For the most part, David Brooks makes two points in today's column. First, a competition-based system (like Paul Ryan's plan) has a better chance of controlling Medicare costs than the alternative of greater centralization, and second, the current debate over Medicare illustrates the core philosophical difference between Republicans and Democrats. Republicans are skeptical about top-down decision making, Democrats are not:
The fact is, there is no dispositive empirical proof about which method is best — the centralized technocratic one or the decentralized market-based one. Politicians wave studies, but they're really just reflecting their overall world views. Democrats have much greater faith in centralized expertise. Republicans (at least the most honest among them) believe that the world is too complicated, knowledge is too imperfect. They have much greater faith in the decentralized discovery process of the market.
[T]his basic debate will define the identities of the two parties for decades. In the age of the Internet and open-source technology, the Democrats are mad to define themselves as the party of top-down centralized planning. Moreover, if 15 Washington-based experts really can save a system as vast as Medicare through a process of top-down control, then this will be the only realm of human endeavor where that sort of engineering actually works.
I'd change Brooks' formulation in the first paragraph: Democrats have much greater faith in centralized expertise when it works, as is the case with health care. Even with their problems, the top-down health-care systems of Canada, the United Kingdom, and Western Europe are cheaper and more cost-effective than our own. Although the Medicare reforms in the Affordable Care Act are modest, there's every reason to believe that they will put downward pressure on Medicare costs and reduce the overall growth rate. In particular, the Independent Payment Advisory Board -- the 15 Washington-based experts in Brooks' column -- promises to be an important mechanism for driving down costs and making Medicare more efficient. Indeed, it's this promise that led the Center for American Progress to include a beefed-up IPAB as the "debt trigger" in their budget plan; with authority over the entire health-care system (and not just Medicare), an aggressive IPAB could corral costs systemwide.
Brooks is right to say that there isn't "dispositive empirical proof" for top-down planning or bottom-up competition, but there's plenty of evidence for the top-down approach, and not much for competition. Besides, as many others have pointed out, Ryan's plan does little for the growth rate of health-care costs and "saves" Medicare by shifting the burden to individuals. If the goal is affordable health care for seniors, then Ryan's plan is a failure, Brooks' dead-ender tenacity notwithstanding.
One last thing. I'm very familiar with the Democratic approach to public policy, and I don't see anything that suggests a categorical preference for central planning. Yes, Democrats support more central control in health care, but cap-and-trade relies on market mechanisms to reduce greenhouse gases. Likewise, Republicans prefer an unregulated economy but are more than happy to use central power when it comes to enforcing their preferences for abortion, gay marriage, and other social issues.
