Paul Ryan’s speech
Monday, July 20 2009
I’ve already posted a little bit about Paul Ryan’s speech, but I want to write something a bit more substantive. It was more or less a collection of GOP-crafted, pollster-tested talking points designed to scare the bejeebus out of ordinary Americans, but I will use this post to give the most charitable response I can. (Update: you can read the speech at BetterHealth – where I also got the picture of him.)
Ryan started by claiming – regarding the current House bill – “nobody read the bill” and Congress has “no idea what it costs”. So what? We’re still weeks away from a full vote, then there’s the Senate bills, reconciliation – and a lot about the final bill that can change in the meantime. It might be months before that bill goes to President Obama for his signature. A lot can change in the meantime, and Ryan was trying to scare us by talking up something that is absolutely ordinary in the legislative process, as far as I can tell.
He said, ‘I don’t want government interfering in the doctor/patient relationship – and I don’t want insurance interfering either.’ (I’m using single quotes to indicate paraphrasing, since I don’t have a transcript and can’t swear to the accuracy of my notes.) He wants a ‘free market democracy that puts patients first’; ‘gov’t should liberate… choice and competition’; ‘dollars should flow through the patients, not government’; ‘the power of the third party – insurance or government – should be shifted to doctors and patients’. All of this sounds wonderful, I admit.
His answer to all these demands is the Patients Choice Act. It’s not a terrible bill, if you’re totally healthy. It’s not a horrible bill if you’re sick – it’s just not as good as what the Democrats have put on the table. The problem is, the basic machinery of Ryan’s bill puts sick people in exactly the same place they would be with the Democratic bill – except entirely reliant on state government for their premiums, stuck with private insurance for health care, and deprived of a public option to circumvent both.
For example, Ryan complained in his speech that ‘two out of three Americans’ will lose their health insurance under the Democrats’ proposals. This is standard-issue GOP mantra, but leaving aside the fact that it’s not true, there is a touch of hypocrisy here: under the PCA, nearly everybody will end up losing their insurance. Ryan made clear in his speech: the PCA is designed to sever the link between employer and insurer. What he obfuscated was the fact that if it passes and is effective, that would mean, in effect, every single American with health benefits would lose their insurance – possibly tens of millions more than the Democrats’ proposal would affect.
There’s a difference in philosophies, sure – but not a lot of daylight between the actual consequences for the employer-based insurance market. In the Democrats’ plan, ‘losing’ insurance means people end up in a health insurance exchange, and some would get need-based subsidies towards purchase of the plan of their choice, including a public option. In Ryan’s plan, ‘losing’ insurance means everyone gets a small tax credit towards purchasing an individual policy on the private market, with no public option.
Ryan also spend a lot of time decrying big government and government interference and government rationing. But look at the PCA: if you are among the 100 million or so chronically ill Americans who can’t buy health insurance except at an exorbitant premium, the PCA pushes you into… state-government-run health insurance exchanges (Sec. 202.d2). These exchanges are fundamentally similar to the health insurance exchanges proposed by the Democrats. The difference is, you don’t get a public option: in Ryan’s plan, the government can only help you buy private insurance. I don’t think very many sick people trust that industry, and it’s not at all clear to me why Ryan thinks taxpayer dollars should be spent plumping CEO bonuses and stock options rather than actual medical care.
The problem is, those 100 million people account for 75% of health care spending in this country. If a significant majority of them end up in the state exchanges – which is almost certain to happen under Ryan’s plan – then most of the health care spending in this country will be, in fact, government controlled. The 25% spent on relatively health people will constitute the entire “free market”, and the rest running through the government – state government, but still government. The difference between state government and the federal government is that states balance their budget, which means if your state has an off year, your health insurance will be a fat target for politicians looking to break even. Look at what’s happening in California with SCHIP – hundreds of thousands of children are going to be denied insurance. This is every bit as much rationing as what Ryan opposes; the difference is that by putting the onus for insurance on the states, rationing in the PCA is front-loaded and focused only on those sick people who can’t afford insurance on their own.
Ryan said that the free-market is necessary to patient-centered care. But most patients – the people who need health care – will be cut out of the free market and put into a government-run health exchange. And meanwhile, for all his talk about big government and the perils of socialized medicine, Ryan has managed to produce a bill that guarantees as much as 75% of health spending will be government controlled in one way or another.
Ryan also claimed that people come from all over the world to get care in the United States, and asking where Americans will go if the US has government-run health care. He apparently doesn’t know that hundreds of thousands of Americans are already leaving the country for medical care – for developing countries like India, Thailand, and Mexico. Those hundreds of thousands are projected to grow into millions in the coming decade, and it’s going to cost American doctors and hospitals a lot of lost revenue. That’s the free market at work.
Finally, the Congressman urged physicians to tell their patients to oppose health care reform – ‘to jam the switchboards’ with their calls. I don’t doubt for a moment that physicians could scare their patients into making those calls. When my physicians want me to do something and I don’t want to do it, usually they say “it could be cancerous”, and that scares me into doing it. No doubt they could do something similar on health reform: “the Democrats’ bill could give you cancer”, and if they said it convincingly enough, I would probaby call.
But that would be physicians using their power to influence patients, not to help them. A far better approach would have physicians asking their patients what they need and what they want from health care reform. I think that sort of dialogue is crucial. I don’t think Congressman Ryan has had that dialogue. I don’t think he knows what’s best for patients, and I don’t even think he knows what’s best for physicians. He certainly didn’t stick around to listen to what the physicians had to say, much less the patients. After a couple questions, Congressman Ryan hurried back to Capitol Hill.
Is there a transcript somewhere of the Q&A session?
Chelsea – not that I am aware of. I think Dr. Val may be working to put together some online videos of the event at getbetterhealth.com . I don’t know if they’re up yet.