During a speech at the Hoover Institution today, Rep. Paul Ryan (R-WI) stood up for Mitt Romney’s efforts to distance Massachusetts’ 2006 health law from Obama’s very similar Affordable Care Act, saying “I think he’s doing the best he can…he’s been pretty clear on how he doesn’t think the president’s health care law works.” But Ryan also claimed, “I’m not a fan of the individual mandate, I don’t think they work. I’m not sure how I would counsel him to defend Romneycare.” Watch it:

But Ryan has more in common with Romney’s Massachusetts health care plan than he probably cares to admit. Shortly after Ryan unveiled his plan to introduce “premium support” into the Medicare system, progressives argued that it includes its own individual mandate, requiring future retirees to purchase coverage from an exchange of private insurers. As Simon Lazarus explained back in May, “Medicare taxes are mandatory, whether workers want to buy eligibility for old-age vouchers or not” and even if an individual opts out of using Ryan’s “premium support’” to purchase private coverage, he or she forfeits all of the taxes paid into the system.

In fact, during a more honest town hall on April 29th, in Racine, Wisconsin, Ryan admitted that his plan includes a mandate:

Q: If Medicare becomes a voucher program, would you require seniors to purchase private insurance and if so isn’t that an individual mandate? If you will not require them to purchase insurance how do you propose to prevent a situation where the costs of uninsured seniors is very expensive and gets passed on to me as a private policy holder? [...]

RYAN: Its mandate works no different than how the current Medicare law works today, which is you just select from a wide range of different plans. It literally would be like Medicare Advantage…

Watch it:

Interestingly, Romney’s own national health care plan is very similar to Ryan’s ‘Roadmap For America’s Future‘ and the Massachusetts governor has praised Ryan’s Medicare proposal, suggesting that the two Republican leaders may yet work together on the issue…in one way or another.

Rep. Paul Ryan (R-WY) is finally offering a Republican replacement for the Affordable Care Act. But don’t expect any new ideas — the chairman of the powerful House Budget Committee has dusted off his “Roadmap For America’s Future” proposal and is now officially offering it up a viable alternative to the ACA. The plan doubles down on Ryan’s effort to end the traditional Medicare program for future retirees and block grants Medicaid to the states, but then goes even further, re-stating Ryan’s long-term goal of ending the existing employer-based health care system and pushing individuals and families into the unregulated individual health insurance market with a voucher in hand.

With the Affordable Care Act fully repealed, Ryan would eliminate the existing subsidy for employer-sponsored insurance and use those dollars to provide families and individuals with tax credits to purchase coverage on their own. Those denied insurance because of a pre-existing conditions can enroll in a state-based high risk pools full of sick people. Americans currently under 55 years of age will move into a private plan outside of the Medicare system and states will receive less federal funds for their Medicaid program through a “block” of dollars that does not keep up with costs.

What could go wrong? Well, if you’ve been following the health care debate for the last decade, you know that the GOP’s boilerplate approach to health care policy has several very significant flaws:

1) Ryan’s “premium support” proposal for Medicare wouldn’t do anything to actually lower the nation’s health care spending. Rather, it reduces government expenditures by asking future enrollees to pay more for their health care coverage. Future seniors would be taken out of the traditional Medicare program and given a “premium support” to purchase more expensive private coverage. As the Congressional Budget Office (CBO) concluded 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.” ”This would more than double out-of-pocket health-care spending by a typical senior to $12,500 per year.”

2) A recent Kaiser Family Foundation report has pointed out that converting the existing matching rate formula into a block grant would give states less money that they would have otherwise received and force local governments to cut eligibility to the program. Kaiser examined different scenarios for state responses to reduced federal Medicaid spending and estimated 31 to 44 million Americans could lose their health insurance coverage. In fact, Republican governors recently admitted that the solution would not work for all states.

3) Ryan argued that reforming the tax code would promote individual ownership of health insurance and offer individuals more choice. He thinks this would create the best of both worlds by allowing certain individuals to leave their employer-sponsored health insurance plans and use tax credits to find coverage on their own. But this would only entice young healthy workers to buy cheaper but less substantive insurance in the individual insurance plan market place, increasing costs for sicker workers and forcing some to opt out entirely. Among those who would lose their health care are 56 million Americans with pre-existing chronic health conditions. The credits would also fail to cover the cost of comprehensive coverage.

4) Ryan advocated for allowing individuals to purchase insurance across state lines. This means that insurers would be able to circumvent consumer protections in certain states and sell bare-bone subprime policies to the healthiest (and most profitable) beneficiaries. Companies would have little incentive to do business in states that require coverage for such things as cancer screenings or have guaranteed issue protections and sell plans across the country that deny coverage altogether to high-cost cases. The Affordable Care Act includes a similar — but far better regulated — provision that allows states to form compacts in which they can establish their own regulations.

5 ) Ryan claimed that reforming the medical liability is a “no brainer.” But the current health care law already includes similar demonstration projects, even if the Congressional Budget Office has concluded that malpractice reforms could at most save $54 billion over 10 years.

The major problem here is Ryan’s ideology and underlining philosophy. It’s what economist Jacob Hacker calls The Great Risk Shift. Republicans are slowly dismantling the New-Deal era institutions that spread economic risks “across rich, and poor, healthy and sick, able-bodied and disabled, young and old” and shifting all of the economic costs and risks onto individuals (or as Ryan calls it, freeing Americans from the “relentless expansion of government and a new culture of dependence“).

In the wake of the Great Depression, “political and business leaders put in place new institutions designed to spread broadly the burden of key economic risks, including the risk of poverty in retirement, the risk of unemployment and disability.” “These public and private institutions did not let the individuals off the hook they required contributions and work and proof of eligibility” and they provided all Americans with a guarantee that if they paid into the system, they would later benefit from it.

But under Ryan’s alternative, the economic costs and risks of insurance are spread across a party of one — the individual. If that individual falls sick or a family loses its breadwinner, she or he is only empowered to lose. As Hacker explains, “The next frontier in the Great Risk Shift is the transformation of existing programs — Medicare and Social Security chief among them — from guaranteed benefits defined by law to individualized private accounts that leave workers and families shouldering more and more of the risks that these programs once covered.”

The Kaiser Family Foundation released its annual report on health care premiums moments ago, showing that family premiums for employer-based coverage increased by 9 percent in 2011, the most since 2005 when premiums rose by 9.2 percent :

The average annual premiums for employer-sponsored health insurance in 2011 are $5,429 for single coverage and $15,073 for family coverage. Compared to 2010, premiums for single coverage are 8% higher and premiums for family coverage are 9% higher. The 9% growth rate in family premiums for 2011 is significantly higher than the 3% growth rate in 2010. Since 2001, average premiums for family coverage have increased 113%.

Charts:

The findings will surely light up conservatives, who will argue, as Michele Bachmann did just yesterday in Iowa, that rising health insurance premiums undermine the effectiveness of the Affordable Care Act. But one can’t test a law that has yet to be implemented. The survey concluded that “many of the most significant provisions of the Patient Protection and Affordable Care Act (ACA) will take effect in 2014,” even as some firms are already making changes to their preventive care benefits and enrolling adult children in their benefit plans. Altogether, however, “these provisions are responsible for 1-2 percentage points of the 9% increase in family premiums in 2011,” Kaiser concluded.

The rest of the rise can be attributed to the usual suspects: the development and dissemination of new technologies and medical services which are often used inefficiently, the aging of the population, unhealthy lifestyles, a growing prevalence of high-cost diseases, lack of information technology, administrative costs and defensive medicine — factors that have increased employer health costs by 9.2 percent in 2005, 11.2 percent in 2004 and 13.9 percent in 2003. Thankfully, the health care law begins to tackle all of these problems through the Independent Payment Advisory Board (IPAB), the tax on high-cost plans and delivery reforms that begin to change the provider reimbursement system.

Christopher Weaver reports that Texas’ request for a waiver for rerouting “federal funds the state would otherwise lose — an undesired consequence of expanding managed care — to subsidize hospitals’ uncompensated care costs” and finance “projects to help the uninsured” won’t make any real improvements in the state’s dilapidated health care system but could be enough to burnish Rick Perry’s conservative credentials with the Republican base. As Weaver puts it, “The initiative’s warm reception by Democrats and consumer advocates, and the federal funds it seeks, could add up to a political liability for Perry. His 2010 book, Fed Up!, rejects any whiff of federal money — and the rules that come with it.”

I would add that the waiver request and the federal governments initial approval of the project suggests that 1) the federal government is far more flexible in allowing states to design their Medicaid programs than Perry often suggests and 2) this is only the latest example of Perry thwarting his “anti-Washington” image and requesting additional federal funds.

In 2009 and then again in 2010, Perry publicly complained about the “strings attached” to the federal dollars associated with increasing Washington’s contribution to the Medicaid program, but ultimately took — even requested — the money. From the Texas’ Health and Human Services Commission website:

– SEPTEMBER 2009: The Center for Medicaid & Medicare Services (CMS) has notified HHSC that Texas qualified for Tier II FMAP reimbursement starting in July 2009. This allows the state to draw a higher federal match for Medicaid expenses. The Tier II federal match rate is 69.85 percent for Texas, up from the Tier I rate of 68.76 percent.

– JANUARY 2010: Texas Qualifies for Tier III Medicaid Match The Center for Medicaid & Medicare Services (CMS) notified HHSC that Texas qualified for Tier III FMAP reimbursement starting in October 2009. This adjustment is based on recent unemployment data and allows the state to draw a higher federal match for Medicaid expenses. The Tier III federal match rate is 70.94 percent for Texas, up from the Tier II rate of 69.85 percent.

– OCTOBER 2010: The ARRA FMAP was set to expire on December 31, 2010 but has been extended for six-months at phased-down rates. The phased-down state fiscal year 2011 FMAP rates are 68.11 percent from January 2011 through March 2011 and 66.23 percent from April 2011 through June 2011. With the FMAP extension, the average state fiscal year 2011 FMAP is 67.33 percent.

The original stimulus package included $87 billion in enhanced federal Medicaid funding, which meant that the federal government had increased its contribution to state Medicaid programs by 6.2 percentage points through Dec. 31, 2010. In August, at the request of 42 governors, Obama signed a six-month phase-out extension of that increase through June 2011.

Perry was one of eight Republican governors who didn’t publicly lobby for the additional dollars in February of 2010, but asked the federal government for the extra funds once they became available. A Perry spokesperson explained that Texans “paid their share of taxes and should get some of that money back” — which is the same argument that Democrats used to dissuade the governor from opting out of the program entirely.