Earlier this afternoon, House Republicans approved Rep. Paul Ryan’s (R-WI) budget framework that would reduce federal spending by $5.8 trillion over the next decade and dramatically alter the Medicare and Medicaid programs. Ryan’s Medicare proposal would eliminate $30 billion from the program by forcing seniors to purchase private coverage beginning in 2022 and by retaining many of the Medicare savings that are part of the Affordable Care Act.

During a Tea Party rally in New Hampshire, likely presidential candidate and former Minnesota governor Tim Pawlenty (R) endorsed the Ryan proposal, saying, “as a general matter and directionally, I think Paul Ryan’s plan moves in the right direction.” But when I pressed him over whether he supports maintaining some of the Medicare cuts that are part of health care reform, Pawlenty demurred, and took another question:

PAWLENTY: I like Paul Ryan’s plan directionally. I don’t think it’s fully filled out in terms of the fact that we still have to address Social Security and when we issue our plan later in this process, it will have some differences[...]

VOLSKY: Do you support the Medicare cuts in his plan that he keeps from Obamacare?

PAWLENTY: Anybody else have a question besides this guy?

Watch it:

Ironically, Republicans attacked the Medicare cuts in the Affordable Care Act throughout the last two years, arguing that such reductions would ration care for seniors and would drive providers out of the program. In an executive order prohibiting Minnesota from implementing the ACA, Pawlenty referred to the cuts as “unrealistic assumptions regarding purported future cost-savings.”

In this revealing interview with NPR’s Robert Siegel, Rep. Paul Ryan (R-WI) dismisses the idea that seniors can find more affordable and efficient coverage from traditional Medicare because such an argument goes against his “philosophy”:

ROBERT: Congressman Ryan, critics of your idea say that the cost of insurance for members of Congress has actually gone up faster with the element of choice than the cost of Medicare has. Why would you, if turned out that indeed the government run program was more cost efficient would you favor it? Or is it in face an ideological preference for the market, even if the market is less efficient?

REP. RYAN: The point I’m trying to make, and there is a difference of I think, philosophy here of what works best. We don’t believe surrendering more of the health-care system over to government is an effective solution to lowering health-care costs. It simply results in rationing and price controlling. [...]

ROBERT: You’re saying that even if the Medicare system were to be comparably more efficient … that you’re saying if it’s not competitive…

REP. RYAN: Competition

ROBERT: You’d prefer what might be conceivably a more expensive system if it involves free-market competition?

REP. RYAN: Actually, no we don’t believe that at all. We believe it will be a less expensive system. But believe you me, we need to do more in the health-care system to get the consumer more power in the health care system so that the patient and their doctor have the real power in the health care system….

It’s all well and good that Republicans “believe” that a system of private insurers would be “less expensive” than traditional fee-for-service Medicare, but they’re wrong. We know that private insurers cost more because we’re already paying private insurers participating in Medicare Advantage an average of 9 percent — about $8.9 billion — more than traditional Medicare with an estimated 13 percent of the payment going towards profits and administrative costs. By contrast, Medicare spends only about 2 percent on administration.

That added cost means that beneficiaries would have to pay a private plan more for the same benefits. As the Congressional Budget Office (CBO) has pointed out in its analysis of the Ryan proposal, “a typical beneficiary would spend more for health care….[because] private plans would cost more than traditional Medicare because of the net effect of differences in payment rates for providers, administrative costs, and utilization of health care services.” “Second, the government’s contribution would grow more slowly than health care costs, leaving more for beneficiaries to pay.”

But Ryan suggests that none of this really matters because for him it’s a difference in “philosophy,” not a rational decision about what actually makes more sense for the beneficiary.

Rep. Paul Ryan (R-WI) has argued that his proposal to voucherize Medicare would not effect Americans over the age of 55, as they would still enroll in the traditional fee-for-service program. Americans currently under 55, however, would have to choose a private plan from a new Medicare exchange in 2022 that would receive an $8,000 voucher from the federal government. Only younger Americans would feel any changes, Ryan insists:

RYAN: So, specifically, what we’re saying is, if you’re 55 and above, no changes whatsoever in Medicare. But, if you’re like me, if you’re 54 and below, Medicare is going insolvent by the end of the decade. It’s going bankrupt. And it’s leading our country towards bankruptcy.

So, future seniors, 54 and below, will get a list of Medicare-approved plans, kind of like how it works today, but for all of Medicare.

But this isn’t a promise Ryan can keep. In 2022, newly-eligible beneficiaries would have to enroll in a private plan, but existing beneficiaries (those who are over 55 today) would also have the option of leaving traditional Medicare. As Ryan’s budget put it, “While there would be no disruptions in the current Medicare fee-for-service program for those currently enrolled or becoming eligible in the next ten years, all seniors would have the choice to opt into the new Medicare program once it begins in 2022. No senior would be forced to stay in the old program.”

That opens up the possibilities of private plans trying to lure away the healthiest beneficiaries (as is currently the case in Medicare Advantage) and of health care providers abandoning traditional Medicare patients for the higher reimbursement rates of private insurers. For chronically ill seniors who are more likely to remain in fee-for-service Medicare this means two things: higher costs (as the healthier beneficiaries exit the risk pool) and fewer doctors.

Ryan could take steps to prevent this kind of provider erosion — most doctors currently accept Medicare patients because of tis sheer size and clout — by requiring physicians who serve seniors using vouchers to also accept enrollees in traditional Medicare. But it’s unclear what the rules would be and the likelihood that today’s seniors would face the risk of adverse selection is still very great.