It would appear that we have hit a point in the public discourse on health care reform where we are pretending like the options are twofold: the Ryan Plan v. the status quo. This is the way that pundit and politicians alike are talking in the main these days.
This is, of course, not only a false dichotomy in the sense that these are not the only two choices that exist, but also because neither is going to be the eventual outcome. The Ryan Plan is both unpopular with the public and it has always lacked a political pathway through the legislative process. Likewise, the status quo for Medicare/Medicaid is on an unsustainable path in fiscal terms and will require reform.
In one sense, perhaps, the debate is legitimate, but more in thematic terms as opposed to specific policy details. To wit: the question of whether health care for the poor and elderly should be voucherized or whether it should remain a single-payer system (as it has been for half a century).
I think it is pretty clear that the latter is going to win the debate (indeed, has already won). As such, the debate should not be (if we want a real debate, that is) between private vouchers and the status quo, but rather how are we going to remold the status quo to deal with costs?
I know that some think that the Ryan Plan polls poorly because it has been attacked in the media. However, I would offer a counter-hypothesis: people actually do not like the idea of changing the system as dramatically as the Plan suggests.
Now, I will grant: some of this is the now-clichéd “Mediscare” bit, as some of the rhetoric has made it sound like Grandma will be tossed from the train if the Ryan Plan passes. This is, of course, untrue, as the Ryan Plan preserves Medicare for persons 55 and over. So, what it does is time shift the train-throwing. Fundamentally, the problem is that what the Ryan Plan does is save the federal government money not, as the phrase goes, by “bending the cost curve,” but rather it does so by cost-shifting the burden of paying for medical care to the individual. Is it any wonder that lacks support?
The bottom line is that we have had some type of single payer, defined entitlement approach since the 1960s–this creates a certain amount of expectation (and not unreasonably). Further, the system has pretty much worked for all those decades, and as such it is not unreasonable to think that it can be fixed and continue to work (although any such fix has to acknowledge the demographic challenges of the aging Baby Boomers). There is also the niggling fact that the rest of the industrialized world has managed to provide health care for its elderly and poor (and, actually, their whole populations). If they can do it Europe, Japan, et al., why can’t the US (what with all our power and exceptionalness and whatnot)?
As such, the voucher idea strikes me as dead. It is one of those things that sounds good if one is prone to think that mixing the phrase “market forces” into a conversation instantly improves the discussion,* but there is a wee problem of evidence to support the assertion. And, I would add for the record: I used to be that guy, and sometimes am still that guy. Markets are great. They are, however, not magical. And, to date I have not seen anything to persuade me that Ryan’s vouchers provide the requisite magic to bring costs down. As I have noted before, I am not convinced that the ever-popular “skin in the game” leads to much in the way of cost savings.*
To get back to the original issue: at some point we are going to have to stop the current silly debate and move on to a more substantive one. The sad thing is, substantive debates, what with all their wonky talk, empirics, and policy debates, are boring. Boring isn’t good for campaigning.
What would really be helpful (and I shan’t hold my breath on this , mind you) is for the Ryan Plan true believes in the rank-and-file to stop pretending like their fantasy will some day come to pass and for the Status Quo Über Alles folks to do the same. If the politicians realize that their tactics aren’t working, then they will have to shift more towards reality. If, on the other hand, the votes wish to persist in Fantasyland, the politicians will gladly join us.
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*Indeed, I would note the libertarian-leaning economist Tyler Cowen has stated “the vouchers idea won’t help cut health care costs.” He discusses the issue here as well.
