He called for rationing Medicare, replacing it with an underfunded voucher system that would dramatically shift costs to elderly Americans. He proposed repealing the Affordable Care Act, slashing Medicaid by $1.4 trillion over the next decade and turning what's left over to the states as block grants. By 2021, his budget would leave up to 44 million more Americans without health insurance. His budget, one which garnered the votes of 235 House Republicans and 40 GOP Senators, would in turn use the savings to deliver $4.2 trillion in tax cuts, most of them to the richest Americans who need them least.
As Politico revealed Tuesday, decimating the U.S. health care system and gutting the American social safety net apparently deserves praise, not scorn. For Politico, the catastrophic impact of Paul Ryan's draconian and dishonest budget matters far less than the fact that people are talking about it:
When House Budget Committee Chairman Paul Ryan released his budget plan in April, the Wisconsin Republican instantly changed the conversation about health care in America. It wasn't always a polite conversation. And it gave way to new Democratic charges that Republicans want to "end Medicare."
But Ryan got everyone talking about ways to get health care entitlements under control -- and he gave Republicans the most detailed illustration to date of how market forces could be used to do that. He has influenced how Republican presidential candidates such as Mitt Romney talk about health care, as they use variations of his Medicare plan in their campaigns. And if Republicans gain power after the 2012 elections, his blueprint is sure to be the starting point for their future health care policies.
As it turns out, Ryan didn't "instantly" change the conversation. Most Republicans, including his party's leadership, refused to endorse his 2010 Roadmap for America's Future until after the November mid-terms were safely won. And Ryan's goal to "end Medicare" is only the beginning of the unraveling of the safety net he would undertake.
To be sure, Ryan's voucher scheme would end Medicare as we know it. As Ezra Klein, Matthew Yglesias and TPM (among others) noted, Ryan's Republican deficit reduction gambit would inevitably lead to the rationing of Medicare.
Because the value of Ryan's vouchers fails to keep up with the out-of-control rise in premiums in the private health insurance market, America's elderly would be forced to pay more out of pocket or accept less coverage. The Washington Post's Klein described the inexorable Republican rationing of Medicare which would then ensue:
The proposal would shift risk from the federal government to seniors themselves. The money seniors would get to buy their own policies would grow more slowly than their health-care costs, and more slowly than their expected Medicare benefits, which means that they'd need to either cut back on how comprehensive their insurance is or how much health-care they purchase. Exacerbating the situation -- and this is important -- Medicare currently pays providers less and works more efficiently than private insurers, so seniors trying to purchase a plan equivalent to Medicare would pay more for it on the private market.
It's hard, given the constraints of our current debate, to call something "rationing" without being accused of slurring it. But this is rationing, and that's not a slur. This is the government capping its payments and moderating their growth in such a way that many seniors will not get the care they need.
Last year, Ryan acknowledged as much.
"Rationing happens today! The question is who will do it? The government? Or you, your doctor and your family?"
Of course, Ryan left out the real culprit - the private insurance market. But with 50 million uninsured, another 25 million underinsured, one in five American postponing needed care and medical costs driving over 60 percent of personal bankruptcies, Congressman Ryan is surely right that "rationing happens today."
As Paul Krugman explained using the chart above:
Medicare actually does a better job of controlling costs than private insurers -- not remotely good enough, but better...
If Medicare costs had risen as fast as private insurance premiums, it would cost around 40 percent more than it does. If private insurers had done as well as Medicare at controlling costs, insurance would be a lot cheaper.
But you don't have to take Paul Krugman's or Ezra Klein's word for it that "the GOP outsources Medicare to private insurers and gives senior citizens checks that cover less and less of the cost of insurance every year." In words and pictures, the nonpartisan Congressional Budget Office issued the same dire warning (see chart at top).
By leaving beneficiaries at the whim of private insurers whose policies cost more and are padded by substantially higher overhead, and by capping the value of their vouchers, Ryan's budget proposal would produce dire consequences. As the CBO concluded in April, "A typical beneficiary would spend more for health care under the proposal." Make that, as Director Douglas Elmendorf explained, a lot more.
Under the [Ryan] proposal, most elderly people who would be entitled to premium support payments would pay more for their health care than they would pay under the current Medicare system. For a typical 65-year-old with average health spending enrolled in a plan with benefits similar to those currently provided by Medicare, CBO estimated the beneficiary's spending on premiums and out-of-pocket expenditures as a share of a benchmark amount: what total health care spending would be if a private insurer covered the beneficiary. By 2030, the beneficiary's share would be 68 percent of that benchmark under the proposal, 25 percent under the extended-baseline scenario, and 30 percent under the alternative fiscal scenario.
But it's not just America's seniors who would suffer at the hands of Politico's health care prize winner. Paul Ryan's plan to repeal "Obamacare" and gut Medicaid would leave millions of lower-income Americans without health care coverage.
Currently, the $300 billion Medicaid program serves roughly 60 million Americans. On average, the federal government picks up 57% of the tab, with poorer states like Mississippi and Alabama getting 75 percent of the funding from Washington. Medicaid not only pays for a third of nursing home care in the United States; it covers a third of all childbirths. (In Texas, the figure is one-half.) As with Medicare, Medicaid provides insurance for substantially less than private insurers (27 percent less for children, 20 percent for adults.)
But as McClatchy explained, the expansion of Medicaid is central pillar of the health care reform law designed to bring health insurance to millions more Americans:
The 2010 law requires that state Medicaid programs in 2014 begin covering all non-elderly people who earn up to 133 percent of the federal poverty level, which would comprise people with incomes of up to $29,400 for a family of four this year.
By 2019, that expansion is expected to add 16 million people to Medicaid, which now provides health coverage for about 60 million low-income Americans. Childless adults and parents who previously earned too much to qualify for the program will make up the bulk of the new enrollees.
Currently, the federal government pays about 57 percent of Medicaid costs on average, while states pay the rest. Under the new law, the federal government will pay the entire cost of the new enrollees for the first three years, after which it will scale down gradually to 90 percent in 2020 and thereafter.
The future implications of the Paul Ryan's Republican bloodletting are clear. While the Congressional Budget Office estimated the expanded Medicaid program under the ACA would provide coverage for more than 15 million Americans, a Commonwealth Fund analysis projected that almost half of the 52 million people who went without insurance in 2010 could gain it under the new Medicaid provisions in the Affordable Care Act:
Now in its latest state-by-state analysis, Kaiser has detailed the devastating impact on Americans' health care of the Ryan budget backed by 98 percent of Congressional Republicans:
Projected federal spending on Medicaid for the 10-year period 2012 to 2021 would fall by $1.4 trillion, a 34 percent decline. By 2021, states would receive $243 billion less annually in federal Medicaid money than they would under current law, a 44 percent reduction.
The effect on enrollment in state Medicaid programs could vary widely. By 2021, between 31 million and 44 million fewer people nationally would have Medicaid coverage under the House Budget Plan relative to expected enrollment under current law, the analysis finds, examining three possible scenarios using different assumptions about how states might respond to lower federal funding. Most of those people, given their low incomes and few options for other coverage, would end up uninsured.
The House Budget Plan also could affect health centers, hospitals and safety-net facilities that serve low-income and uninsured people and rely heavily on Medicaid revenues. By 2021, hospitals could see reductions in Medicaid funding of between 31 percent and 38 percent annually, or as much as $84.3 billion, under the plan compared with projected funding under current law. The reductions would come at a time when millions more people would lack coverage, increasing the potential demand for uncompensated hospital care.
As Steve Benen pointed out, the health care carnage Paul Ryan would inflict isn't limited to its body count. The truth is another casualty of Ryan's supposed conversation-changer:
Perhaps best of all, independent scrutiny found that the numbers in Paul Ryan's plan simply didn't add up.
Bad math and even worse health care. In a nutshell, that's what qualifies Paul Ryan as the Health Care Policymaker of the year. Of course, Politico is only worried about "winning the morning," not winning America's future. For that, Americans will have to turn to President Obama and the Democrats.
(This piece also appears at Perrspectives.)