The Agenda

Follow-Up on Austin Frakt on the Ryan Roadmap

Austin has responded to critics of his latest Kaiser Health News column, including yours truly, with a Medicare voucher proposal of his own.

I’ve narrowly critiqued Representative Paul Ryan’s Medicare voucher plan on the grounds that it is too similar to an expansion of the Medicare Advantage (MA) program, which itself is more costly per beneficiary than traditional fee-for-service (FFS) Medicare. The basis for my understanding of Rep. Ryan’s plan is his own staff, with whom I’ve spoken. The basis for my understanding of MA is my own career studying and publishing on it. So, I’m quite confident in my ability to accurately compare the two and draw policy conclusions.

I appreciate Austin’s confidence. I would, however, be very surprised to learn that Rep. Ryan’s staff would reject the idea of learning from the pre-2000 FEHBP, which, as Walton Francis has argued, proved very successful at containing costs, limiting administrative overhead, and resisting capture by medical providers. I actually don’t think Austin’s expertise is at issue. I happily accept that Austin knows the Medicare Advantage program well, and that he sees similarities between MA and the Roadmap. I still think that the outline offered in the Roadmap offers a great deal of room for maneuver with regard to how premium support Medicare would work in practice. And so the question is whether we have another model for shifting Medicare to a premium support model that ought to be taken into account.

The conditions Austin outlines for the kind of Medicare voucher system he would endorse are worth reading. I am, as regular readers know, a great believer in experimentation. I wonder, however, if Austin is proposing a true level playing field behind Medicare Advantage and Medicare FFS. I’m hoping that James Capretta will write more about this in his forthcoming column for Kaiser Health News.

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