House Budget Committee Chairman Paul Ryan (R) and Senator Ron Wyden (D) are out today with a joint proposal on Medicare reform, and structurally, the plan makes a lot of sense. The plan is built much like the “premium support” plan that Ryan has been advancing for the last year.
However, there are two key differences from Ryan’s original proposal. One is that traditional fee-for-service Medicare would be retained as a “public option” that seniors could choose, using their premium support payments to buy insurance from the government instead of from a private insurer. The other is that the plan does not include Ryan’s aggressive cap that would have held the growth in the value of Medicare benefits to CPI. As I wrote at the time, this was an implausibly low target, especially because the plan lacked accompanying cost-control measures. Wyden-Ryan aims to hold overall Medicare cost growth to GDP growth plus 1 percent, which is still ambitious but plausible.
I like this proposal structurally. What I don’t like about it is another feature it keeps from Ryan’s original plan–it wouldn’t be effective until 2022, and then only for new retirees. That means, like Ryan’s proposal before it, it saves no money this decade and almost no money in the next decade. I understand the political impulse–it avoids impacting anybody now, so maybe Ryan and Wyden won’t get beaten up for taking away Granny’s benefits. But this delay is still a serious mistake–reforms should be effective immediately, and for current participants as well as new ones.
First of all, if you touch Medicare, you’re going to be hit with “Mediscare” attacks. Saying he would delay effectiveness until 2022 didn’t stop Democrats from savaging Ryan’s plan as “ending Medicare as we know it.” No matter how many times you scream that your Medicare changes hold Granny harmless, your opponents will attack you for wanting to put her on an ice floe. If you’re going to take the hit, your plan might as well be effective right away.
Secondly, there’s no longer very much to hold Granny harmless from. A real problem with Ryan’s plan was that it was going to cause Medicare benefits to wither over time, with premium support payments becoming increasingly insufficient to buy an insurance plan. Wyden-Ryan avoids that situation–seniors would continue to get a payment that covers the cost of FFS Medicare or another plan that includes all the same benefits as FFS Medicare, on the same premium schedule laid out in the law today. You don’t need to exclude current seniors from this plan to allow them to live out the retirements they had planned on.
The downside of including current over-55s in reform is smaller than widely thought, but the upside is large. Indeed, “save money now” is the key lesson I draw from pension reform fights in states around the country.
In 2009, a lot of states passed “pension reform” that only changed benefits for newly hired employees, meaning that pension checks would start being smaller for a handful of workers around 2040. These reforms met little political resistance because current workers got to keep earning the same benefits as before. Lawmakers also found, to their chagrin, that the reforms saved trivial amounts of money in the current period. A lot of these states had to come back for another round of reform that would actually create current-period savings, and more recent pension reforms have been better.
Rhode Island just enacted the country’s most aggressive pension reform law, with big changes to the benefits that current workers will earn in future years and even reductions in the value of pensions currently being drawn by retirees. It sounds painful, and it is. But the law is popular– a Brown University poll out today finds 61 percent support. Public support for the law stems from the fact that it saves real money, avoiding the need for sharp tax increases and creating room in the budget to spend more on public services. Structured and sold correctly, these sorts of reforms do not have to be political poison.
The United States needs Medicare reform for the same reason Rhode Island needed pension reform–without adjustments, Medicare will eat the budget and make the rest of government dysfunctional. Fixing that problem should be a winning proposition, but you can’t fix it if reform is always something that has to happen “later.” Wyden and Ryan have hit upon a good structure, but they should seize the moment and urge its implementation today, not in 2022.
I'm curious why you assume that GDP plus 1% is an achievable goal for Medicare costs? The drivers of Medicare (and, more widely, health care in general) costs are well known , but can be broadly summarized as:
1. Perverse incentives to both patients and providers towards increased volume and increased usage.
2. Conversely, few if any incentives to patients or providers to be more cost-conscious, since most patients (particularly the heaviest consumers) aren't exposed to marginal costs and very few providers truly share in the benefits of cost savings.
3. Defensive medicine driven by an occasionally punitive, and more importantly, capricious and arbitrary malpractice environment.
4. True advances in technology, which are always going to be associated with increased costs (i.e., if you want me to treat you only with therapies available in 1985, it'll be pretty cheap).
5. Duplicative care driven mostly by the fact that it tends to be much easier to simply repeat a test than it is to get usable results of a prior test done elsewhere (a problem dramatically worsened by your friends in DC when they scared the bejesus out of every medical records department in the country after implementation of the HIPAA law).
6. True fraud, which exists but is less common than you'd think (at least in its undeniable and intentional form, as opposed to the 'overpayments because of poor documentation or disagreements as to the most appropriate care' that gets referred to as 'fraud' by CMS investigators).
and probably most importantly...
7. More people living for more years and consuming more care while doing so. Everyone dies of *something*, after all, and one of the biggest drivers of costs is the improvement in health among middle-aged folks over the last few decades. Dropping dead at your desk of a heart attack at the age of 56 is cheap (actually, from Medicare's standpoint, it's free); dying at the age of 85 of Alzheimer's after decades of care for five other ailments can be incredibly expensive. Ironically, the decreased smoking rates of the last thirty years is a major contributor to *increased* total healthcare spending - since dead patients don't consume health care.
Most of those causes are not addressed in any way by any plan that's currently on the table.
Reply to this commentLinkReport AbuseI agree with Mr. Barro 100% - if there's to be Medicare reform, it needs to take effect ASAP, rather than under a political expedient to delay it in order to mitigate political backlashes. Congress and the President need to treat this as a "do now" issue, with no view towards the approaching elections or the strong possibility of the White House changing hands.
Reply to this commentLinkReport AbuseAnd while I strongly disagree with National Review's non-endorcement of Newt Gingrich for President, they should ask the Speaker and the other candidates (a) what they think of the Ryan-Wyden plan, and (b) if they support it, would they commit to getting it in place and adopted to begin immediately to save Medicare soon after taking office. I believe that the Speaker would agree on both points, and that whoever the nominee is, he or she would be able to ride this plan into the White House. It's a shame the Speaker wasn't NR's choice for the nominee, because Newt Gingrich would be the best man, other than Congressmen Ryan and Wyden themselves, to articuiate this proposal to the American people, get their buy-in and support, and work in a bipartisan fashion to get it it place as soon after the election as possible. Of course, the chance that either the proposal would be a success, or that a conservative Republican had a hand in its' creation, would mean that the liberals would fight it tooth and nail. The biggest losers from the proposal becoming law would be liberal Democrats, who want the government to completely control healthcare in this country - whether it breaks the bank or not.