What Paul Ryan’s budget actually does
Paul Ryan’s plan for Medicare and Paul Ryan’s plan for Medicaid rely on the same bait-and-switch: They use a reform to disguise a cut.
In Medicare’s case, the reform is privatization. The current Medicare program would be dissolved and the next generation of seniors would choose from Medicare-certified private plans on an exchange. But that wouldn’t save money. In fact, it would cost money. As the Congressional Budget Office has said (pdf), since Medicare is cheaper than private insurance, beneficiaries will see “higher premiums in the private market for a package of benefits similar to that currently provided by Medicare.”
In Medicaid’s case, the reform is block-granting. Right now, the federal government shares Medicaid costs with the states. That means their payments increase or decrease with Medicaid’s actual rate of spending. Under a block grant system, that’d stop. They’d simply give states a lump sum at the beginning of the year and that’d have to suffice. And if a recession hits and more people need Medicaid or a nasty flu descends and lots of disabled beneficiaries end up in the hospital with pneumonia? Too bad.
In both cases, what saves money is not the reform. It’s the cut. For Medicare, the cut is that the government wouldn’t cover the full cost of the private Medicare plans, and the portion they would cover is set to shrink as time goes on. In Medicaid, the block grants are set to increase more slowly than health-care costs, which is to say, the federal government will shoulder a smaller share of the costs than it currently does. The question for both plans is the same: What happens to beneficiaries?
Remember how the Affordable Care Act was really, really, really long? There was a reason for that. It was full of delivery-system reforms meant to make the health-care system cheaper and more efficient — things like bundling payments for illnesses and reducing reimbursements to hospitals with high rates of infection and creating a center tasked with seeding cost-control experiments throughout Medicare and encouraging the formation of Accountable Care Organizations. The hope is that those reforms will cut costs, which will make the rest of the bill’s cuts possible (more on that here). Republicans, notably, have been skeptical that these reforms will work, and have argued that the cuts won’t stick because beneficiaries will revolt.
To my knowledge, Ryan’s budget doesn’t attempt to reform the medical-care sector. It just has cuts. The hope is that those cuts will force consumers to be smarter shoppers and doctors to be more economical and states to be more innovative. But all that’s been tried, and it hasn’t been enough. That’s why the Affordable Care Act had to go so much further, digging deep into the delivery system, and why Republicans had at least a plausible case that some of its cuts wouldn’t stick. But now the GOP needs to apply the same skepticism to their own programs: Cuts aren’t enough, and if they somehow manage to distract people from the cuts by repeating the words “block grants” and “flexibility” and “premium support” over and over again, they’ll simply end up seeing their cuts ignored when it becomes clear that they’ll mean leaving the old and the poor without health care. What Ryan has here isn’t so much a plan to control spending as a plan to cut spending, whatever the consequences.