I just watched Paul Ryan speak with Maria Bartiromo about his budget, and I was struck by how little he said about how his plan works in practice. Ryan’s office has refused repeated requests for interviews, but here are the questions I’d like to see asked — and followed up on:
1) In the Roadmap for America’s Future, you capped the growth in Medicare spending between inflation and medical inflation, In Ryan-Rivlin, you held it to GDP+1 percentage point. In your budget, you’ve brought it down to inflation, which is much lower, but you haven’t added any new cost controls. What makes you believe your targets are achievable? And what do we do if they’re not achieved?
2) The main cost control in your plan is that seniors will purchase regulated private health insurance on an exchange. But the Medicare Advantage program, in which seniors choose regulated private insurance options on an exchange and receive the savings through increased benefits, has proven more expensive than traditional Medicare. Why will your exchanges achieve such dramatically different results than the Medicare Advantage exchanges?
3) Alice Rivlin, your original coauthor on the premium-support model, believes the exchanges in your plan are functionally identical to those in the Affordable Care Act, and that if you believe one will have a dramatic impact on costs, so too should the other. How, specifically, do your exchanges differ from those in the Affordable Care Act?
4) You’ve repeatedly compared your Medicare plan to the health-care benefits you receive as a member of Congress. But the system that gives you those benefits, the Federal Employee Health Benefits Program, has not held its cost growth to anywhere near the rate of inflation, or even below that of Medicare. So why will that same model achieve such dramatically different results in Medicare?
5) The Congressional Budget Office says that private insurance will be more expensive than traditional Medicare insurance of the same quality, and under that analysis, your plan saves money by shifting costs. What happens if they’re right? Would you support your plan if, in 10 years, the savings proved to be primarily achieved through shifting costs to seniors?
6) You say that states can cut Medicaid costs dramatically by taking more control over the program. But Medicaid is already much cheaper than private insurance or Medicare. What’s the evidence that significant further savings can be achieved save through lowering quality or reducing eligibility?
7) You say government control never works in health care. But other developed countries pay much less than we do and don’t appear to suffer from worse outcomes. So what, specifically, is your evidence that the health-care system in the Netherlands, or in France, or in Germany, doesn’t work?
8) Is it fair to reduce spending on Medicaid even as we cut taxes on the rich?
I’ve heard some of these questions posed, but I’ve never heard them answered.