Ross Douthat suggests that we liberals are being too hard on Rep. Paul Ryan's "Roadmap for America's Future." In particular, we're being too hard on his Medicare proposal:
The difference between the cost-control proposals in the Democratic bill and the cost-control proposals in Ryan’s roadmap isn’t that the former are “complicated and really hard to understand” (read: smart) while the latter are simple, unimaginative and cruel. It’s that the Democratic bill wouldn’t come close to balancing the budget in the long run, and Ryan’s plan would.
But this just isn't true. In fact, Ryan's plan doesn't have any cost controls. It merely has payment caps. Here's a description of how it would work, excerpted from Ryan's summary of the legislative text:
Medicare Payment. For beneficiaries first becoming eligible on or after 1 January 2021, creates a standard Medicare payment to be used for the purchase of private-sector health coverage.
- Payment Amount. Standard payment is the average amount Medicare currently spends per beneficiary, and is indexed for inflation by the projected average of the consumer price index and the medical economic index. For affected beneficiaries, the payment replaces all components of the current Medicare program.
Aside from a few minor bells and whistles related to risk and income adjustments, that's it. Ryan takes the average amount Medicare spends today and sets that as the cap for vouchers that would be given to seniors to buy private insurance. The value of the vouchers would deliberately be allowed to grow at a lower rate than medical inflation.
This isn't cost control. Regardless of what you think about Democratic cost control proposals, there's nothing in Ryan's plan that even attempts to reduce medical costs.1 There's simply an arbitrary cap on how much the government will pay. In 30 years that cap will be about half what it takes to actually buy insurance, and if you can't afford to pay the other half yourself then you're out of luck.
Now it's true that if we adopted Ryan's plan and stuck to it, it would balance the budget. But not by reining in medical costs. It would balance the budget by simply refusing to pay for medical treatment for all seniors. The same is true for Ryan's discretionary budgeting proposal: he simply sets a cap and declares that the domestic discretionary budget has to meet it.
This is silliness. Anybody can pick up a piece of paper, write down some cap numbers, and declare the budget balanced. But that does nothing to bind future congresses and provides no plausible mechanism for actually reducing spending. It's just a number, not a serious proposal.
1Actually, elsewhere in his plan there are two proposals that might reduce the growth of medical costs a bit: full transparency on pricing and tort reform caps. But whether or not you like these ideas, they're a fringe part of Ryan's plan that would have only a minor impact on cost control. What's more, they don't matter. Ryan's plan specifically limits voucher growth to less than medical inflation no matter what medical inflation is. So even if these things lower medical inflation a bit, they'd lower the voucher cap at the same time. No matter how you slice it, his plan relies on simply capping payments and then letting seniors sink or swim.