CBS News / Alex Wong
The central idea behind Paul Ryan’s prescription for Medicare is that it would turn the program from a defined benefit program to a defined contribution program. Think 401k versus pension. The effect would work the same way for the government that it did for the corporations that cancelled their pensions. It would shift risk from the payer to the beneficiary.
Ryan’s vision of Medicare breaks the covenant that Lyndon Johnson forged with the American people when he said, “No longer will illness crush and destroy the savings that they have so carefully put away over a lifetime so that they might enjoy dignity in their later years.” Ryan wants to break that covenant. It isn’t he isn’t smart; I think he is. It’s not that he isn’t creative. The problem is that he has no intellectual capacity for analysis beyond his ideological lynchpin: Ayn Rand. In this, he resembles a young Alan Greenspan. His capacity for overreach, for hubris, for the “young gun-ness” of it all equals Greenspan’s, who was the primary cheerleader for a system of free market excesses that led to our meltdown. And as to Greenspan, even the thought of his vaunted 1990s pronouncements is enough to make one shudder today: “Capitalism is based on self-interest and self-esteem; it holds integrity and trustworthiness as cardinal virtues and [blah blah blah…]”
Paul Ryan, like Greenspan, has got a blind spot big enough to drive a truck through. That blind spot is his unquestioning belief in the power of the free market. His belief in markets goes to quirky extravagance; he requires that all his staff read Rand’s horrid, 1,000-page, Atlas Shrugged. But he’s wrong about markets. Dead wrong.
What Happens When the Free Market Isn’t?
Ryan believes that the market serves to effect transformational price efficiencies based on competition. Such efficiencies—read “prices reductions”—do occur in certain sectors of the economy, sectors like high-tech consumer gadgetry. That’s because those products are products, and they are products based on a rapid obsolescence and improvement curve that serves to trigger repeated price reductions over time. And it doesn’t hurt that they are all made in China. Think big-screen TVs.
Health care, though, is not a big-screen arena. The cost of technology in health care keeps going up, but that is not the nut. Health care reflects the costs of operating gargantuan systems employing armies of nurses, technicians, doctors, and, increasingly, administrators. Those costs are not heading down anytime soon.
The theory behind Ryan’s plan has been misunderstood or poorly communicated by many, including, recently, Bill Maher, who earned a PolitiFact False rating for his critique of the Ryan plan. Strictly speaking, Ryan proposes insurance premium supports. This refers to a periodic payment at some level that the consumer uses to shop for an individual insurance plan. Think of it as a voucher, but a voucher that is not intended necessarily to cover the full cost of a full-featured insurance plan.
The value of the voucher decreases over time due to systemic inflation and particularly because of cost increases in medical care, which will drive up the cost of private insurance. While systemic inflation may be anticipated to remain somewhat stable, the cost of medical care is guaranteed to skyrocket until we do something about it—likely never, or so it would seem at this twisted moment.
Medical insurance companies comprise a sector that has historically been immune to meaningful price competition. Having witnessed large nonprofits attempting to buy group insurance in the marketplace for decades, I have come to understand that insurance companies do not actually compete on the basis of price—and certainly never at a transformational level. Instead, medical insurance companies behave more like a cartel.
Cost savings are achieved mostly by cost shifting back to the company wishing to buy insurance or its employees. We see endless examples of this trend going back to the early 1990’s, but we see no actual competition on the basis of price at any meaningful level. And this is just how it would go for granny with her voucher.
What’s even more crucial is that this market per se doesn’t yet exist. The market for individual policies is nothing but a cruel joke, and I say that as a buyer with years of experience as a consumer as well as an analyst. Consider the cruel joke of starter plans offered to twentysomething women that do not cover maternity care, the one major medical expense they are likely to incur during this decade of their lives. No, the free market in individual health care plans is a cynical ploy to offer little at a very dear cost.
The elephant in the room is that a demographic that begins at age 65 is little more than a decade away from the crushing burden of medical expenses associated with chronic or life-ending disease. Many individuals incur greater medical expenses in the last two months to two years of life than they do during the balance of their lives. No individual insurance market can pool sufficient resources to fund million-dollar medical bills based on $274 monthly insurance premium supports for seniors.
While I don’t see Ryan as an idiot, I see his plan as a cruel joke. It is a plan for unknowable family tragedies. A senior would be a fool to give up Medicare for Ryan’s scheme. I get the feeling that the real numbers don’t matter to Ryan; they matter so little that he hasn’t even run them. Ryan’s plan is a faith-based plan, and that faith largely resides in Ayn Rand. Ryan’s goal is to starve government. The how and the cost don’t matter. This is a crusade. The benefits of the health plans this scheme would spawn would be mere ephemera in the face of the country’s most intractable diseases, like cancer, heart disease and diabetes. These are the diseases that end countless lives, and Ryan’s plan in the end would no more provide a defense against them than 401k’s offer security to the millions of Americans who regard their direly underfunded plans with quiet despair. Ryan’s plan is a recipe for geriatric poverty and misery, nothing more.
While real Medicare reform must tackle the cost of care with new models of care delivery, no one is ready for that. The Democrats proved that by addressing the cost of care only (in the tiniest way) peripherally in the health care reform act. But Ryan is offering a snake oil that would be far more harmful to seniors, and it’s almost is if he doesn’t even understand why that statement is true, so blinded is he by the light of his cherished, adolescent, ideology.
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And, I can't help but point out that Ryan himself would not be where he is today without government "entitlements." He used his dad's Social Security benefits to go to college. Don't ask him to admit it, that would be admitting a fact .
I love your comparisons to defined contribution plans and cartels, and the fact that health care doesn't really respond to free market stimuli.
Great stuff, as always. Hope it winds up on the cover.
Ryan is a clown. Such an obvious one people are seeing right through his monument to Rand.
His plan isn't playing in Peoria, as they say.
What has survived has cost us trillions. Programs like Medicare and Medicaid are financial disasters. These chickens are coming home to roost in a way that even congressional representatives can’t ignore them.
In the context of looming financial crises, Ryan is trying to do something to avert disaster. We spend $3 on entitlements for every $1 on defense. Entitlement outlays alone captures the entire federal collection stream. There is more than sufficient justification for questioning entitlement spending and our national priorities.
I won’t disagree that Ryan’s plan sucks. Just quit whining and come up with your own plan that will lead to balanced budgets . . . . . . . . SOON.
2) Few people are willing to economize on their health. If a doctor tells me I should have another test, I might wonder if I need it, but I assume she knows more than me. So, consumers don't act as much of a brake on costs.
3) No one likes insurance companies that put the brakes on, either. That's been proven. When it comes to deadly diseases, people get very, very upset at being told that while this treatment has a tiny chance of curing you at an enormous cost, we don't think it's worth it, because tiny is greater than zero and you're gonna die soon.
Of course, seniors have health problems, often expensive ones.
All insurance suffers from the incentive insurance companies have to avoid the sick or likely-to-be-sick. If Ryan figures out how to cover those with pre-existing conditions --- and cover them well, not unacceptably --- he will have significantly changed the insurance market.
He'll have to cover the uninsurable well, because they won't be a poor, ignorable minority, they'll be every other voter's grandmother.
Very useful post as usual. For me, the most important component of his silly plan is that it doesn’t account for the societal costs associated with people would have been alive if they had kept Medicare as it is delivered right now. When one conducts economic analyses such as those presented by Paul Ryan, you need to estimate the costs associated with preventable deaths. This is the only way you can compare different plans, including the do-nothing alternative (current version of Medicare). When people are alive, they positively contribute to the society both in terms of direct and indirect economic impacts. The current value of value of one life saved stands at about $4.2 million, …yes million! Even if we assume that the life of an ‘older person’ is worth less (which may be--which I won’t explain here--, but never used in practice) than the average person, the benefits of keeping older people alive can be very substantial.
In this study (Decker, S.L., Remler, D.K. (2004) How much might universal health insurance reduce socioeconomic disparities in health? A comparison of the US and Canada. Applied Health Economics and Health Policy, 3 (4), pp. 205-216), the authors show that after people turn 65 in the U.S., their health status improves because of…. Medicare. If we revert back to the existing health care system, one does not need to think too hard about what will be the general health status of people above 65.
What has survived has cost us trillions. Programs like Medicare and Medicaid are financial disasters. These chickens are coming home to roost in a way that even congressional representatives can’t ignore them.
In the context of looming financial crises, Ryan is trying to do something to avert disaster. We spend $3 on entitlements for every $1 on defense. Entitlement outlays alone captures the entire federal collection stream. There is more than sufficient justification for questioning entitlement spending and our national priorities.
I won’t disagree that Ryan’s plan sucks. Just quit whining and come up with your own plan that will lead to balanced budgets . . . . . . . . SOON."
Again UncleChri, we're still waiting for you to show us the opinions you discussed above.
This sucks for me (I am eligible for medicare but do not have it) because I have doctors who have been *my* doctor for anywhere from 10 to 30 years. Medicare (and Worker's Comp) breaks those relationships. That's brutal.
Your mention of the last two months of care (maybe that should be extended to six months, the period of eligibility for hospice) points to a potential area for cost-cutting. I for one have told my family that I will not accept extensive, heroic medical care if I develop a fatal condition. Our American denial of death is a huge problem, a cultural one, and has to be addressed generally as well as in any medical care compensation plan. I hope someday it will come to be viewed as unacceptable to demand treatment to extend your life for two months. Yeah, life is beautiful. And it ends in death. We have to accept that, and reject the romance of "battling" death to the end like it was an injustice.
How many times do we hear Republicans whining about the legacy we'll leave our children unless we slash the budget yesterday. What makes them think that any senior would want want to bestow the equivalent of a health care 401K on their children and grandchildren?
There's nothing abstract about this recognition. It's a threat to future generations and an acknowledged one. Here's hoping people act on that knowledge.
Only a true political/economic idiot would blame this debt on social spending. I mean really, you'd have to be an obtuse, one-dimensional hack ideologue to arrive at that conclusion. You'd have to ignore 12.5 trillion of Republican-generated debt and be put in the pitiful position of whining about the far smaller cost of "entitlements." It would be like tattooing "kick me!" on your forehead, but only as afterthought, as it's obvious something like that has already happened many times.
But opine away, Clucking Aparatchickens of True Belief. It makes the rest of us feel blessed.
Besides, I'd put the New Deal and Great Society -- even with their flaws -- up against 30 years of supply-side destruction and would bet my last dollar a whopping majority of Americans would choose the far more prosperous New Deal/GS template.
Watching Ryan ridiculed by his own constituents, and Boehner backpeddling away from the Rode to Preposterous Presumptions should send a message to everyone, even the Aparatchickens.
Read some polls, Chris. It'll break your ideological heart.
Coincidentally, I'm writing about the Rand/Greenspan/Ryan connection, too, and I pointed out the same apt connection you did: "it would turn the program from a defined benefit program to a defined contribution program." Yes, we see how well those defined contribution programs are working out for workers.
These programs are working out VERY well for CEO's, however. The easiest way to expose this scam is to point out that high-level corporate executives don't risk suffering the same vagaries of the marketplace -- their golden parachutes are guaranteed come what may --even to the point of surviving a corporate bankruptcy.
"How many times do we hear Republicans whining about the legacy we'll leave our children unless we slash the budget yesterday. What makes them think that any senior would want want to bestow the equivalent of a health care 401K on their children and grandchildren?"
Let me answer this question for you by making two statements:
First, the federal government has a far greater constitutional obligation to pay our debts, to preserve the value of our currency, and to prevent our economic collapse than it does to administer a health care system for the nation as a whole or even for just its elderly citizens.
Second, the terrible consequences of an economic collapse for our children will be far, far, greater than the absence of government sponsored healthcare for them.
Your question does open the door to why cuts in Medicare will hurt. It does not correctly prioritize the interests of this nation.
Chris
The primary thing that drove the current debt is conservative ideology. The primary driver of future debt, now that we've arrived at this low point, is health care. I don't know how you manage to separate how much Medicare costs from how much health care costs based simply on which entity is paying. The fact -- demonstrated in real world use -- is that Medicare is far more efficient and less costly than privatized replacements or enhancements.
That's why this is sooo funny:
**First, the federal government has a far greater constitutional obligation to pay our debts, to preserve the value of our currency, and to prevent our economic collapse than it does to administer a health care system for the nation as a whole or even for just its elderly citizens.**
Not only is your analysis obtuse to cost based on a false division of what is public spending either way, you attack the very best cost-containing, therefore deficit reducing program available as...costing too much? The last part of your statement contradicts, blatantly and in total, the first part. I enjoy watching you accomplish that rarest of all argumentative traps -- the single sentence self-negating statement.
To complete the pair, you throw in the self-negating thought, where you compound your error by emphatic repetition of the concept:
**Second, the terrible consequences of an economic collapse for our children will be far, far, greater than the absence of government sponsored healthcare for them.**
But, as reality has demonstrated, and as I illuminated, the first part has a direct relation to the last. Same thing, in a big way.
You really should try to think these things through before you presume to educate others. And the apocalyptic pronouncements are pointless embellishments. Don't be such a drama queen.
Just a suggestion...
Health care, like some other segments of economy does not play in a free market. In a free market you don't have gate keepers, i.e. insurance companies, who can decide if they will sell you their product or not. And as you pointed out, insurance companies do not improve their products, they just limit their service. And besides, have they found any insurance companies who will jump into the exchange?
Uncle Cri implies that Medicare, and I guess by implication, that socialized health care are unaffordable. Tell that to the dozens of countries that have such a system and are further away from state bankruptcy than the U.S.
The principles are pretty simple.
Health care costs a lot for any one person.
We all will incur costs at some point.
Some people incur a lot more costs than others.
Dispensing with a state system of spreading health care costs over the entire population means that the rich will get great health care and everyone else gets adequate to criminally limited.
Uncle Cri, transferring the cost burden to the individual does NOT make society any wealthier. It just gets it off the government's books.
You do understand that already, the U.S. spends around 30-50% MORE per capita of its GDP on health care. And with worse outcomes if things like longevity and infant mortality are counted. Are you really suggesting that the current model, already the costliest, most privatized, and least effective of comparable countries suffers only from being insufficiently privatized? What the hell evidence is there for this ludicrous contention?
On the positive side, Paul O'Rourke's comments are spot on.
I'd argue that the US has a hell of a lot greater obligation to the health of its citizens than to the people of Afghanistan or Iraq. End the wars, slash defense spending and we'll have plenty of money to keep Americans healthy --- hell, and maybe even develop a health care system that isn't second rate in the developed world when you compare costs and outcomes.
The notion that we must choose between civilized health care for seniors and a functional government is beyond preposterous, as several of you pointed out. And yet, there it is, thrown in our faces in a variety of venues.
Also the notion that Medicare is a poorly run program: where is the evidence for that? Every government program manifests some level of fraud, but in relation to its per capita impact, Medicare fraud is a tiny percentage of its dollar capitation. If anyone seriously wants to advance that our private insurance companies are run in a more efficient manner, they need to first consider the percentage of premiums going into executive compensation, administrative waste and general gatekeeping. I have walked through Medicare claims for serious illnesses with others and have found the program to be surprisingly seamless. (And I can say the same thing about Social Security program administration, too.)
Ryan's plan is horrible policy and he deserves to be trounced for it. That we have seen evidence of some backlash is encouraging, but much more needs to be done. Seniors in the streets? An anti-tea party backlash? Democracy Wisconsin-style? It's too early to tell, but certainly a ground game is needed if we are to withstand the assault upon health care support for seniors. This isn't to say that Medicare doesn't need reform. One minor but easily accomplished adjustment is to increase co-pays, in some cases by a couple hundred percent. But Ryan is outlandish on Medicare. I can't believe we have to deal with policy discourse at this level.
Look at how we treat health care in this country. If you are an individual who pays for their own health care either by way of insurance of out of pocket you approach it as your money and make much wiser choices. If your employer or the government pays well the sky is the limit. Every pain, sneeze or discomfort means a trip to the doctor and the hope of a prescription. We want a pill for every ill and are willing to pay anything as long as it is not our money.
Companies that institute costs linked to wellness behaviors for employees find employees take their health care cost more serious. Why because they have to pay out of their pocket for their bad choices not the company.
When you pay it makes you a better consumer. You ask your doctor more questions, and you look at your bills and challenge why it cost 40 dollars for a Tylenol. You question the reasoning for expensive test, drugs or procedures. Is it for my benefit or is it for the doctor's benefit because he or she does not want to spend the time actually treating you?
There is a lot of things we could do to make the health care system better in this country, but it is not going to get better until everyone including seniors understand it is a resource that is not unlimited.
Maybe the answer is everyone has to pay then this country will see the real bloated cost of healthcare and maybe they would actually do something to fix it. Companies that institute a reward program for staying healthy and charge those who don't more on the average see a healthier workforce and lower cost. Why because employees have a vested interest in reducing cost because they shoulder some of the cost.
And why not treat healthcare like any other consumer cost. Maybe if hospitals and doctors had to compete for customers they would provide better service and lower cost. Why should they be able to continue raising cost and lowering service especially at the expense of the tax payer.
I'm all for getting rid of the tax deduction (subsidy) for businesses to provide health insurance to employees. Currently the market for individual health policies is distorted by the fact that almost every policy holder will abandon their policy as soon as they get the opportunity to exchange it for tax subsidized job-based insurance.
But, you are wrong on a number of points:
1) Doctors and hospitals do compete, but they tend to compete on quality, not cost. If you need a coronary bypass, are you willing to pay more for a higher chance of a successful outcome? Most people say yes, whether it is out of pocket or paid by insurance. The people who run to the doctor for every sniffle are not many and not the problem.
Consolidation is another reason for bloated costs. Just look at the Boston area case study, as the many, many hospitals got bought out and put into a limited number of hospital holding companies, prices soared. Monopoly power in action.
The next issue is the really bizarre accounting of hospitals, which I also feel should be illegal. But that's a whole separate rant.
2) People need health insurance like they need car and home insurance. Even careful people get robbed, have hurricanes do major and unaffordably expensive damage to their houses. Even healthy people get struck by expensive diseases like lymphoma.
3) The real benefits from investments in personal health come from dealing with chronic disease -- getting diabetes, blood pressure, asthma etc under control. That usually takes a significant investment in medical effort. Lowered premiums for the healthy will probably accrue to those who are healthy, not those who have managed to decrease the severity of their chronic disease.
The current structure of the industry makes helping unhealthy people get healthier to be uneconomical. The average person changes jobs ever 5 years. Companies change insurance carriers about as often. That makes the average person be on an insurance company's roles for about 3 year. Any insurance company has a limited incentive to invest in this kind of preventative care because any improvements in health will likely accrue to another insurance company in a few years.
This is one of the reasons why the sort of inexpensive nurse-run clinic you see in countries like the UK for weight, diabetes, asthma, newborns is rare in the US, making the kind of close medical supervision that getting these diseases under control often takes expensive.
And when you consider the public has paid for the majority of the nation's healthcare infrastructure yet the very people who paid for the hospitals, universities to train doctors, and tax breaks and grants to the non-profit hospital system (which accounts for 72% of the hospitals) can't afford to use it sometimes even with insurance.
Now the GOP wants to pass the cost of coverage on to the public again so the healthcare system can continue to reap more profits.
Not that it is possible, but what if there was no insurance. Could a doctor charge 75 dollars for 5 minutes of their time? Could a hospital charge 375 a day for a bed? Could a surgeon charge 3,000 dollars for a few hours work? No because there would be no customers. Of course millions would have to die to correct the market and the idea of that is far to cold blooded for even the most ardent free market individual. But, the idea that society can continue to pay for a system that even the government can't afford means something is very wrong and unless drastic reform takes place it will bankrupt this society.
1. Each year’s delay in significantly reducing the annual deficit will obviously add $1 trillion or more to the national debt.
2. Each year’s delay in significantly modifying entitlement spending, especially Medicare, will add $10 trillion in unfunded liabilities to America’s future obligations.
3. Average lifetime individual contributions to Medicare are now approximately $150,000, while average disbursements to its individual beneficiaries before death now exceed $450,000.
4. Medicare and Medicaid are likely significant contributors to increasing healthcare costs since their implementation in 1967.
In reading the foregoing comments, not many of these views (again, held by all sides in the Arizona delegation to Congress) are reflected in the thinking of their authors.
One suggests that I am implying that Medicare (in its present form) is unaffordable. To him, I award the ‘DUH!’ trophy for Obvious Realizations.
Another suggests that our entitlement programs are validated because other countries implement such collectivism better than we do. Pointing to the fact that we do not share our Constitution with any other country is unlikely to change a mind which can make this point.
Further, it’s doubtful that pointing to the facts that countries like Britain, Germany, and France have all shed large parts of their socialism and that four others in the Euro-zone are in, or near, bankruptcy, largely because of welfare spending, will sway such astute thinking. We can simply revel in this kind of reasoning and that this isn’t the only area in which America comes in last place and has set the bar at a level below which no others can do worse.
Another suggests that absorbing some poll results should ease an ideological mind regarding the facts that entitlement spending now equals federal revenues from all sources and (from that point of view) that we have to borrow the additional $1.5 trillion each year to fund all of our discretionary spending. To him, I would suggest that arithmetic is a dictatorship within which no amount of heel clicking, triangulating, or opinionating will render $2.3 trillion in collections less $3.8 trillion in outlays anything other than $1.5 trillion in deficits. This will remain true no matter how desperately one may wish it otherwise and no matter how lopsided the plurality may favor a different result.
However, in conjunction with this last conclusion, I offer a cranial extraction procedure for $50. Wherever your head is to believe that our current course won’t eventually bankrupt this country, I will, for this fee, come to your location with the appropriate tool to remove your head from whatever warm, dark, place allows you to produce such argument so obviously unleavened by either information or reason.
A fourth deftly counters the assertion that our federal government has a higher duty to pay our national debts, preserve the value of our currency, and prevent our economic collapse than it does to administer national healthcare by referring to vague, presumably less important, obligations that we have to the citizens of Afghanistan and Iraq. I find such logic unassailable. My presumption would also be that we have even less important obligations to Israelis, Palestinians, Egyptians, and chickens in Southeast Asia, but that hasn’t prevented the expenditure of tax dollars on these groups as well.
When our members in Congress appear better informed, more intelligent, and clearer on these issues than OS bloggers and responders, I have to worry. There isn’t one Member of Congress, or staffer, I met this past week who believes that keeping Medicare, and most other entitlement programs, the way they are is a viable option – not one, not any, none, zero, nada. Such programs MUST be changed.
My suggestion, in case anyone missed it, is to get entitlement spending off government books, as one of the foregoing, trophy-winning critics so clearly deduced from my writings.
Our current Constitution was adopted in 1787. We didn’t get Social Security until 1936; and Medicare didn’t come around until 1967.
In the intervening 149- to 180-year periods, this country found no ‘social contract’ to supply individual citizens with retirement, disability, widow, death, or health benefits, not to speak of housing, food, or unemployment benefits, despite the economic recessions (excepting 'The Great Depression') which occurred during both of those periods. Since the discovery of these constitutional obligations by socialists and progressives, such programs have cost us trillions in taxes, deficits, and spending.
The Ryan recommendations regarding Medicare may suck. His budget plan for the coming decades may suck. The hard part is developing models for the replacement programs and a different set of budgets that do not suck, that mitigate the inevitable hurt, and that solve (quickly) the huge financial shortfalls that, despite the blog author’s contention, will ruin this country economically – sooner rather than later.
Ready, set, think. Don’t emote.
Same argument, now further embellished.
1. If you're going to cite the Constitution, cite an example. Then you won't look like you're using an emotional plea based upon nothing-- a word that describes your level of Constitutional knowledge.
2. The Founders enacted a federal single payer health care plan in 1798. Ouch!
3. Your use of "socialist progressives" would make you look even more dull and ideologically constipated...if that were possible.
4. Medicare and Medicaid didn't make costs jump. The costs trended steadily with other country's per capita spending...until Reaganomics, when they exploded. American Exceptionalism, I guess.
5. The debt was moderate and more or less benign until Conservatives trashed the economy and our fiscal condition. It seems this calls us to trash Conservatism, and revert back to the New Deal economic template, which was the most successful in our history. For some reason you ignore history and want to look forward with blinkers...that ignore the Conservative damage and encourage a deeper damage.
6. You're in no condition to either educate or correct anyone, as you're a rather average ideologue whose tunnel vision cannot view the full scope of problems/solutions.
7. You have limited and selective facts you use to support a very emotional argument--it must be emotional as it's not factual in the sense of reviewing all relevant facts. It's emotional because after all the piffling 'facts," you end up where you began -- stuck in an ideological (read that unintelligent) rut. This is because you're starting from an ideological conclusion and then looking for 'facts" to support it.
8. I'd say you have your head up your ass, but that would imply a differentiation between the two.
Thanks for playing, even if out of your league.
Excellent post Steve! :)