Obama's plan, says Ezra, includes both the cost controls in the ACA and this:
He then proposes to shave a further half-percentage point off the [healthcare system's] growth rate by introducing value-based insurance — where we pay more for treatments that are proven to work than for treatments that are not proven to work — into Medicare and giving generic drugs quicker entry into the marketplace. These programs have worked at smaller scales and in more limited pilots. We don’t know if they’ll work across the entire Medicare system, but we have reason to think they will.
He then focuses on the fail-safe trigger if the costs don't come down. It's a trigger that Ryan doesn't have.
To my mind, the core difference is that Ryan shifts Medicare from the feds to seniors and Medicaid from the feds to the states. It's hard to see how this won't simply mean many more people going without access to any healthcare at all – especially since Ryan proposes to abolish the ACA as well. But it certainly insulates the federal government from going broke. Obama, meanwhile, offers nothing so drastic. And his speech today was really a defense of the status quo with much more top-down rationing, tax hikes for the wealthy and pressure on the drug companies.
So you have a radical end of health insurance as we know it; or a drift toward patching the existing framework as best we can – and a fail-safe trigger for more taxes and spending cuts if none of it works.
Politically methinks: meep, meep. Whether fiscally, it works is another matter entirely. But that, I guess, is what the trigger is for.