well noted for. At least when the rationing is done by who could afford it, there was always room to provide greater services to all by increasing the wealth that exists in the world. Once the focus shifts to dividing up the wealth while the needs grow seemingly without bound, well, I guess we can look forwrad to our chocolate rations being increased to 20 grams.
One more note, the biggest problem with the Ryan Plan is the name “The Path ot Prosperity.” I can well understand that the government living within its means is necessary condition for sustained prosperity, but it is hardly a sufficient condition, unless you believe prosperity springs forth from government.
Charles,
Render unto Ceaser what is his. If you’re a fan of Friedman, that’s cool.
But when it comes to the Modern Interpretation of “the Invisible Hand” credit it to the right person. The idea that the invisible hand a. works for the good of society and b. works on a grand scale are both modern claims (pushed by M. Friedman among others) which are clearly not in Smith’s texts (Smith, in fact only uses the phrase 3 times across all works and never in relation to “Free Markets”).
In some cases the modern deployment of the metaphor is directly antithetical to the points that Smith was making (especially in — and I’m going from memory here — books II and III of Wealth of Nations).
Well, first of all, Medicare was enacted more than 40 years ago and it’s Medicare we’re talking about. Between 1960 and 1995 poverty rates among the elderly fell from 35% to 10%. Medicare isn’t the only cause of the improvement but it’s one of them. Many of the elderly simply couldn’t afford healthcare prior to Medicare. Period. Do you want me to dredge up statistics on the health of the elderly prior to the enactment of Medicare or will you accept that it’s helped?
Healthcare is now enormously more expensive relative to incomes than it was then. I don’t think it’s too much of a stretch to suggest that without substantial assistance many of the elderly would have great difficulty paying for healthcare.
“…we ditch the free market aspects all together and let the bureaucrats start generating five year plans with the attendant hypocrisy, corruption, and terrible results they are well noted for…”
Who proposed that? Talk about strawmen…
This also requires pretending that the current system doesn’t have “the attendant hypocrisy, corruption, and terrible results.”
“Medicare isn’t the only cause of the improvement but it’s one of them. Many of the elderly simply couldn’t afford healthcare prior to Medicare. Period.”
Sure, but according to Charles Austin, they were also free — gloriously, wonderously, happily free to die in poverty and sickness, apparently because they’d “made bad decisions.” This is the wonder and joy of our system of freedom, that many people die in needless poverty, thus proving to others that they’re morally superior.
But that is rather the point: markets are not amenable to all things (e.g., human rights) and public goods like roads could function on a wholly market based system, but we wouldn’t like the results.
Part of the question is whether good public health, to use Dave’s phrase, is a public good or simply an individualized commodity like an TV.
Do you honestly think that the pharma market is an utterly free one? The likelihood is that you pay a set co-pay for your drugs, which is not* the result of a pure free market. Indeed, unless you pay for your drugs without the benefits of insurance, it is likely that you do not even know the actual prices of the drugs in question.
I am honestly not sure what your point is.
Are you saying that you have managed to deal with those difficulties (and my heart goes out to you in dealing with such a problem) without any insurance? Does your mother not qualify for Medicare (or that if she does, you have refused to utilize it)? Are you saying that you have been able to deal with all of her expenses out of pocket?
How are people freer here than in Europe or Canada, especially in terms of general public health? Again: I am unsure of your point.
*edited-I left out that rather key word.
“People here are freer, and that means that some of them make bad choices”
Certainly not if you include the concept of positive liberty. We spend hours hassling with insurance companies over payments. If you lose your job, you lose your insurance. If you want to be self-employed, but have any kind of chronic illness, you probably cannot get insurance. If you make a mistake, and go to an out of network doc who you legitimately believed was in network, you could lose thousands of dollars. If you cannot afford to manage your diabetes or hypertension correctly, you can end up on a dialysis machine three times a week. Read libertarian writer Welch about how much freer one is in a French type system.
http://reason.com/archives/2009/12/07/why-prefer-french-health-care
Steve
charles, like steven I am a bit unsure if your point. but tell me what happens to the alzheimer’s patient who’s not fortunate enough to have a devoted and competent son? I believe you yourself have pointed out that the function of a business is to make money, not provide social services. how is the alzheimer’s patient who does not have an advocate to have a hope of proper care? Or perhaps any care at all?
anjin good luck to you and your Mom.
I’ve been through it with my Mom who, thankfully had MD Anderson to treat her cancer.
Paid mostly by that horrible Medicare.
By saving her life that horrible Medicare keeps a small business open with employees happily working towards the now hard to find American dream.
Charles, you make it too easy.
Soooo…. you, and you alone, are paying for these scripts? At 5 times the price an ins co would? Say it is so, I dare you….
25 years??? Wow… must be some kind of record. My father went from diagnosis of Alzheimers to death in less than15 yrs. And if you have learned anything from your mothers experience, but NOT the neccessity of Medicare… What was it?
Charles, has it ever occured to you that some people have nothing but bad choices?
Apples and oranges, Charles, apples and oranges.
Glad to here somebody on the right admit that health care is rationed….
What world do you live in Charles? Sometimes the free market does not work. At what point will you come to that realization? ALL of western Europe has guaranteed health care for all… yes, none are perfect…. BUT NAME ME ONE THAT IS AS F*CKED UP AS OURS????
I have said it before and I will say it again: We live in the richest country in the world…. But we can not take care of our aged? Our disabled? Our children?
There is something wrong with us.
Anjin, not sure what to say, except prepare for the inevitable and hope you do not have to say to your mother what I had to say. (“Mom, maybe it is time to die?”)
Vulnerable is the word you were looking for I think, and it is the word that is applicable to all of our aged. Why can we not protect them? Are they not worth it?
I personally want to keep medicare as it is, for some it is not a problem paying for health-care, and if a poor person needs to go into a nursing home or have surgery that cost more than the voucher what then? Ryan does not care, I have seen other plans so much better than his plan and it balances the deficit a lot sooner than his. Why are we so eager to make seniors suffer in what supposed to be golden years. The haves do not want to help out the have nots` Take back the Bush tax cuts, and look for other ways to balance the budget. I feel this is just another way to pad the pockets of politicians by getting insurance companies more business,with shoddy health-care.
And Charles, I do not mean to belittle your experiences with your M-I-L. I just think you exagerate a little bit when you say 25 yrs (you don’t intentionally) Best of luck, it only gets worse from here.
Sorry to say.
My wife finally stopped coming with me to see my father. It was just too hard.
You dirty socialist you…don’t you realize how UnMurican your line of thinking is…
tom p — we’ve been caring for my MIL for 25 years, don’t know how long she’s been afflicted with Alzheimers, perhaps 10, who knows. Sorry for any confusion.
As to the rest of it, I don’t care, Obama is awesome.
@charles
Funny response to me. I didn’t offer statistics in this thread (I responded to some) and I didn’t propose a cure (in other threads I offered sympathy for the “look at OECD plans that work, and just choose one” position).
Even if an OECD plan gave us approximately the same health care, it would save us tremendous money. That’s something charles is usually for …
Tom – yes Vulnerable is the correct word, been posting from my phone, which sometimes has ideas of its own. Surgery went well, we are lucky – early detection via screening and a full professor of surgery from UC performing the operation.
Charles, I note without surprise that you have not shared your thoughts about what happens to the elderly and sick who do not have devoted children or other advocate under the Ryan plan. Perhaps living too long is simply a bad choice in their case…
We’re just coming to the realization that my Dad may be suffering from the early stages of Alzheimers. Fortunately he had the good sense (on his 3rd go-round) to marry a younger woman, a woman is to my atheistic eyes the very model of what a Christian should be.
And of course as a 20 year army man he has socialist health care — everything covered.
@Charles
“People here are freer, and that means that some of them make bad choices.”
See, that’s the crux for Charles: Being poor is a moral failure. That’s the foundation of his views on economics, and by extension, health care policy. Once you grasp that about him, and think about the connection between morality and desert, all he writes becomes very clear.
Coda
No word yet from the Emergency Room where Rep. Ryan was taken after the bus ran over him.