The New York Times: A Real Choice on Medicare

The New York Times editorializes on competing plans for the future of Medicare:

We know it is not how most people want to spend their time, but Americans need to give a close reading to the Democrats’ and Republicans’ plans for Medicare reform. There are stark differences that will profoundly affect all of our lives — and clear political choices to come.

Click here for the complete editorial, which lays out the differences and similarities between the Democratic and Republican plans for the nation's 46-year commitment to old age health care:

President Obama wants to retain Medicare as an entitlement in which the federal government pays for a defined set of medical services. The Ryan proposal would give those turning age 65 in 2022 “premium support” payments to help them buy private policies. There is little doubt that the Republican proposal would sharply reduce federal spending on Medicare by capping what the government would pay at very low levels. But it could cause great hardship by shifting a lot of the burden to beneficiaries. The Congressional Budget Office estimates that by 2022 new enrollees would have to pay at least $6,400 more out of pocket to buy coverage comparable to traditional Medicare.

It's an open question as to whether either proposal is the right one. Congressman Ryan's proposal would, as the Times points out, reduce spending on Medicare. It would do little, however, to reduce spending on health care as costs would simply be passed from the government to the elderly.

Unless their use is mandated and heavily regulated, the insurance vouchers are likely to be practically worthless. Individual health insurance is sold on the basis of experience-rated premiums, meaning that the claims experience of the relevant group dictates the price of an individual premium. No group requires medical care more than the elderly, and their premiums will reflect a pool consisting only of the elderly. The CBO estimate for 2022 reflects only the first year of Rep. Ryan's plan. By design, in subsequent years the value of the vouchers increases at less than the rate of medical inflation; over time, they will purchase less and less insurance. Thus, even if premiums don't go up, coverage will go down at the time of life when people need it most.

What about President Obama's proposal? Economist Laurence Kotlikoff argues that we have already passed the point of no return regarding Medicare, and that even well-executed reforms will be too little too late. Given the proven power of medical, pharmaceutical, and insurance lobbyists and given Congress' unwillingness to turn Medicare reform over to an independent commission, it's easy to imagine that many if not most reforms will be hobbled right from the starting gate.

At the end of the day, the best way to reform Medicare may be to eliminate it as a vehicle dedicated to elder health care (as the Republicans propose) and put in its place either a single program of basic benefits that covers all Americans or strong incentives to individual states to tailor universal coverage to their needs and sociopolitical culture.