I Know You Are But What Am I? Medicare Edition

Republicans' pleasure over Mitt Romney picking Paul Ryan for his running mate is tempered by their nervousness that Democrats will use Ryan's budget to hammer them on Medicare, particularly in Florida. And yes, they will. So how are Republicans going to respond? The answer is that they'll employ the time-honored "I know you are, but what am I?" strategy.

The National Republican Congressional Committee—the House Republicans' campaign arm—is sending out memos to its members telling them to, in the title of one, "Stay on offense on Medicare." And how do you do it? You say, we're not the ones who want to destroy Medicare, the Democrats are the ones who want to destroy Medicare! We're already hearing it from Romney and Ryan, and it'll be coming from all kinds of other places as well; here's the Heritage Foundation saying "Obamacare ends Medicare as we know it." (How? Because it's all governmenty.)

This kind of muddying of the waters has worked before. Here's one of my favorite ads from 2010, in which Dan Coats tells voters that his opponent "voted with Nancy Pelosi to force seniors into Barack Obama's government-run health care program, reducing the protection Medicare provides!" If you can spot the contradiction in that sentence, you're smarter than the average Indiana voter; Coats won easily.

There are a couple of things to understand about this debate, or whatever version of a "debate" we're going to have about it. First, Paul Ryan's current position is less radical than it used to be. The first version of his vaunted budget completely eliminated Medicare as it exists now (a single-payer insurance program) and turned it into a voucher program, leaving seniors who now have more security in their health coverage than other Americans at the mercy of the insurance companies. When he and everybody else realized how politically toxic that was, the next version of his budget proposed to give everyone vouchers, but retained traditional Medicare as an option seniors could choose. This is basically what Mitt Romney proposes as well. All of this is presented as a way to save the program; the plan on Romney's web site is titled "Medicare: Preserve it. Strengthen it."

Second, as Suzy Khimm explains, though Ryan does want to cut Medicare, the most draconian cuts he proposes are not to Medicare but to Medicaid. In fact, he wants to cut the health insurance program for the poor so deeply, "19 million more people would have to be cut from the program in 2021 because of Ryan's block-grant reform, according to the Kaiser Family Foundation. If states managed to curb health-care spending growth in Medicaid, 14 million beneficiaries would still lose Medicaid coverage under the Ryan plan. And that's on top of the 11 million Americans who would lose Medicaid coverage because the Ryan plan would repeal Obamacare. So all in all, Ryan's cuts could mean as many as 30 million Medicaid beneficiaries lose their coverage." And within the GOP, Ryan's position on Medicaid—slash it deeply and turn it into a block grant program, which would permit states to start shedding people from the rolls—has become gospel.

But to return to Medicare, there's one thing to watch out for. The Republicans' argument is that we have to move toward privatization because Medicare's costs will continue to grow. This presumes that the cost problem comes from the fact that Medicare is a government program, and once we get that magical private sector competition going, costs will come down.

But that's just false. Medicare isn't expensive because it's a government program, it's expensive because it serves a population with lots of medical needs, and that population is getting bigger as the baby boomers start to retire. Medicare is cheaper than private insurance. We found this out when we instituted Medicare Advantage, under which private companies administer Medicare benefits. That market magic, Republicans said, would bring down costs. What happened? It was more expensive, and taxpayers ended up subsidizing private insurance companies to administer benefits for more cost than the government does.

One of the things Obamacare did was end those subsidies. That's part of the "Medicare cuts" Republicans are now condemning as they try to pose as the protectors of Medicare. And that gets us to the final point. While discussion of people's motives usually does more harm than good, in this case it's essential to understanding the issue. Conservatives have hated Medicare since before it was enacted in 1965, when Ronald Reagan went around the country telling people that if it passed we would no longer be a free nation. It's everything they despise: a big government program that actually performs better and more efficiently than its private-sector counterparts, and is loved by its beneficiaries. That makes it stubbornly resistant to attack. But they've never stopped trying, and just because they're saying now they want to "save" it doesn't mean they aren't trying still.

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