One Man's Agenda 1, Honest Debate 0

In his column today, New York Times columnist David Brooks writes:

But it should be possible to strengthen the safety net while modernizing some of the Great Society structures. Paul Ryan, a Republican, and Alice Rivlin, a Democrat, have come up with a Medicare reform plan in which new enrollees would receive a fixed contribution from the government, growing a bit faster than inflation. They would apply that money against the cost of health insurance. This would make Medicare a defined contribution program and save hundreds of billions. If Obama said he was open to thinking about this sort of fundamental reform, he'd generate tremendous excitement on the right.

Medicare inflation is a Titanic burden on the health care system and on the overall economy. It must be addressed, and one way to start is with an honest presentation and not an ingenuous sales job. Unfortunately, Mr Brooks' remarks are closer to the latter.

You may well believe that the Ryan plan is the best way to curb Medicare costs: It would likely save billions of dollars, would offer the benefits of portability, would force greater consumer involvement in health care choices, and would limit the health care role of government to that of financier. If you do advocate Rep Ryan's approach, then you also know that the vouchers are scheduled to take effect in 2021 based on 2010 dollars. You are also aware that while they are indeed indexed to a rate above general inflation, they are also indexed at a rate below the higher rate of medical inflation. The idea is to provide momentum to reign in Medicare costs, but it requires elders to increasingly bear the risks of success or failure. That is the actual crux of the question about the Ryan plan: We can save billions of dollars, but who bears the cost and the risk? And is the answer to that question acceptable? What are the alternatives? Many advocates of the Ryan plan are prepared to discuss these questions honestly, but unfortunately one of the leading columnists in the country is not.

If we're to accomplish anything, we must debate health care proposals based on their actual content, not on what sounds most inviting. Mr Brooks has failed to contribute to that debate.

Choice?

David Brooks argues that the future of health care comes down to "centralized technocratic" planning or a a free market solution. Health care, he sagely observes, is "phenomenally complicated," then goes on to inform us that providers have more information than patients and that insurance companies "are rapacious and are not in the business of optimizing care."

Brooks then compares what he calls the Affordable Care Act's concentration of cost-control power into a board of fifteen experts with the Republican laissez-faire model, which opposes top-down decision making (at least from the government). Rep. Paul Ryan's proposal to finance U.S. health care with a "premium support system" would replace fee-for-service medicine (in fact, it would not):

Seniors would select from a menu of insurance plans. Their consumer choices would drive a continual, bottom-up process of innovation. Providers could use local knowledge to meet specific circumstances.

Brooks writes with great confidence that this will happen -- presumably due to the Magic of the Market -- without explaining exactly how or why anyone should buy this argument.

Jonathan Cohn points out that the Republican plan has a track record, and that it's not especially encouraging. He argues that Ryancare would effectively eliminate health insurance for elders and summons the 1959 congressional testimony of retired autoworker John Barclay:

We retired workers are very proud of being citizens of the greatest country in the world, but … we cannot think it is the greatest possible country when about 65 percent of the aged do not have any insurance to deal with their needs for hospitalization and medical care. Without such insurance, the retired person must pretty much exhaust any savings he has before he can get free hospitalization. This is a constant source of worry. Many of my acquaintances will not visit a doctor for minor illness because they have no money to pay for drugs. After they exhaust their savings they go on welfare to get medical aid, but then, in many cases, it is too late.

The real difference between Democrats and Republicans on health care is not, Cohn writes, between an idealized free market and Stalinist central planning. Rather,

The most salient difference is that Democrats would preserve Medicare's fundamental guarantee of health benefits at affordable prices. Republicans would not.

Meanwhile, Ezra Klein contests Brooks' claim that

...if 15 Washington-based experts really can save a system as vast as Medicare through a process of top-down control, then this will be the only realm of human endeavor where that sort of engineering actually works.

It happens all the time, Klein writes: Around the world, government-regulated and -planned health care has a excellent track record for controlling costs without sacrificing outcomes.

At The Economist, M.S. dismisses Brooks as well, and focuses on the distortion brought about by the marketing and advertising of drugs and devices. 

As I've written before, Ryancare substitutes ideology for honesty. Brooks sips from this cup of Kool-Aid regularly, rarely if ever pointing out that Ryancare is all in on controlling costs by shifting them to elders. If that's what the country wants, then it's what we should do. But how about being up front about the choice?