The Republican position on Medicare, which is Paul Ryan's position, holds that ideally we should transform the program into limited subsidies for private insurance. Failing that, we should keep Medicare as wasteful as possible -- any proposal to impose more efficient use of Medicare resources is "rationing." That is the basis for Ryan's argument for his Medicare plan. The whipping boy is the Independent Payment Advisory Board, which would try to steer Medicare away from ineffective procedures. Ryan says this will create a hellish dystopia of price controls and diminished quality. Here is is explaining his position:
Except Ryan himself proposed an even stronger version of IPAB way back in 2009. Health care economist Don Taylor wrote this last month -- I just saw it today via Kate Pickert:
Rep. Ryan has undergone quite a change of heart from May 2009 to May 2011. Don’t take my word for it, lets look at the details of the PCA that he co-sponsored in May, 2009.
Title VIII of the PCA created two boards: a Health Services Commission, and a Quality Forum. Following are key portions of the bill text with line numbers removed (but the full section is relatively short pp. 205-216, so you can read the entire section for yourself in just a few minutes)
Purpose, sec. 801 (b), p. 207
(b) PURPOSE.—The purpose of the Commission is to enhance the quality, appropriateness, and effectiveness of health care services, and access to such services, through the establishment of a broad base of scientific research and through the promotion of improvements in clinical practice and in the organization, financing, and delivery of health care services.Duties, sec. 802 (a), p. 207-08
(a) IN GENERAL.—In carrying out section 801(b), the Commissioners shall conduct and support research, demonstration projects, evaluations, training, guideline development, and the dissemination of information, on health care services and on systems for the delivery of such services, including activities with respect to—(1) the effectiveness, efficiency, and quality of health care services; (2) the outcomes of health care services and procedures; (3) clinical practice, including primary care and practice-oriented research; (4) health care technologies, facilities, and equipment; (5) health care costs, productivity, and market forces; (6) health promotion and disease prevention; (7) health statistics and epidemiology; and (8) medical liability....
Obviously Rep. Ryan can change his mind, and seems to have done so. However, going from proposing what could be thought of as IPAB-on-steroids to deriding the general approach as rationing-that-is-harmful is quite a big change.
Taylor's post includes much more detail about the similarities between Ryan's plan and IPAB, the main differences being that Ryan's plan is even stronger. At the time it was proposed, Taylor supported Ryan's measure:
Any such effort will undoubtedly be called rationing by those wanting to kill it, and quality improvement and cost-effectiveness by those arguing for it. Whatever we call it, we must begin to look at inflation in the health care system generally and in Medicare in particular.
I can't emphasize strongly enough how powerfully this undercuts Ryan's argument. The whole claim is premised on attacking IPAB as bound to fail and a massive imposition upon freedom. Of course, the argument that it's big government for the government to try to cut wasteful spending is itself pretty silly. But Ryan isn't even consistent about this. Why is he treated as a serious figure?