Politics & Policy

Ryan Gets Serious

Paul Ryan's Medicare fix is a tough sell, but a real plan.

The Democrats are having trouble finding enough votes to pass their health-care bill — maybe you’ve heard? The trouble stems from the bill’s many unpopular provisions: It would raise taxes, force people to buy government-approved coverage, and cut Medicare. In the aftermath of Scott Brown’s election to the Senate, the Democrats had no clear way forward. Brown didn’t just deny them a crucial 60th vote in Senate; he did it by running explicitly against the Democrats’ version of health-care reform. How can a political party enact legislation that the public simply doesn’t want?

The obvious solution is to convince the public that every conceivable alternative would be worse. But so far, that hasn’t worked. Polling on the subject indicates that the public, while not happy with the status quo, prefers it to the Obama-Pelosi-Reid monstrosity. And the piecemeal reforms around which Republicans have coalesced — equalizing the tax treatment of health benefits, reducing the role of the state regulatory agencies, enacting some sort of medical tort reform — appear by comparison to be modest and pragmatic ways to control premium inflation.

Needing a Republican bogeyman, the Democrats found one in Rep. Paul Ryan (R., Wis.), the ranking member on the House Budget Committee and one of the more entrepreneurial members of Congress. Ryan has put forward a plan called “A Roadmap for America’s Future,” which, according to the Congressional Budget Office, would repair America’s structural deficit. Because one cannot talk about the budget picture without addressing the growth of entitlement spending, Ryan’s plan includes a way to fix Medicare to which the adjective “modest” does not apply. His approach would replace traditional fee-for-service Medicare with a voucher program, and, over time, total spending on the vouchers would be much less than what the government is projected to spend on Medicare under current law.

Suddenly, the Democrats have a big and controversial target to shoot at, and they are loading up their guns gleefully. They seem almost relieved. Like fractious conservatives in the period immediately following the fall of Communism, liberals started to crack up once their common enemy lost power. After a long year of infighting over issues such as the public option and the excise tax on employer-provided health benefits, they are reunited in their opposition to a Republican bad guy, even if Paul Ryan makes a poor stand-in for George W. Bush.

This has put the Republican leadership in a bind. On the one hand, they want to keep the focus on Obamacare — it’s not dead yet — and deny the Democrats any safe haven in the form of a controversial Republican alternative. On the other hand, the nation confronts three options when it comes to entitlement spending: control it, allow taxes to soar, or both. Republicans must come forward with a credible plan at some point. Having no plan means effectively standing for fiscal collapse, severe cuts to Medicare, and much higher taxes on the middle class.

Ryan has put a credible plan on the table. It isn’t perfect, but no plan for controlling the cost growth at the heart of the entitlement problem is going to be uncontroversial. As Ryan put it to me, “If we are going to get serious about controlling costs, then either the individual is going to be in control of their health-care decisions or government is going to be in control.” Putting the individual in control sounds like the no-brainer choice, but in the past voters have expressed a preference for less risk, not more control, when it comes to their post-retirement well-being. Getting Republicans to embrace the politically perilous task of explaining to people that the status quo entails more risk, not less, will be no easy feat.

For now, the GOP leadership wants to proceed along two tracks: Stay away from big, specific reforms until the most dangerous items on the Democrats’ agenda have succumbed to the politics of the election cycle; and, meanwhile, develop a “Contract with America”–style set of positive agenda items on which to run. The plan is to pivot to this second track at some point between now and November. But details about this new contract have not been forthcoming. Will it include a specific plan for getting us out of the debt trap? Or will it eschew these for broad platitudes, so that the focus stays on the Democrats’ unpopular agenda?

The desire to remain vague is understandable as long as there is a threat that Obamacare might pass. And the political dangers of including something like the Ryan plan in the platform for 2010 are clear. But here’s the contrarian case:

The Democrats have already put forward a health-care bill that cuts Medicare, complete with the rationing board that inspired Sarah Palin’s memorable bit of resonant hyperbole. Medicare cuts are on the table, and we know how the other side would do it: price controls that force providers to leave the system and a federal apparatus that thinks it knows better than you or your doctor what treatments you need.

The Ryan alternative — reduced spending, but in voucher form, which allows patients to comparison-shop on quality and price –would likely prove to be effective at controlling costs, balancing out the spending reductions. And if we do nothing, we’ll get Medicare cuts anyway, in the context of a debt crisis that leaves us with no choice but to ration care.

Politicians do not generally consider elections to be good times for serious conversations about the nation’s problems. This year, the nation’s problems are so great that it’s possible the calculus has changed. If they want to appeal to the growing number of Americans whose heads are spinning at the size of Obama’s deficits, Republicans might need to start that conversation. Ryan’s plan provides as good a starting point as any.

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