This Michael Goldfarb post is a very nice example of the problems Paul Ryan's budget is causing for Republicans. Goldfarb e-mails an unnamed Republican health policy expert to ask if Ryan's Medicare proposal actually embraces rationing in order to control costs. The expert has a tough time with it, to say the least. And Goldfarb never gets an answer to his question.Our expert by pointing Goldfarb towards the Medicare Sustainable Growth Rate in an attempt to prove that Medicare currently imposes a budget -- which is to say, that the government caps care and rations. SGR -- which only affects Medicare Part B -- was instituted in 1998 to try and control costs and impose some order on payments. The mechanism is fairly simple: Congress decides how much Medicare should spend, and if that's exceeded, physician payments are slashed by an equivalent amount. On the face, our expert is right.Yet Medicare costs, as you may have heard, have not settled into a quiet existence of fly fishing and crossword puzzles. The problem, as our correspondent admits, is that Congress won't permit these cuts. Spending exceeds the SGR but Congress averts the automated response. Most recently, Ted Kennedy dramatically returned to the Senate to override Bush's veto and forestall a 10 percent cut in reimbursements. The bill passed with 69 votes. And why won't Congress allow these cuts to go forward? Because the result would be fewer providers accepting Medicare which would in turn mean longer waits for services and general unhappiness among a constituency that views letter-wring as recreation and voting as mandatory.But what our anonymous expert doesn't say is as interesting as what he does say. He argues that "rationing by cost is built into the current Medicare system," even though he admits that Congress refuses to allow it. But he doesn't argue that the Republicans are not imposing a global budget and beginning the system's slide towards rationing. Because that's not a viable argument. In other words, he spins Goldfarb by changing the subject back to something that isn't, in reality, happening. He never, however, answers Goldfarb's actual question.For what it's worth, here's the answer Gldfarb is looking for: The difference between SGR as it works in theory and the Republican proposal as it appears on the page is that under SGR, if Part B costs grow faster than the government has decided they should grow, physicians, as a whole, take a cut in reimbursements. The system suffers collectively. Under the Republican alternative, where individuals are given a check to purchase care on their own, if the system's costs grow faster than the government has decided they should grow, then individuals will be priced out of coverage entirely. The suffering is concentrated among the economically vulnerable. And this is, it should be said, the economically vulnerable elderly. It's a return to a world in which our grandparents could find themselves uninsured. It's also wildly unlikely. But it's evidence of how hard this is: Even when Republicans roll up their sleeves and develop their ideal alternative, it's still the government setting arbitrary budgets and forcing the sharp rationing of care. They may not want to become Europe, but their budget admits that they've already excepted the necessity. The honest argument, at this point, is not whether we ration, but how we ration. Related: Paul Ryan hearts health care rationing. REPUBLICANS TRY AND EXPLAIN PAUL RYAN'S BUDGET TO EACH OTHER. FAIL.
This Michael Goldfarb post is a very nice example of the problems Paul Ryan's budget is causing for Republicans. Goldfarb e-mails an unnamed Republican health policy expert to ask if Ryan's Medicare proposal actually embraces rationing in order to control costs. The expert has a tough time with it, to say the least. And Goldfarb never gets an answer to his question.Our expert by pointing Goldfarb towards the Medicare Sustainable Growth Rate in an attempt to prove that Medicare currently imposes a budget -- which is to say, that the government caps care and rations. SGR -- which only affects Medicare Part B -- was instituted in 1998 to try and control costs and impose some order on payments. The mechanism is fairly simple: Congress decides how much Medicare should spend, and if that's exceeded, physician payments are slashed by an equivalent amount. On the face, our expert is right.Yet Medicare costs, as you may have heard, have not settled into a quiet existence of fly fishing and crossword puzzles. The problem, as our correspondent admits, is that Congress won't permit these cuts. Spending exceeds the SGR but Congress averts the automated response. Most recently, Ted Kennedy dramatically returned to the Senate to override Bush's veto and forestall a 10 percent cut in reimbursements. The bill passed with 69 votes. And why won't Congress allow these cuts to go forward? Because the result would be fewer providers accepting Medicare which would in turn mean longer waits for services and general unhappiness among a constituency that views letter-wring as recreation and voting as mandatory.But what our anonymous expert doesn't say is as interesting as what he does say. He argues that "rationing by cost is built into the current Medicare system," even though he admits that Congress refuses to allow it. But he doesn't argue that the Republicans are not imposing a global budget and beginning the system's slide towards rationing. Because that's not a viable argument. In other words, he spins Goldfarb by changing the subject back to something that isn't, in reality, happening. He never, however, answers Goldfarb's actual question.For what it's worth, here's the answer Gldfarb is looking for: The difference between SGR as it works in theory and the Republican proposal as it appears on the page is that under SGR, if Part B costs grow faster than the government has decided they should grow, physicians, as a whole, take a cut in reimbursements. The system suffers collectively. Under the Republican alternative, where individuals are given a check to purchase care on their own, if the system's costs grow faster than the government has decided they should grow, then individuals will be priced out of coverage entirely. The suffering is concentrated among the economically vulnerable. And this is, it should be said, the economically vulnerable elderly. It's a return to a world in which our grandparents could find themselves uninsured. It's also wildly unlikely. But it's evidence of how hard this is: Even when Republicans roll up their sleeves and develop their ideal alternative, it's still the government setting arbitrary budgets and forcing the sharp rationing of care. They may not want to become Europe, but their budget admits that they've already excepted the necessity. The honest argument, at this point, is not whether we ration, but how we ration. Related: Paul Ryan hearts health care rationing. 
