"Seriousness" Really Does Mean Screwing the Less Fortunate.

Ezra Klein lists the ways the Affordable Care Act pushes Medicare toward smarter and more efficient ways of buying health care, then notes Paul Ryan's plan does none of that. It simply "appeals to people who have an ideological take on health-care reform and believe we can make Medicare cheaper by handing it over to private insurers and telling seniors to act like consumers."

What's interesting is, even if such changes could control cost growth, it likely wouldn’t show in CBO’s scoring. The ACA got stung by this same problem: Its grab bag of reforms was scored by CBO as producing zero savings. With both Ryan's consumer-driven changes and the ACA's delivery-system reforms, you're talking about cost control through altered behavior, which is hazy. But increasing taxes or slashing reimbursement rates or capping Medicare growth at inflation all come with hard numbers and are much less difficult to extrapolate from. The ACA still got a pretty good deficit-reduction score, but if its structural reforms work, its savings could be much higher. Ryan got to his much more striking score by just slashing in hard terms.

This shines a rather different light on the “seriousness” accolades Ryan's been getting. The implicit criterion for "seriousness" is a really dramatic deficit-reduction score. But by that measure, going after the structure of how we buy health care never qualifies.

The point of structural reform is to deliver equal value for lower cost. That's why the ACA relied on them more. But that also means it rescues the budget without having to do what Ryan does -- take a chainsaw to aid for middle- and lower-income Americans. These structural reforms generally don't show up in the deficit predictions. Only the chainsaw does. So only the chainsaw gets any respect. It's utterly cockamamie.