To listen to the Romney/Ryan ticket, you'd think the official title for their Medicare reform proposal began with the word "bipartisan." That prefix refers to Sen. Ron Wyden, a Democrat from Oregon who joined Paul Ryan on a proposal to remake Medicare along premium-support lines. Wyden, however, has been angrily rejecting the claim that his plan is similar to Romney's. "Gov. Romney is talking nonsense," he said in a statement.
To be honest, however, the two plans look fairly similar to me. So I asked Wyden: How, specifically, are they different? An edited transcript of our conversation follows.
Ezra Klein: Governor Romney says his approach to Medicare reform is bipartisan because you’ve endorsed it. You say that’s wrong. So what, specifically, is the difference between your approaches?
Ron Wyden: My view is that the policies that were adopted by the Republican House majority and the Romney campaign do not preserve the Medicare guarantee. And that’s what the [Ryan/Wyden] white paper was all about. It was a set of options for improving on the existing Medicare system with public and private choices, beefing up consumer protection, adopting a new way to control costs and put Medicare on a budget so you can protect the guarantee.
Probably the two most significant specific differences between what Governor Romney is talking about and the white paper is, first, that the Romney campaign and the governor would repeal the Affordable Care Act. To lay a foundation for putting together a program to protect the guarantee and protect the budget, you need the changes the Affordable Care Act makes to Medicare, like bundled payments and moving the system towards pay-for-quality. Without it, you can’t move to premium support.
The second difference is that the Romney approach completely pulls the rug out from under the poorest and most vulnerable seniors. In the white paper, protections for so-called dual eligibles, the people in both Medicare and Medicaid, are bulletproof. There’s no way to throw them under the bus. Gov. Romney says he’d block grant the Medicaid program and push those cuts onto the people, which would do enormous harm to those people whose protection was at the center of the white paper.
When you wrote the white paper with Ryan, however, Ryan was already pushing his budget, which block grants Medicaid and repeals the Affordable Care Act. Those ideas have been core to the political project Ryan has been engaged in over the last few years. And he didn’t abandon them to sign onto your paper. So how is this different?
Mitt Romney is the head of the ticket. And the primary development since the white paper came out was that the House Republicans were not willing to accept what was in the white paper. That’s why I went to the floor when we were debating the Ryan budget in the Senate and spoke specifically against the Medicare portion and voted against it. And there’s no evidence that Gov. Romney will see the world any differently.
There would not have been a white paper if there was a requirement to go forward with a proposal that included block granting Medicaid. When you’re trying to lay out a set of possibilities to deal with the premier domestic issue of the time, everyone talks about what’s important to them. And that was important to him. But I said there’s no agreement if that’s included. I said the heart of it is that Medicare continues on as a public program and there are robust consumer protections and the premium support is progressive. And what Paul Ryan was interested in doing was looking at new approaches in terms of competitive bidding and the like.
In the broader conversation over Medicare, the reforms in the Affordable Care Act and premium support are seen as sharply divergent paths. The ACA relies on delivery-system reform and the IPAB, while premium support relies on vouchers and competition. But you’re saying they’re not opposed at all. In fact, they’re best done together.
I’ll make a substantive point and then a political point. I feel strongly that to tee premium support up for a decade from now — which is what the white paper called for — you need the kind of delivery system reforms envisioned in the Affordable Care Act to accelerate the trend toward more coordinated care and paying for quality and bundled payments. If you don’t accept those, and Gov. Romney says just rip the Affordable Care Act up and go to our form of coupon care, you’ll never had have any of these reforms.
Number two, I’ve found that more and more Americans are coming around to this head-scratching exercise where they ask, shouldn’t we do the same things for people over 65 that we’re doing for people under 65? Can’t we start the march to an integrated system?
One frustration for me in this debate has been that Republicans have essentially lifted the insurance market structure from the Affordable Care Act, which they say will save no money, and moved it to Medicare, where they say it will save tons of money. But it’s the same idea! The Affordable Care Act’s exchanges use an almost identical competitive-bidding process to the Medicare exchanges in Ryan’s budget. I don’t see how you can say one will save money but the other won’t.
People have described it almost as ideological bedlam. You have Republicans saying that what they're so strongly opposed to in the Affordable Care Act is exactly what they'd like to see done in Medicare. And then if you give traditional Medicare, which I think has to keep its purchasing power and we have some ideas for that, but if it did that, it would end up essentially being the public option that Democrats have been for.