A reader writes:
I'm not sure if you consider this a "hard left" question or not, but why don't you plainly state what Paul Ryan is trying to do: abolish Medicare. I'm not saying we can't have a policy debate about it, but let's speak honestly and admit that the policy calls for the end of federally-subsidized and guaranteed medical care for the elderly. (Josh Marshall lays this out pretty clearly.) Do you think calling the policy an "abolition" or "elimination" of Medicare is somehow unfair?
And regarding Ryan, it's pretty amazing that you think he is acting like an honest broker here. The plan simply ignores the CBO budget estimates (which the Republicans insisted were the "gold standard" until they didn't agree with the estimates) and assert that repeal of Obamacare will reduce the deficit despite all math to the contrary. Also – how is it an act of seriousness that grapples with Bush-era deficit creation to continue cutting taxes for the rich and cutting services for the poor? He doesn''t even recommend getting rid of the Bush era tax cuts.
Since Medicare will abolish itself in its current trajectory, I think the onus is on those who want to do little to rein in its cost. Yes, the pilot programs in Obama's universal health reform could bear dividends in the future. But I doubt they will be enough. As for the tax cuts, I agree and said so. The Ryan plan could lower tax rates and increase tax revenues, if Ryan wanted to. It's the semi-religious, a priori refusal to raise revenues that gets in the way. Another writes:
Boy, that reader response you printed was something else. Saying that Rep. Ryan wants to essentially round up and gas the poor strikes me as Moore Award-esque. But that said, I, as a hardened liberaltarian, take issue with the idea that Ryan's plan is "serious."
First of all, there's this whole notion about taking on Bob Gates' recommendation for targeting "inefficiencies" within the Pentagon. This statement, to me, is so nebulous as to be completely meaningless. Isn't it inefficient to have troops stationed in Germany sixty-five years after the end of World War II? Isn't it inefficient to keep the private-public debacle of the military-industrial complex going? Isn't it inefficient to fight two or three (depending on how one views Libya) wars to continue to extend the influence
of the American Empire? But these aren't the inefficiencies Gates was talking about; like most small-time thinkers, Gates was referring more to redundant posts and bureaucratic mumbo-jumbo. Sure, it's a good idea to eliminate waste, but "targeting inefficiencies" sounds, to me, like another buzz-phrase like McCain's taking on "earmarks." Sure, it sounds good, but what the hell does it actually mean?
Then there's Ryan's absurd notion of reforming the tax code. Having just paid my own taxes, I'd be thrilled as hell to reform the tax code, and I like what he has to say about closing loopholes. But you have to watch the sneaky language that he uses. What does he mean when he says the GOP wants to consolidate brackets? That, to me, sounds like a terrible idea. What particular brackets would he consolidate? Would a person earning $30,000 per year now suddenly be in the same bracket as one earning $100,000? Would someone earning $75,000 be in the same bracket as someone earning $300,000?
Lastly, I actually agree with Ryan that open-checkbook Medicare is an unviable option. I know this for a fact because my grandmother, a wealthy woman, still got Medicare checks (as well as Social Security) until her death. That said, I'm not convinced about the reforms Ryan recommends. In particular, the plan for individuals to choose from premiums gives me the heebie-jeebies because that's not what Medicare is supposed to be for.
Medicare is supposed to supplement any costs that elderly and enfeebled patients might have over and above what they can pay – a safety net, if you will, to avoid having a bunch of dying seniors the way we did during the Great Depression. But let's say I'm a senior who has hip problems but not upper respiratory problems. I choose a Medicare option based on that information. Suddenly, at age 75, I develop pneumonia, which really drags down my respiratory system (this is not far-fetched). Would Rep. Ryan's plan cover my health problems if I were unable to afford them.
I want to be clear: I'm glad somebody is talking fiscal sense in this country. I've been let down time and time again by the president and the do-jack-shit Democrats of the last few Congresses. But I think a lot of Ryan's proposals, while occasionally well-intentioned, recede into the morass of typical bullshit that we've been getting from politicians of all stripes for the past decade.
There's some of that in there – especially the assumptions about future growth and unemployment. But if we see the Ryan plan as the opening bid, and work constructively to keep the savings he promises by different means and with different emphases, we can make it a better and fairer proposal. Another:
The thing is, Andrew, is that you have a habit of viewing warmly any plan that anyone ever comes up with that appears to be a budget cut, no matter how appalling that idea is. If some Republican tomorrow got on TV and announced that he could cut the defense budget 15% by outsourcing nuclear weapons production to the North Koreans and paying them in plutonium, you'd say something to the effect of "well, it's an unrealistic and somewhat facetious idea, but at least it shows that the GOP sincerely wants to cut government spending." Everybody has their own policy issues that they get soft on – yours is fiscal conservatism. And there's nothing wrong with that, except that the ideas they're coming up with are dangerous and half-baked and need to be called out as such by people who are interested in fiscal conservatism and are sane.
Of course Medicare spends too much money – of course, we're going to be in serious fiscal trouble in 20 years if something isn't done about it. But every sane proposal that gets put up, the Republicans either ignore or twist into something utterly demented.
End of life care is some outrageous and alarming percentage of medical spending, but if you suggest trying to convince people that their 92-year-old grandfather shouldn't go through another round of chemotherapy and surgery at a cost to taxpayers (via Medicare) of $120,000, when it has a 5% chance of working anyway, and will make him miserable for the three months he'll have left regardless of what care he gets, you get accused of trying to kill the elderly or rationing care.
Drug prices are beyond ridiculous, and in a uniquely American way. Don't get me wrong – you and I both have literally been kept alive by the discoveries of the pharmaceutical industry, but I've had the experience of buying a prescription drug in Italy at 1/10 the price it sells for in the US (and was identical – both US and Italian formulations of the drug were manufactured in Switzerland!). I'm also currently on another medication which is so insanely expensive and rare (I have to mail order it, my insurance pays something like $4000 per dose) that were I to lose insurance, I'd be in serious, serious danger.
Of course drug companies need to make money to keep making new drugs, but there's a lot of evidence that suggests that prices are arbitrary and capricious (see that compounded drug for premature birth that was in the news this month, sold for 100x as much when the monopoly in its manufacture was given to one company?). Want to control costs? Control drug prices. But even suggest it, and the implication is that you're putting a revolver to the collective heads of the public. Strangely enough the VA seems to do perfectly well getting medications to veterans at $10 a prescription, without bankrupting drug companies, but suggest that the non-VA government do anything to set prices and suddenly you're a socialist.
For that matter, the whole Medicare payment system is set up in such a way that people who are treated the most poorly are the most profitable patients. One Medicare patient can be bounced around from doctor to doctor making money for each medical practice, but ironically getting very poor care because his or her treatment is so bad that it only leads to more treatment. But suggest that fee-for-service might not be the best route, and that we should reward outcomes and not process, and you get accused of socialism or of wanting to enslave doctors.
Want to cut the deficit seriously? Look at those three areas. Any one of them could cut tens of billions from Medicare spending. But it's a lot less sexy than redoing everything for ideological reasons.
These are points well-taken. But my embrace of almost any plan that really would cut spending and lower deficits is a function of how serious the fiscal gap now is. By the way, I have long supported the Obamacare proposal – killed by Sara Palin – that all Medicare recipients should be asked if they wish to issue instructions via a proxy about how they want end-of-life care. No pressure. But my bet is that a hefty proportion of Americans do not want a massively expensive effort to keep them alive for a few more days – when that money could be better spent or saved. On drugs, I favor a co-pay that is a percentage of the actual cost of the drug. 20 percent would be a good start. Once you do that, patients have a real incentive to forgo the latest innovation and pick a generic.
(Photo: Representative Paul Ryan, a Republican from Wisconsin and chairman of the House Budget Committee, pauses during a news conference at the U.S. Capitol in Washington, D.C., U.S., on Tuesday, April 5, 2011. U.S. House Republicans today unveiled a plan to overhaul the federal budget and slash the deficit in coming years by about three-quarters, with a $6-trillion cut in spending and 25 percent cap on tax rates. By Joshua Roberts/Bloomberg via Getty Images.)
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