House Budget Committee Chairman Paul Ryan (R-WI), in addition to his radical Roadmap for America’s Future (which turns Medicare into a privatized voucher system), has also released the Ryan-Rivlin Medicare plan, which he co-authored with former Congressional Budget Office director Alice Rivlin. While the plan would dramatically change Medicare for the worse by turning it into a voucherized system, it does rely on one key similarity with the Affordable Care Act: it sets up exchanges where various private health insurance plans would compete for customers.
As the Washington Post’s Ezra Klein explained, “the theory behind Ryan-Rivlin’s cost controls is the same theory behind the Affordable Care Act’s exchanges — they even work the same way.” The Tax Policy Center agreed, saying that the exchanges are “exactly the model of the ACA.” Rivlin herself confirms this view, saying “I keep talking to Paul and trying to convince him of that…But even if he agreed with me, he couldn’t say so.”
Today, at a “Playbook Breakfast” event hosted by Politico, I asked Ryan to square this seeming contradiction. If he believes exchanges will work in Ryan-Rivlin, why does he believe that they won’t in the Affordable Care Act? He said that it’s not the idea, but the execution that he disagrees with:
Exchange is not necessarily a dirty word. How I would do exchanges are very different than how Alice wants to do exchanges. So Rivlin-Ryan didn’t get to the level of specificity of how these exchanges must be designed, because I have a different opinion with Alice on how they ought to be designed. She would just continue ObamaCare in throughout the system. I disagree with that.
Ryan is so receptive toward this concept that he even calls it the same thing in Ryan-Rivlin that it’s called in the Affordable Care Act: an exchange. The problem with Ryan’s exchanges, however, is that the vouchers he and Rivlin envision replacing current Medicare payments would likely not be enough to cover the cost of plans in the exchange. Plus, as the Center on Budget and Policy Priorities found, there would be insufficient consumer protections within those exchanges:
The Ryan-Rivlin proposal sets no specific benefit standards for the private plans offered in the Medicare Exchange. The plans would therefore likely vary widely, presenting a potentially bewildering set of choices to many people who are very old or frail. Seniors and people with disabilities would receive only whatever benefits they could afford to purchase with their voucher and personal resources.
But Ryan’s willingness to endorse the concept of an exchange as an effective policy tool runs counter to the Republican message on the Affordable Care Act, which is that it is a socialist abomination that must be repealed in its entirety.