One of the most despairing aspects of the last 10 years has been Republicans’ failure to get serious about Medicare spending. As I’ve written many times, Medicare is the monster that will swallow us up if we don’t do something about it. Yet Republicans have made matters worse over the years in a number of ways. Two of the most serious are the passage of the wildly expensive and totally unfunded Medicare Part D prescription drug coverage under President Bush, and the cynical scare tactics used on seniors during the presidential election and health care reform debates to try to preserve the status quo. I’m therefore very encouraged that House Budget Committee Chairman Rep. Paul Ryan has made a proposal to limit the growth of Medicare spending. In particular I’m grateful that this proposal actually goes directly at the unsustainable spending issue and is sufficiently bold to address the problems. It doesn’t dance around the edges or focus on red meat but irrelevant issues like “death panels” and tort reform. There are plenty of problems with the specifics but Ryan has opened the debate in a useful way. Ironically, there is a chance that Ryan’s move will actually bring Republicans and Democrats closer together on health care reform and that Ryan will help in making PPACA more successful. Here’s what I mean:
- The effects of health care reforms in the commercial market –whether by private industry, states of the federal government– are heavily muted by Medicare. As the largest customer by far of most hospitals and many physician practices, what Medicare does dominates provider decision making. When commercial payers try to change something they get ignored. Under the Ryan proposal, Medicare patients would act much more like commercial patients than they do today, and insurance market reforms would presumably cross into the Medicare population to a much greater extent.
- Putting seniors into the private health insurance market will lead to a convergence of views about how that market should operate. In particular, the debate over the treatment of people with pre-existing conditions (which is most people in Medicare) will become much more real.
- We’ll also see the limitations (some would say the folly) of relying on private health insurers to control costs. It will become clear that very serious delivery system restructuring is needed along with changes in attitude on the part of patients and providers. I can’t wait for that discussion to begin in earnest
- Today seniors –regardless of income or wealth– are subsidized by many working class people who pay Medicare taxes and income taxes. Reducing the burden on them will make health insurance more affordable or at a minimum share the societal burden more equally
While I’m not ready to buy in to the Ryan plan as it stands, I’m very appreciative of the fact that he’s putting it forward and hope it will lead to a serious, civil debate.