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Rep. Paul Ryan: 'Rationing happens today! The question is who will do it?'


Rep. Paul Ryan is the ranking Republican on the House Budget Committee. His budget proposal, 'A Roadmap for America's Future,' was scored (pdf) by the Congressional Budget Office as erasing the long-term deficit entirely. I commented on it here. I spoke to the congressman this afternoon about his bill, the conservative vision for health-care reform, and the problems of Congress. The transcript has been lightly edited for length and clarity.

Your budget appears to agree with the Obama team on an important premise: The deficit problem is a health-care problem.

Absolutely. Just look at the numbers. It’s not a theory. It’s a fact.

Looking at your proposals for Medicare and Medicaid, I’d characterize your approach as privatizing programs and then capping the government’s contributions to them.

I think you compartmentalize the programs. Don’t do that. I’m trying to take a disjointed series of programs and transform them into a real health care market. You have to look at the other things I do in health care outside of the entitlement programs to get a full sense of what I’m trying to accomplish.

Obviously, you and I have different premises and philosophies, but you wrote a very good piece last year on the tax exclusion that really hit the nail on the head. I believe that by fixing the tax exclusion – which subsidizes the wrong people, by the way, people with jobs who already have health insurance – you’re attacking the root cause of health inflation. That’ll change the health care marketplace itself. Going forward, what I try to replicate in my Medicare and Medicaid proposals is a system that makes the patient the nucleus of the system. That will make a system in which doctors, hospitals and insurers compete against each other for the patient’s benefit.

When you talk about making people more powerful, that brings up some questions about the employer market. In theory, the employer market is big enough to have this effect. It’s big enough to work like a real market. But we both agree it’s not a real market, and even more, that you should end the exclusion. Where we part is on the question of who has the power. I’d say consumers don’t have the power. You’ll give consumers buying power. But I’d look at decisions power. And the real power there lies with doctors. I don’t do anything without a doctor telling me to do it. How does this change the doctor’s behavior?

What I also have in this bill is the health care services commission. It is a system whereby all these stakeholders in health care – providers, doctors, insurers, consumer groups, hospitals, unions – all come up with standard metrics that are standardized that we hold for price and quality and best practices. It’s a lot different than a comparative effectiveness approach. This way, the consumer sees who’s good and who’s bad. I think we need to make a big reach towards transparency.

I had lunch with a bunch of manufacturers yesterday. One gentleman had a 20-minute cataract procedure that cost $14,000. He couldn’t understand why it cost so much. In Milwaukee, the price of the same MRI ranges from $400 to $4,000. So you have a system in place that doesn’t function like a marketplace. You need to inject those market principles and an economic incentive to act on them. Then you have to break the insurance monopolies. That’s why I’m a fan of risk pools to subsidize people with preexisting conditions. I have a Medicare exchange to set up a certified Medicare system so people can select among those plans.

The whole point I’m trying to make here is that we have to understand these programs are growing themselves into extinction. The question, at the end of the day, is who’s going to be in control of this system. Is it the individual or the government? I don’t want the government more in control of the system.

A word we should bring into play here is "rationing."

Rationing happens today! The question is who will do it? The government? Or you, your doctor and your family?

That ends up being the interesting question. The theory of the Medicare system, of the European systems, is that the best way to do this is to have the government fund research to discover the effectiveness of treatments and then use its purchasing power the same way Wal-Mart would – to drive prices down. Medicare, as the CBO said in its report to you, pays less than private insurance.

But Medicare is growing at an unsustainable rate. And yet it underpays doctors.

But private insurance is growing that quickly as well. And this question of underpayment is doctors and hospitals making less than they expect to make. What you’re talking about, bringing Medicare spending down very sharply, is even more vulnerable to that critique. You do it on the patient side, not the provider side, but they will feel they’re getting vouchers that aren’t generous enough to keep up with health-care costs.

So what I’m saying is that rather than having government ration care to manage decline, let’s take those market signals that work in every sector of the economy to reduce cost and improve competition. I got Lasik in 2000. That’s a cash surgery. It cost me $2,000 an eye. Since then, it’s been revolutionized three times and now costs $800 an eye. This sector isn’t immune from free-market principles.

The Lasik thing is interesting because it gets to the question of whether health care is a market. When I think of getting Lasik, or buying a television, I can walk out of the store. That’s what gives me as a consumer my power in the market. But if I have chest pains and my doctor prescribes a bypass, how do I walk out of the store?

In Milwaukee, the price of bypass ranges from $47,000 to $100,000. Nobody knows where to go for quality, or the prices. So wouldn’t it be good for the prices and quality metrics to be publicized? And let people make a decision. There’ll always be some level of co-pay or deductible or co-insurance that’s going to push people towards the best value. Then, when you have those chest pains and you’re being rushed in the ambulance, you’ll be rushed to a hospital that’s all along been competing for business and has been improved by that process. You’ll get better health care than you otherwise would. That’s how you improve the system.

You’re arguing that the benefits of competition accrue, and so even if you don’t choose at the moment of emergency, there’s still an effect from a higher-functioning market.

Absolutely. I don’t know anything about cars. I look at Consumer Reports and their ratings. What matters is that someone who knows about cars went and figured this out. The car company is competing for the really tough customer who goes under the hood. I’m not saying every American has to be that consumer. But enough people have to so the rest of us can benefit.

But take cars. Lots of people buy crappy cars, or bad televisions. I make bad purchases all the time. Liberals and conservatives are together on the publishing of quality metrics. But this stuff is more complicated and diffuse than cars. That’s not to say the consumer shouldn’t have a role. I’m a big Wyden-Bennett guy, frankly.

I have a lot of respect for that plan. If I were a Democrat, it’s the bill I’d be on. He’s got more mandates than I’d like. But if Ron Wyden and I were in a room, we could hammer out a deal by tomorrow.

Well, let’s talk about Wyden-Bennett for a second. We’ve seen this health-care reform debate wear on. Putting aside whether the Democrats have a good plan, it’s certainly been good for Republicans to make it into a bad plan. Wyden-Bennett, which is more disruptive, never went anywhere. It becomes very difficult to see how anything big enough to work is safe enough to propose.

You’re so right about that. I did some thinking when I first put this out in 2008. I decided that if the people of southern Wisconsin sent me here to represent them, I need to be part of the solution. I feel obligated to put big ideas on the table and break up the status quo and this awful inertia we have out here. We shoot at anyone who pops their head above the foxhole and proposes anything big. This fiscal situation will destroy us if we don’t start stepping up. I don’t have all the answers. I put out a real, credible plan in the hopes that other members of Congress will do the same, and we can get on with the business of hashing out how to fix the problem.

So there are a couple of folks out there who do this. You, Wyden, Pete Stark, who feel safe enough to propose big things. But how do you deal with the fact that nobody is wrong about the political benefits of this stance of full opposition? Republicans are doing well at it this year. Democrats did it nicely in 2006. No one is wrong about this. You and I agree that market incentives matter. And the market of elections pushes against cooperation.

This is my 12th year. If I lose my job over this, then so be it. In that case, I can be doing more productive things. If you’re given the opportunity to serve, you better serve like it’s your last term every term. It’s just the way I look at it. I sleep well at night.

Then let’s back up to the Senate bill. Some of the things in that bill, like exchanges and redoing the market, are in your bill. I know you don’t agree with it. But if you were paring it back, what would you keep?

The whole premise of it is wrong, in my opinion. It’s to have a more government-centric system

What’s government-centric about it exactly?

You’re erecting a bureaucracy to determine how this happens. Federalizing the regulation of health insurance in Washington. You’re having a person design how insurance can be sold. You’re mandating people buy it. It will stifle innovation and competition in health care. If we were talking about Wyden’s plan, I could give 15 things I like. But this isn’t that.

Let me ask you about the regulation piece of this. Insurance is a complex product. People get sold stuff that just plain doesn’t work and they don’t know it till it catches them. The Senate bill doesn’t design plans in a granular way. But it sets the minimum for it.

I agree with that. In the Patient’s Choice Act, we do an actuarially equivalent minimum in each exchange that’s equal to the Blue Cross/Blue Shield Standard Option.

But that’s how the Senate bill works, too. It’s an actuarial value.

I’m more familiar with the House bill. But the Senate bill goes a lot further than that. You need to define what insurance is. I agree with that. But what we’re trying to achieve here is a system in which the patient is the driver of it, not government bureaucrats.

Let me back you up on that, though.

I gotta get going in one minute, I apologize.

Final question. You agree that we need to define what insurance is. In the Senate bill, you’ve got an actuarial value for insurance and patients come and decide which plan to purchase. I look at the bill, and I’m more of a big government guy, and it looks like an application of market principles to me. Where in that exchange transaction do you find the heavy hand of the government?

We set up state-based exchanges. You don’t have to participate in the exchange if you don’t want to. You don’t have to sell it in the exchange if you don’t want to. I don’t want a closed system that will gravitate towards more government control. I want it to be decentralized that has regulatory competition and market competition. You can be in or out of the exchange, which keeps everybody honest. That to me is very important.

Photo credit: By Katie Derksen/The Washington Post

By Ezra Klein  |  February 2, 2010; 6:30 PM ET
Categories:  Interviews  
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Well, I guess you can't have a better standard metric than one that is standardized. Who'd lie about a thing like that?

I certainly agree that Medicare pays medical providers less than they would like to receive. I'm not sure, however, that this is the same thing as "underpays." It actually overpays compared to everywhere else in the world.

Some things are just not a market. A market assumes some sort of parity between contractees, at least to the extent that either of them is free to walk away. But if one is having a heart attack and the other has the power of life and death, that is no longer a market. It is effectively a monopoly since you will die if you take the time to go anywhere else.

I don't understand why conservatives believe that everything is a market. Some things just aren't.

Posted by: pj_camp | February 2, 2010 6:54 PM | Report abuse

Long term, deficits will be a healthcare problem. Today, however, it's a spending problem.

I wonder if he'd be so quick to agree with the way you've framed it here, Ezra.

Posted by: whoisjohngaltcom | February 2, 2010 7:08 PM | Report abuse

Great job, Ezra!

I honestly tried to keep an open mind (as open as possible, given that Ryan is a Republican), but here's where I laughed out loud:

Q: "But if I have chest pains and my doctor prescribes a bypass, how do I walk out of the store?"
A: "In Milwaukee, the price of bypass ranges from $47,000 to $100,000. Nobody knows where to go for quality, or the prices. So wouldn’t it be good for the prices and quality metrics to be publicized? And let people make a decision. There’ll always be some level of co-pay or deductible or co-insurance that’s going to push people towards the best value. Then, when you have those chest pains and you’re being rushed in the ambulance, you’ll be rushed to a hospital that’s all along been competing for business and has been improved by that process. You’ll get better health care than you otherwise would. That’s how you improve the system."

If I'm having chest pains, I'd prefer a conscious choice between Saks and Walmart. But that's not feasible. So, I could end up at a WalMart, at a Saks, or at any place in between. Is that supposed to be a convincing sales pitch?

Honestly, the guy deserves credit for stepping up and addressing some issues. But when the concept of "rationing" is discussed without even a mention of insurance companies, why bother pretending that this is an honest discussion? This isn't a choice between the individual and the government ("We, the people", might I add). This is a choice between the corporation and the government. And as of right now, the corporation has a lot to answer for.

The only people left in America who still insist that the Market always delivers the best that we, as a nation, have to offer are those completely lacking in imagination and standards.

Posted by: slag | February 2, 2010 7:31 PM | Report abuse

Paul Ryan might be the first Republican in Congress to act like an adult since Obama came into office. This is what spirited opposition should look like.

I disagree with almost everything he says, but I'm glad he is saying it in the manner he does.

Posted by: cmo101 | February 2, 2010 7:46 PM | Report abuse


Wouldn't the Wyden Bennet plan still come across the same problems as you talked about in the chest pain/bypass example? Doesn't the Wyden Bennett plan give vouchers to people like Paul Ryan's plan? How are those vouchers indexed to the rising cost of health care?

Posted by: nathanpunwani | February 2, 2010 7:51 PM | Report abuse

Great (if too brief) interview, Ezra.

That being said, I don't object to the general principle of market-based solutions, but I think the projected outcomes are at least as pie-in-the-sky as the deficit-reduction claims of the HCR currently stuck in the senate.

I just don't see how he can say with any certitude, especially giving the multitude of factors involved in healthcare and the healthcare marketplace, that the outcomes would be so positive.

"The market" doesn't necessarily offer the best that we, as a nation, have to offer, but there's some good stuff out of the marketplace. Especially when it's not distorted. I'm not sure Paul Ryan's solution guarantees any less distortion than we have now.

Posted by: Kevin_Willis | February 2, 2010 7:55 PM | Report abuse

Congrats, Ezra, you've just legitimized the Ryan approach to healthcare reform. This interview will become the GOP's p.r. centerpiece: "In a thoughtful and wide-ranging policy discussion, even prominent progressive healthcare pundit Ezra Klein conceded that the Ryan plan would improve on the current legislation . . ."

This ranks up there with "I haven't paid attention to the Massachusetts special election" and "Olympia Snowe will heed the call of history -- heady stuff" and "the 60-vote option is soooooo much awesomer than reconciliation" and "the public option? who cares?"


Posted by: scarlota | February 2, 2010 8:10 PM | Report abuse

Some nice dialogue here.

A couple of reactions:

-- Ryan touches on a number of arguments countering Ezra's belief that markets can't work in health care. A heavy dose on informing consumers on quality and cost. Quality is key here. You like talking about the inability of patients to push back on a recommendation for a bypass. What's most important is going to the right hospital, with a CT surgeon that conducts a sufficient number of procedures per year, hospitals that have lower costs with the same outcome. Consumers can't make those decisions today. They should have that power.

-- Employers don's consume health care. People do. I don't see who thinks that the employer model makes sense as a functioning market. Wyden's whole focus on choice is based on the premise that an efficient employer market still wouldn't work well. Wyden's right.

-- I think regulatory competition via state-based exchanges has a lot of merit. Given that the "right" answer is far from clear, the benefit of regulatory variety, with some basics guaranteed at the federal level (e.g. actuarial value) has promise. I'd be real curious to hear the policy merits of sole federal oversight. This seems to be more an ideological battle than a policy one.

-- He goes too far in allowing insurance to exist out of the exchange. There's a base set of regulations and oversight that should apply to all plans, all should sit in the exchange. Your points on insurance plan complexity and people getting screwed when its too late is very true. Government should help people make the right decisions, and that doesn't mean that individuals should be on their own.

Posted by: wisewon | February 2, 2010 8:12 PM | Report abuse

"What I also have in this bill is the health care services commission. It is a system whereby all these stakeholders in health care – providers, doctors, insurers, consumer groups, hospitals, unions – all come up with standard metrics that are standardized that we hold for price and quality and best practices. It’s a lot different than a comparative effectiveness approach. This way, the consumer sees who’s good and who’s bad. I think we need to make a big reach towards transparency."

Dead on. This is really important. Democrats have fallen for a scientific/academic purity that more data needs to be collected before any standards could get put in place, i.e. comparative effectiveness. That's true-- but just a little-- we'll never have enough data to make 100% firm conclusions, that isn't how medicine and science work. A LOT of standards could be put in place now. But it requires uncomfortable questions to be asked and answers to be put in place. It requires a mature understanding that quality assessments will always be made on imperfect information--but its information that is still better than most other things outside of medicine. Its a a lot easier politically to punt on the tough questions of standards and accountability and instead talk about the need for more research. Ryan is pushing right to the heart of the matter. So while you says liberals are for quality metrics, they put comparative effectiveness ahead of quality metrics. That was a huge mistake.

-- Democrats should take notice. If the Republican party could get some other folks who actually care about health care and understand it too, this debate won't be so uneven. Ryan has good points on most of Ezra's challenges and he's right on many of them.

Posted by: wisewon | February 2, 2010 8:18 PM | Report abuse


You were schooled by a conservative who has channeled the collective wisdom of middle America. We don't want or need the goverment to be our daddies. We can figure out the amount of health care we need and who to get it from far better than any burecrat. Scott Brown was elected for a reason; To keep big goverment pinheads from destroying our way of life.

Posted by: cummije5 | February 2, 2010 8:32 PM | Report abuse

Another bold political prediction of the day: after the collapse of the Democratic legislation (soon), the GOP will coalesce around the Ryan plan as their template for healthcare reform. And this interview will be cited repeatedly as a justification for the Republican approach. I can just hear the television ads: "You may not know it from all the liberal noise out of Washington, but Republicans have really great ideas about healthcare reform, too! Time to get government out of your doctor choices altogether. The Ryan plan -- why, even a progressive expert like Ezra Klein could find something to like!"

Credit where credit's due: Snowe and Ryan have played EK like a Stradivarius. With friends like this one, genuine healthcare reform -- the kind that truly helps lower- and middle-income families -- doesn't need enemies . . .

Posted by: scarlota | February 2, 2010 8:34 PM | Report abuse

"You were schooled by a conservative who has channeled the collective wisdom of middle America."

Dude-I just now polled Middle America, and we've all determined that you're an idiot.

Posted by: slag | February 2, 2010 8:41 PM | Report abuse

Great Job Ezra.

I share comments by 'cmo101'; indeed we have got a rare species here - an adult GOP member willing to articulate and defend a serious HCR plan.

I do not think that by airing this interview you are legitimizing non-Lefty GOP plan. You are legitimizing only one thing here - 'going every nook and corner to find solutions for our problems' regardless of how chips fall. That is great.

Merits of Paul Ryan's plan - I am all ready to read intelligent commentary by you folks rather than opining based on limited study.

Posted by: umesh409 | February 2, 2010 9:01 PM | Report abuse

Interesting conversation. Ryan seems intellectually honest and has sensible points but a few things to keep in mind.

1. His plan does not really shift power away from government fully to the individual. To a good extent, the power is shifted to insurance companies. It is the insurance companies who decide which providers are on their preferred lists and they enact heavy financial incentives and dissincentives that limit choices for individuals.
2. Standardized metrics on price is probably a no-brainer. Metrics on quality is a lot more delicate. Take, for example, the notion that the surgeon and hospital who does more procedures is better. Well, many academic hospitals and physicians do less procedures because the evidence shows that conservative management is just as good or better. And since they are salaried, they have no financial incentive to do more procedures. If your metric is based on outcomes, some physicians and hospitals may chose to avoid sicker patients and risky procedures in order to pad their numbers (this already happens today). Many many experts have been working on how to measure quality for years. The point is, whatever metric you devise will carry incentives that will impact physician and hospital behavior in potentially negative ways. Therefore the metrics that will likely emerge (some already have) will yield relatively marginal differences between doctors and hospitals and not affect market dynamics as strongly as one might think.

The bottom line is twofold. Most of the assumptions on which the perfect competition market model works do not apply to health care. Secondly, Ezra is right in pointing out that Healthcare providers (Doctors) will always wield the greatest market power within the system and the only things that change physician behavior are scientific evidence, policies, and payment/reimbursement incentives. Individual patients can never have the power to significantly affect policies or reimbursement incentives. Those powers belongs to insurance companies, healthcare delivery systems, and the government.

Posted by: lagnappe | February 2, 2010 9:33 PM | Report abuse

Awesome. Everyone here has praised you, Mr. Klein, and it's well-deserved. But I think Rep. Ryan deserves HUGE KUDOS for standing up and saying what a conservative approach to governing might look like. I don't agree with him but at least its an actual discussion. Maybe FoxNews will hire Ryan as commentator!

Posted by: stevedwight | February 2, 2010 10:24 PM | Report abuse

Seriously scarlotta, grow up. Ezra conducted a seriously good interview here that engaged the man on the merits of his plan. To his credit, Ryan engaged on the merits (mostly) as well. If the debate in Congress were anywhere near what Ezra had with Ryan, we might get somewhere.

Treating your opponents like adults when they're acting like adults is no vice. Good for Rep. Ryan for taking this issue seriously and not just as fodder for the next election. I'd hate it if his plan were enacted whole cloth, but if, on the other hand, Democrats took some of his ideas and in exchange Republicans stopped acting like children when discussing healthcare in public and would ensure at least some measure of bipartisanship, well, I could probably swallow it.

Posted by: MosBen | February 2, 2010 10:28 PM | Report abuse

He's riiiiight!

Eliminate the deduction for employer provided insurance and use the money to fund universal health care.

It's just like when Reagan broke a huge logjam in the 80's and reduced marginal tax rates by eliminating deductions.

It sooo works.

Posted by: bgmma50 | February 2, 2010 10:42 PM | Report abuse

Good, substantive interview. Great follow-ups too. A reporter with a more generalist bent wouldn't have been able to ask the 400 level questions.

In reference to Ryan's statement about competition in the marketplace, there have to be some federal standards.

In terms of autos it would be a disaster if we left it up to states to determine things like auto-safety standards and said no federal rules should apply. What would happen to things like seat-belts, air-bags, or fuel efficiency standards in that kind of environment?

Why should we apply a lower standard when it comes to the quality of health care markets?

There needs to be some baseline and standardization in terms of regulations as they relate to issues such as rescission, policy cancellations, etc.

Where is the consumer choice in an environment where an insurer can effectively dump a customer because the servicing costs become too high, and what good is consumer choice if real choice only exists for people who least need the product in the first place?

Posted by: JPRS | February 2, 2010 11:01 PM | Report abuse

Regarding walking out when you have chest pains.....

First of all, an approach that relies on personal responsibility and choice works extremely well with the smaller, day to day health care choices we make. Doctor visits, prescription meds, lab tests, etc. It's cumbersome and silly to structure a system that relies on government and bureaucracy to regulate those types of expenditures. Much of our health care system is not all that different from Lasik.

This is exactly why the government, if it is going to be in the health care guarantee and delivery business, should only be in it for catastrophic care only. Through the government we can provide major medical, catastropic coverage and subsidize it for everybody and do so fairly cheaply. Reducing the exclusion will pay for it. Then leave the purchase of insurance for low copays, low deductibles, prescription drugs, higher annual and lifetime caps to the marketplace and to individual choice and responsibility.

Posted by: bgmma50 | February 2, 2010 11:01 PM | Report abuse

As the parent of a child with a severe genetic disease and extensive medical needs, I live the healthcare crisis each day. For years now, my private insurance has repeatedly sought to cut off the most basic medications he needs to live. Fortunately, I live in an affluent "blue" state with a strong commitment to Medicaid, which kicks in to cover his exorbitant medical costs even as private insurance has walked away, again and again.

From my perspective, then, the private sector has failed miserably and the public sector has literally saved my child's life, multiple times. That's why I'm personally invested in this debate, and that's why I find Ezra Klein's weird waffling on healthcare reform -- snubbing PO advocates while elevating the arguments of privatizers -- deeply troubling. If EK believes Ryan's ideas are better than, say, Wyden's or Pelosi's or Schumer's, then he should say so, plainly and unequivocally. On the other hand, if he believes Ryan is a extremist-in-moderate's clothing, then he should say so, plainly and unequivocally. His readers deserve nothing less -- especially the progressive ones.

Posted by: scarlota | February 2, 2010 11:07 PM | Report abuse

So, how soon can we get Ryan and Wyden in a room??

Posted by: gocowboys | February 3, 2010 12:11 AM | Report abuse

I think caps on spending growth are the way to go, and I prefer to be the one to make the decisions about what I want, and choose best value providers in non-emergency situations. The situation we are in now, where it costs me the same to go to Saks or Target is not helping those who are trying to provide value in health care. We need published standard pricing now. This shouldn't be like buying a used car- I should be able to choose whether I want the $4000 or $400 MRI, and I should be given the benefit of choosing the less expensive option if it is suitable for my needs, since I don't need a lobby with fresh brewed Starbucks in it or whatever.

Posted by: staticvars | February 3, 2010 12:13 AM | Report abuse

The Senate bill does a lot of the heavy lifting for Ryan to get toward a system he'd like. Having that bill pass and Republicans take over in 2010 and 2012 clears away many of the barriers for his plan. The difference between the premise of a government centered system and a whatever centered system is a bunch of arcane provisions and regulations that's more easy to change than setting up the market in the first place, not to mention getting an excise tax through.

Democrats should read the interview and realize it's a lot harder to really rip a bill that's passed into law. On the surface, the approaches are similar and will the details move the country?

Posted by: windshouter | February 3, 2010 12:32 AM | Report abuse

This was a most enjoyable and stimulating interview. It sounds like Ryan has really looked at this stuff and has serious thoughts about it. My concerns about what he says are: 1) If you have chest pains and the Dr. says you need a bypass, your ability to choose the provider is limited by how soon the procedure must be performed. If it is an emergency the patient is at the mercy of what the doctor says and cannot make an informed choice about where to have the bypass.

2) I disagree with him, and this may be because he's more familiar with the House bill, about the preference for state-exchanges rather than federal exchanges. I think that the way that Obama and the Congressional Dems worked it out, where you have state-based exchanges with federal minimums, is the way to go, by providing flexibility while setting a baseline for what needs to be covered in a plan. I don't see how that's very different from what Ryan is proposing.

I do like his point about taxing plans b/c it seems like it would align the providers and consumers together, and reduce insurance influence.

I frankly think the House needs to pass the Senate bill and then work on fixing the glitches, such as Nelson's Nebraska deal.

Posted by: jschreiber1 | February 3, 2010 1:14 AM | Report abuse

Fine. Pass the Ryan plan. It's equally bad as Liebercare, and it will get at least one Republican vote.

Posted by: bmull | February 3, 2010 1:26 AM | Report abuse

great job ezra.

Posted by: schaffermommy | February 3, 2010 1:29 AM | Report abuse

So this is supposed to be a good idea, turn it all over to insurance companies selling in state insurance exchanges. Then eliminate all government intervention and Medicare. Who really thinks this would work that's not nuts ? For profit health care and insurance companies are the problem. Do you really think the average middle class American would not be less well off in this situation ? I agree with many on here. Let the house pass the Senate Bill and make fixes in reconciliation. When has the Repubs free market tinkering benefitted the average individual in the last thirty years ? Just ignore them until they prove they can compromise and talk like adults. This Congressman acts like this so risky for him to propose this. Give me a break, he knows it is full of Repub talking points and will never be considered. Ezra was much too deferential in this interview and hurt his own cause.

Posted by: Falmouth1 | February 3, 2010 6:20 AM | Report abuse

1. His plan does not really shift power away from government fully to the individual. To a good extent, the power is shifted to insurance companies. It is the insurance companies who decide which providers are on their preferred lists and they enact heavy financial incentives and dissincentives that limit choices for individuals.

Posted by: lagnappe | February 2, 2010 9:33 PM | Report abuse

You really (before you speak) should understand how the contract negotiations work with insurers and hospitals and doctors. Most of the doctors moving in and out of networks is the doctors decision and not the insurer. The insurers do not take a list and say "We'll take this one and this one and this one . . ."

Doctors when they get out of medical school LOVE insurers because they build their practice for them and then once they feel as if people will come to them wihtout regard to cost they'll drop insurers (and their required discounts) like a bad habit.

Its a shame because the truth sounds much less sinister.

Posted by: visionbrkr | February 3, 2010 7:30 AM | Report abuse

what slag doesn't seem to get is that its not the consumer making the conscious choice of Hospital X over Hospital Y when you get a heart attack. Its hospital X realizing on its own (prior to that heart attack) that it must (to compete with hospital Y) increase its best practices and efficencies. This is one of the better plans the Republicans have put out there but I'd rather still have Wyden-Bennett because while I'd like to believe Americans can be good and smart consumers of healthcare, I can't get myself to believe it on a national scale.

Posted by: visionbrkr | February 3, 2010 7:35 AM | Report abuse

Scarlota: I think my opinions on the plan, and its relative worth, are pretty clear. Click on the commentary link in the introduction, where I say the plan is "a blunt object of a proposal, swung with incredible force at a vulnerable target."

But the fact that I disagree with the plan, and that many of you do, as well, is not the same as saying that we shouldn't hear out what conservatives think about health-care reform. We spend so much time arguing in bad faith in this town that there's a danger we totally forget how to argue in good faith.

Posted by: Ezra Klein | February 3, 2010 7:53 AM | Report abuse

This was the most informative debate I have seen on the WAPO in months.

It is a shame our congressional discourse cannot follow these lines. Find what you can agree on, compromise on what you don't, and start fixing the problem.

Obstructionist grandstanding by both parties has brought this country to its knees. No wonder everyone is so pissed off.

Posted by: trident420 | February 3, 2010 10:07 AM | Report abuse

Your desire for a political Utopia is admirable, Ezra, with enlightened Obama-esque back-and-forth discourse; but again, as with Massachusetts, as with Snowe, you're misreading the Republican political strategy here. Ryan may or may not be offering some intriguing policy ideas for a wonk to chew over, but the underlying drive to destroy the social safety net burns bright. Besides, I haven't seen too many Republicans "arguing in good faith" over the past year while Democrats have bargained away the policies that the base cherishes. And yes, you've played a major role in that dynamic, with persistent, public ambivalence about the PO, the insistence of 60-votes over reconciliation when it was increasingly evident that the math was fragile, etc.

Look, I'm at an advantage here: I grew up in the evangelical South, in a ruby-red corner of a ruby-red state; virtually everyone I knew were far-right Republicans, including parents, siblings, pastors, friends, acquaintances. I know what motivates them: an unending holy war to destroy the Democratic party. This new "I'm not a tea partier" tactic -- appearing reasonable and engaged in policy details, respectful of Democrats -- will allow them 1) to kill Democratic "socialized" medicine; 2) resurrect the privatization zombie as *the* solution, winning back independents; 3) take full credit for reform; 4) push the Democratic party toward the Whig dustbin. Theda S. and others more or less agree.

Posted by: scarlota | February 3, 2010 10:07 AM | Report abuse

What Ryan doesn't say is that his plan is to basically to hand seniors a check for ten grand or so and tell them to go buy whatever insurance they can find. No insurance company has to take their money, that is the beauty of his free market.

Posted by: flounder2 | February 3, 2010 10:10 AM | Report abuse

Ezra, I have to agree w/ Scarlota to some extent. I don't think your opposition to the Ryan plan is as clear as it could be. Meaning: I don't think you've made a very strong case against it. In your interview, even, you get to the point of saying, "You and I agree that market incentives matter." You weren't able to put a dent in the proposal, unfortunately. I think the conversation did go your way a bit more when you brought up the Senate bill and it appeared that Ryan was a little unfamiliar with the details. But in terms of Ryan's own plan, it almost sounds like something you could support. And I know you called it a "blunt object...", but I wasn't sure how this by itself was a major critique given that Wyden-Bennett is also a blunt object, and you support that. It seems like your major objection to Ryan is (a) politically infeasible; and (b) privatization/vouchers. But on point (b), again, I don't think you were too persuasive here.

Maybe you can follow up on this with another overview of the plan, or perhaps an interview with another health expert about the plan?

Posted by: gocowboys | February 3, 2010 10:21 AM | Report abuse

Ezra's hero, Ezekiel Emanuel, Obama's health care advisor, brother to Rahm, is also a MAJOR voucher advocate--

--- even for the elderly which is kind of what impoverished seniors had before Medicare,

where they had a little money to spend---- but no insurance company wanted to insure the old, except at very high premiums or few benefits----

How much care will seniors be able to buy with a discounted voucher?

That's the problem with health care funding, the majority of the money has to used for the sick---makes people like Ryan and Emanuel crazy.

--so their strategy for health care is rationing with vouchers-----

---a system of "SURVIVAL OF THE RICHEST"

All of us better stay healthy with this set of DEMS and GOPers in office !!!

Posted by: johnowl | February 3, 2010 10:32 AM | Report abuse

It was a good honest exchange, right up until the end when Ryan refused to back up his claim that the current bill leads us to "a more government-centric system." He completely ignores Ezra's point that the Senate bill is set up in a way that Ryan just said he supports.

It's convenient for Ryan to praise Wyden-Bennett because it's not on offer! So he can look reasonable saying that he and Wyden would hammer out a bill by tomorrow. But when Ezra asks him what ACTUAL COMPROMISES he could make on the current bill, Ryan throws up a bunch of jumbled talking points. "government bureaucrats" "stifle innovation" "uh, i've got to get going..."

I think Obama got it right when he said that these people have demonized him and this plan so much that it's now become impossible for them to negotiate. If Ryan got in that room with Wyden, the right would disown him. Because he would have handed Obama a victory. The fact that right now a victory for Obama is also a victory for suffering Americans is apparently neither here nor there.

Posted by: HappyRockefeller | February 3, 2010 10:44 AM | Report abuse

For an interviewer, I thought that Ezra made his opinion of the plan pretty clear. More importantly, it's important to debate the issues reasonably when you get the chance. Ryan went out on a limb to talk to Ezra, they talked through the issues with some dispute, and we're all better off. Beats a situation where Ryan just gets attacked, shuts up, and we near nothing.

Also, I'll echo what windshouter said, that the Senate bill is a necessary prerequisite for his proposal. The problem for seniors is one of cost: they don't really fit the insurance model, because they're facing relatively certain costs. Going to a market with fewer resources puts a lot of pressure on them, and you need regulation and forced offering so that they can actually get coverage. There needs to be a guarantee that their voucher will actually be good for something.

Good thing that we at least have a Republican on the record saying that price pressure must be put on providers, even though he did try to avoid that rhetorically.

Posted by: etdean1 | February 3, 2010 10:49 AM | Report abuse

I was very pleased to read this interview. There need to be some Republicans willing to vocally stand *for* things and not just against them.

I agree strongly with the larger principle behind Ryan's ideas -- that the system needs to introduce some ways in which consumers actually have information about the product they're getting. His proposal of how to do so ends up having just as much centralized control as the existing legislation, though; whoever is creating evaluations of doctors has tremendous power to influence purchasing decisions of consumers.

He also doesn't at all address the issues of recision and pre-existing conditions in this interview. Since the scope of the existing legislation is essentially just to deal with those problems and to pay for it with various cost-controlling measures, he really ought to be largely in favor of the current legislation if these issues matter to him. I don't know if they do.

Still, I'm terribly glad to have someone in the GOP actually trying to accomplish something.

Posted by: jeffwacker | February 3, 2010 11:21 AM | Report abuse

The status quo of letting Medicare pay for most senior's health bills can't continue on current trends. It simply can't. As a (potential) future senior in the 2050s, I oppose letting Medicare grow so much that it sinks the country, even if I'm getting in the ballpark of $50,000/yr on average in benefits from the program.

So while you might trash Paul Ryan's idea, there needs to be a credible liberal alternative which would drastically slash Medicare benefits in some way, shape or form. Ryan wants the government to commit to a defined dollar value of benefits for those under 55, and allow us to plan/save for our future health needs. The payment is adjusted both for income and for current health status, so both those with pre-existing conditions and lower incomes receive greater government support. It also fully funds HSAs for low income seniors to help with deductibles and co-pays. I'd be okay with this plan.

The liberal alternative needs to be as credible in terms of controlling costs. The liberals could offer to spend a set percentage of GDP now and forever (say 7%, or ~$1 trillion in 2010) to finance a British-style National Health Service. That would be about $3,200 per American, or roughly inline with many of the less expensive universal health care systems in Europe. At the same time, once the system was in place, Medicare, Medicaid, SCHIP and the insurance tax deduction would all go away. There would be no spending or tax expenses on healthcare at the federal level, and states would be allowed to get rid of Medicaid. Anyone who wanted to opt out of the system and continue using private insurance or private hospitals could do so. I would get rid of regulation except that necessary to avoid having insurance companies dump sick policy holders into the public system. Basically I'd suggest eliminating recissions (insurers could require tests and have a third party provide health history before creating a policy), and to require all insurers to explicitly offer a policy rider (at actuarial cost to the policy holder) which would allow policyholders to continue receiving insurance benefits if they become too sick to work/continue to pay for the policy - insurance insurance if you will. I'd be okay with this plan too, or something similar.

What I am not okay with is trying to throw in ad-hoc incentives to reduce spending, and hope to Jesus that they bend the cost curve. Those incentives - such as the employer tax - are better than nothing, and so the Senate bill is probably better than nothing. That said, what I want is for the government to explicitly cap its expenditure commitment and set up a sustainable system going forward.

Posted by: justin84 | February 3, 2010 11:34 AM | Report abuse

Kudos to you Ezra Klein!

This is a fantastic interview!

How does it feel to get a scoop directly from the next President of the United States?

Posted by: FastEddieO007 | February 3, 2010 12:25 PM | Report abuse

For what its worth, there are many people who genuinely fear that FEDERAL GOVERNMENT CONTROL OVER OUR ACCESS TO HEALTHCARE is far more dangerous than Insurance Corporation control over our healthcare.

That is Lieberman's vantage point. That is Olympia Snowe's. And that is Paul Ryan's.

Corporations in and of themselves are merely vehicles for market-driven healthcare, whereby the only other alternative is government-regulated healthcare.

Paul Ryan proposes a hybrid---a government-regulated healthcare that does not completely abolish market-driven alternatives. More importantly it designs the government-regulations so that it has market-driven effect maintained.

Lieberman and Snowe would come together around something like that.

But Democrats will never get more than 55 sure Senate votes for their continued insistence on government-regulated controls that are definitively sanitized of market-driven effects out of rigid adherence to ideological extremism that if someone benefits financially from providing a better service, the government does not have enough control.

Posted by: FastEddieO007 | February 3, 2010 12:34 PM | Report abuse

Obama and the Dems chose to not listen to anyone else. They new it all just like Hillary did during the Clinton years. The Republicans gave opinions and the Dems ignored them, killing suggestions in committee. So when the Dems can;t even agree on their own bill, the voters want to hang them and are oppossed to the bill, yhe blame it on Republicans. All the Republicans did was stand by and watch the Dems attack each other. Only until the payoffs to the unions and a few Senators came about could the Dems produce a bill. But blame it on Republicans, sure.

Posted by: jschmidt2 | February 3, 2010 12:46 PM | Report abuse


A well-regulated market doesn't abolish market incentives.

If it's a well-designed regulatory structure it makes it harder for sellers to cheat customers with deceptive marketing tactics.

I don't see why someone would favor a market where it is easier for sellers to deceive customers; and where we provide a market incentive for deceptive practices.

Effectively that's what Ryan is selling. That may not be his intention, but that is the most likely practical effect.

The insurers right now are pushing hard for a race-to-the-bottom approach akin to the consumer credit market (e.g. where the lowest state standard effectively becomes THE national standard).

Posted by: JPRS | February 3, 2010 12:50 PM | Report abuse


Right the DEMS ignored opinions -- things like single-payer, and the public option.

GOP/industry provisions were incorporated into both the House and Senate bills, so the notion that their opinions were ignored isn't born out by the facts.

The reality is that the GOP isn't committed to reform in this area (or pretty much ANY area) because right now they don't see any political advantage in doing so (e.g. the thinking is that the Dems will reap the lion's share of the credit).

In terms of the GOP's commitment to health care: At a time when premiums DOUBLED, the GOP never invested significant political capital into reforming the system, or addressing abuses. Their lethargic approach to the issue from 2001-2007 says all that needs to be said about where they really stand on this issue.

For them the best health care system in the world is one where 30,000 uninsured die each year; where middle and working class families lose their savings and homes; and where they get a nice industry kick-back in the form of campaign contribs every time elections roll around.

Posted by: JPRS | February 3, 2010 12:59 PM | Report abuse

If you want to see how the Ezra and liberal Democratic preferred healthcare reform, single payer, really works check out the article about the Canadian premier traveling to the U.S. to get his heart surgery. Behold the liberal future of American healthcare: the wealthy traveling out of the country to get away from substandard government run healthcare. Joy, Joy. As for Rep. Ryan, I think the Republicans would be smart to put his market oriented true healtcare reform front and center in their counter to the Democrats big government non-reform.

Posted by: RobT1 | February 3, 2010 1:02 PM | Report abuse


Single-payer is one of many better alternatives to the current system.

You never hear people in Canada losing homes and life savings because of medical emergencies. Canadians actually tend to live 3 years longer on average than Americans too. So even though they pay less than half of what we pay for health care, the results aren't that substandard for the typical person.

In reference to world-views: The "liberal" view is one that believes that every American should have a shot at the American Dream.

The conservative view is that the majority are born to service the needs of a handful of rich, corrupt, b-stards.

Posted by: JPRS | February 3, 2010 1:21 PM | Report abuse

Ezra, in your former post you said that the subsidies in Ryan's proposal are indexed to the average of health care prices and the CPI. With a large generation of boomers aging I figure health care prices will continue to rise faster than the CPI no matter what reforms are put in place. There will be more demand for health care. So, doesn't that mean even if Ryan's health insurance market works to make health insurance/care more competitive that the subsidies he proposes will, over time, shrink in comparison to health insurance premiums?

That's assuming that in addition to identifying me as an organ donar my drivers license also tells the ambulance to take me to hospital X for heart problems, hospital Y for stroke, and hospital Z for bleeding wounds/broken limbs.

Posted by: ideallydc | February 3, 2010 1:26 PM | Report abuse

Two points about Ryan's arguments -- one: The Republicans have been touting the market solution for 25 years and so far they have made very little progress, despite occasional majorities in Congress. It all sounds good but giving consumers the so-called "power" is not the only answer. Which leads me to point two: I don't know about the rest of you, but my Ph.D. doesn't really help a lot to understand evidence of coverage documents or other incredibly complex insurance and medical issues. To think that the general population can read a consumers report on medical care and choose the right treatment or doctor like they do a TV is irresponsible.

Don't elevate Ryan to too high a pedestal. He didn't really answer Ezra's basic questions.

Posted by: LindaB1 | February 3, 2010 2:13 PM | Report abuse


you never hear about american dying because they are not allowed to get the treatment in their own country, even though they can afford it.

and you know full well that canadians live longer, on average, because they eat less fast food and dont shoot each other or do as many hard drugs. oh, and because they can come to the US for serious and urgent medical issues.

If we go with Obamacare Americans AND Canadians will live shorter lives.

Posted by: dummypants | February 3, 2010 2:16 PM | Report abuse

"what slag doesn't seem to get is that its not the consumer making the conscious choice of Hospital X over Hospital Y when you get a heart attack. Its hospital X realizing on its own (prior to that heart attack) that it must (to compete with hospital Y) increase its best practices and efficencies."

Are you trying to imply that either Saks or Walmart doesn't exist in the world? That one or both of them are just a figment of my imagination? Or are you suggesting that hospitals and other healthcare providers would be exempt from the market forces that created those two very different institutions?

Posted by: slag | February 3, 2010 2:23 PM | Report abuse

I certainly wish that Ryan and Wyden would get in a room and try to hash this out. I believe that anything they produce would be a dramatic improvement on the bills currently being considered in Congress.

A Wyden/Ryan approach would recognize at its core that people respond strongly to economic incentives, even in health care. Human response to economic incentives has been observed over centuries. To create a system that doesn't fundamentally recognize that core element of human behavior is likely doomed to failure and is incredibly naive.

Posted by: bjb57 | February 3, 2010 2:42 PM | Report abuse

The Democrats OVER-REGULATE healthcare the moment they impose a ban on any doctors who are participating within the government's exchange from offering out-of-pocket services.

Thus if the government deems it to be wasteful to allow a dying grandmother to get hip surgery, the only way that dying grandmother can go get it anyway is to find a doctor who is making a living completely exempt from the government-sanctioned system.

While a connected politician can talk how generously he would be to pay out-of-pocket for his grandmother, no middle class family can count on being so generous when their grandmother faces the same problem. The prohibitive cost of out-of-the-pocket transactions implies that ALL MIDDLE CLASS FAMILIES WILL LOSE HEALTHCARE AUTONOMY IF OBAMA & PELOSI AREN'T STOPPED!

Do any of you guys on this get it?

To put it simply, this is why politicians like Scott Brown are winning states like Massachusetts!

Posted by: FastEddieO007 | February 3, 2010 2:43 PM | Report abuse


Canadians don't live longer because they live healthier lives.

If you ever have the fortune to travel to a major city in the eastern half of Canada I recommend that you visit a local McDonald's and enjoy one of their national specialties dishes -- French Fries topped with cheese curd and gravy (it's called poutine).

In the times that I've traveled to Canada I've met some pretty obese Canadians, so as a matter of anecdote it's likely not just lifestyle differences that account for their longer life-span.

The U.S. does have some good specialists (we're better in some areas worse in others). On balance though for all of the extra money that we spend we don't really get significantly better outcomes.

Obamacare at a minimum will save some lives and it will result in fewer bankruptcies due to medical emergencies. It's far from ideal, but it has the potential to be a step in the right direction.

The fact is that Americans DO die because of lack of timely, affordable medical care.

I personally know of a couple instances where Americans with middle class incomes, college educations, etc died in the U.S. of preventable diseases -- simply because they couldn't afford insurance at a time when a major illness hit.

In one case the person did get some treatment at an ED, lost his house, car, everything in the interim. He would have died an even more miserable death if he hadn't received support from a friend's family (they let him stay in their home while he was dying, and paid for him to have an apartment in the last couple months of his life).

The other case involved a person who changed jobs and who was unable to afford COBRA and lost insurance. During that time period he was diagnosed with cancer and before long it was over.

There's also the infamous case in 2007 of 12 year old Dermonte Driver who died because his family couldn't afford to get him to a dentist. The state ultimately ended up spending over $250,000 in an emergency to save his life (unsuccessfully).

Access to preventative care would have saved the kid's life and taxpayers around $250,000.

In all these cases, if these people had the good fortune to be born in Canada, in western Europe, Japan, or any other developed democracy with high-quality universal care there's a better than 50-50 chance that they would be alive today. The failures of our health care system are truly a national shame. The fact that we pay more than anyone else for the same or worse outcomes suggests that we aren't that smart at a policy level either.

Posted by: JPRS | February 3, 2010 3:07 PM | Report abuse

Paul Ryan says:

"Rationing happens today! The question is who will do it? The government? Or you, your doctor and your family?"

which is mostly nonsense. Ryan's plan would have the government rationing vouchers of insufficient value to recipients, and private health insurance companies rationing health care to recipients. Most recipients and their families will have little control over this rationing.

Posted by: AviN1 | February 3, 2010 3:32 PM | Report abuse

Ezra got schooled. Simple as that. To deny that is ludicrous.

This guy ate his lunch, but then we ARE talking about the smartest guy in Washington who also just happens to be the only adult in town.

Posted by: websterr1 | February 3, 2010 4:01 PM | Report abuse

Just reading all this makes it obvious that health care in the US needs to be simplified--ie: single payer, government run plan. There should be no profit in taking care of the people's health, which is vital to the well-being of our country. I realize that this would require a huge reordering of the health care industry and eliminating a lot of insurance companies, but it would free up so much people power and energy for more productive use.

At age 80, my husband and I have had to deal with the world of Medigap and Part D Drug plans for the first time after being dropped by my husband's former employer. We were horrified to to discover the wide variety of plans, charges, etc. that are offered for the (maybe) same coverage. Actually it could be called Elder Abuse!! There are a huge number of people who are not able to navigate through the "system" to their own advantage and are truly at the mercy of insurance companies (who, by the way, definitely "ration" care by defining how sick you have to be before certain coverage will be approved or if it will be).

Maybe I've lived too long but it is sad to watch grown people arguing and fighting and maneuvering for their own gain at the expense of making life better for others.

Posted by: jallison1 | February 3, 2010 4:56 PM | Report abuse


Ezra was schooled in the sense that he would have lost on points if the people doing the judging were high school Republicans.

If the discussion was looked at by health care economists, or even someone with more than a 200 level understanding of economics, the verdict would probably be that this wasn't even a debate, so much as a discussion between two well-informed people with some fundamental disagreements. The main downside with Ryan's plan is that he doesn't fully spell out the consequences of his proposal; his view about the likely consequences to consumers depend on some fairly optimistic assumptions (not unlike Wolfowitz's assertion in 2002 that an Iraqi reconstruction post invasion would be largely self-financing).

Posted by: JPRS | February 3, 2010 4:56 PM | Report abuse

If anyone was serious about using the marketplace, they would plan to get my employer out of the decision-making of which company and which plan I get to 'choose'. When every plan available is available to me, I will make the best choice for me. When some states (one state?) have low or no regulations or requirements on the type of policies offered, I will again have no real choice. Put every plan on an exchange and let me choose. Or put them on a website, whatever.

Posted by: LauraNo | February 3, 2010 5:07 PM | Report abuse

Great interview. I wish it could have been longer.

Posted by: MikeR4 | February 3, 2010 6:22 PM | Report abuse

"Behold the liberal future of American healthcare: the wealthy traveling out of the country to get away from substandard government run healthcare."
Posted by: RobT1 | February 3, 2010 1:02 PM

Tee Hee. And maybe the not so wealthy as well. I for one am sort of counting on clinics opening up across the border in Mexico. And I've derived a great deal of comfort reading about Dr. Devi Shetty, the Henry Ford of heart surgery, opening a facility in the Cayman Islands.

Hey, maybe if we enact tort reform, we might be able to get him to open a clinic here!

Posted by: bgmma50 | February 3, 2010 7:19 PM | Report abuse

"Canadians actually tend to live 3 years longer on average than Americans too." Posted by: JPRS

Sigh. Aside from the fact that life expectancy is not a valid measurement of a health care system, the difference in life expectancies is less than 3 percent. The rates of obesity are 31.1 for American males vs. 17.0 for Canadian males and 32.2 vs 19 respectively for females. If you then remove excess American deaths due to homicide, accidents, voila.

If you truly want to compare health care systems, try comparing outcomes for people with diagnosed diseases.

Posted by: bgmma50 | February 3, 2010 7:28 PM | Report abuse

I appreciate Mr. Ryan's initiative and philosphy about treating every term like his last. First, his plan also covers Social Security and includes some excellent reform concepts.

Regarding healthcare, I think folks are placing too much faith in the free market. The free market won't solve obesity, which drives $190 billion per year in additional costs. It won't solve Medicare/Medicaid fraud of $60 billion. It won't eliminate $200-$350 billion of insurance industry overhead, much of which could be removed under a single payer system. It doesn't handle the fact that an elderly person near the end of their life can demand extremely expensive medical treatment; nearly one-third of Medicare costs are for end-of-life care. It will take decades to overcome the massive nursing, doctor, and hospital bed shortage, including government incentives.

My view is that extremly tough choices will have to be made and that free market principles simply won't work when demand is so much greater than supply. Price is not the right way to ration healthcare; it should be based on clinical need and both the quality and duration of life extension.

Posted by: Factified | February 3, 2010 9:01 PM | Report abuse


Life expectancy is at best a rough proxy

However, if you keep finding OVER, and OVER, and OVER again that the U.S. comes up short compared to different countries, it should at an absolute minimum raise questions. Especially given the huge chunk of GDP that the health care sector consumes in this country.

Ideally, yes, you'll want to look at treatments for a range of diseases and medical services.

Even on that basis, you will find that Canada with less than half the annual expenditures measures up extremely well against the U.S. system. For those without any coverage, there's no comparison. Canada kicks our ass. For those with quality employer based coverage the differences in many cases are negligible. We just tend to pay a lot more for those same services (and our system tends to create a lot more headaches -- even for the insured).

Posted by: JPRS | February 3, 2010 9:34 PM | Report abuse


I would dispute your characterization that the US comes up short over and over and over again, for the reasons I already mentioned. And for those who have employer based insurance the differences are not necessarily negligible. It depends.

You are correct that for those without insurance, Canada kicks our ass. And that we spend a lot more than they do. But the quality of the care in all of those countries that you claim kick our ass depends to a large extent on advances in drugs, medical procedures, and devices developed in this country. Innovations that that are spurred in no small part because we do spend enormous amounts of money on them. So, I fully expect that the quality of care in this country and every other country will stagnate to some extent if we are successful in bending the cost curve. (I don't concede, by the way, that either the House or the Senate bill bends the cost curve)

Posted by: bgmma50 | February 3, 2010 10:09 PM | Report abuse


Thanks for a great interview. Ryan is currently my favorite politician. The GOP is too stupid to see that they have someone in their midst with both leadership qualities and good ideas.


Posted by: FatTriplet3 | February 3, 2010 10:45 PM | Report abuse

"So, how soon can we get Ryan and Wyden in a room??"

Exactly. Easily the most sane democrat and the most sane republican.

Posted by: invention13 | February 3, 2010 10:45 PM | Report abuse

Explain to me again exactly what an insurance company contributes to the actual functions of the doctor/patient relationship?

And how much do we pay for what might happen?

Now tell me again how smart we are.

Posted by: ThePoliticalStraycom | February 4, 2010 12:37 AM | Report abuse

You did a public service with this interview, Mr. Klein. Thanks.

If we had Mr. Ryan and a few sensible democrats in a room, I think that bipartisan reforms are possible.

The House or Senate bills will not contain costs and only make matters worse. Nothing reasonable is possible until these complicated monstrosities are abandoned.

Obama says he is a "pragmatist" but his ideology blinds him to the fact that Medicare costs are exploding, not because it is a market based system, but because it is a one-size fits all government bureaucracy.
There is no mechanism for such a bureacracy to control costs except by limiting payments to doctors and effectively rationing service. People like Medicare because they have the mistaken belief that they are getting something for nothing. In fact, the costs are just being shifted and deferred to the debt which will eventually bring it down like every other Ponzi scheme.

There is no way to control costs except by putting these decisions more in the patients' hands, which is what Rep. Ryan is recommending.

That we have to have this discussion at all shows how little basic economics is understood.

But more than cost and efficiency a market based--i.e. individual decision based--system is consistent with individual freedom. A government bureaucracy based system is not.

How do "liberals" (the word means freedom) rationalize opposition to government interference with women having abortions, but then favor huge government bureaucracies to decide and interfere with every intimate health care decision of 300M people?

Posted by: blackmage | February 4, 2010 5:14 AM | Report abuse

Explain to me again exactly what an insurance company contributes to the actual functions of the doctor/patient relationship?

Here goes...a insurance company is a modular entity offering consumers a market-driven option in competition with other such entities...these many market driven option may come and go depending on which innovate and offer the best options.

This kind of system has historically outperformed a non-modular offering that is welded to the government machinery.

Most times, other countries have only switched to this non-modular government apparatus under the conditions that all of these modular market-driven options were ceased, and the citizens were mandated to choose the government.

Posted by: FastEddieO007 | February 4, 2010 5:57 AM | Report abuse

The biggest FORK IN THE ROAD between these federal healthcare radicals and mainstream middle class Americans is the insistence by radicals that any doctors participating in their new federal system be banned from offering out-of-pocket services.

Only doctors who choose to make their entire living out of the new federal system can offer out-of-pocket services.

This means a powerfully connected politician like Barack Obama can buy hip surgery for his dying grandmother if he chooses, but all of us middle class schmucks will be dead-out-of-luck.


Posted by: FastEddieO007 | February 4, 2010 9:24 AM | Report abuse


Posted by: liseliz | February 5, 2010 11:58 AM | Report abuse

"It's been for the Republicans to make it a bad bill" Wow Ezra, your bias is showing. What a surprise. Maybe Republicans call it a bad bill, because on the merits IT IS A BAD BILL. Thank you Paul Ryan

Posted by: subframer | February 6, 2010 7:58 AM | Report abuse

Please read "The Healing of America" by T.R. Reid, a foreign correspondent for the Washington Post. He reviews all of the worlds major players and their response to health care issues. In any every measure of success for dollars spent our health care is a dismal failure. Our health care system allows 22,000 thousand Americans to die every year for lack of health care but it now consumes 17% of our gross domestic product, far and away the most in the world, and it shows no sign s of slowing its rate of increase. Instead of manufacturing straw men to beat up, look at your circle of friends and peers and ask yourself, who deserves health care and who doesn't. When we do that 85% of us are in favor of universal health. Then the insurance companies, who having been making huge profits and paying their executives huge bonuses, bring up all of those people we love to hate and soon the whole endeavor goes down in flames. Americans need to educate themselves about health care instead of allowing the news media at the behest of corporate America to misdirect our attention. We need to bring our health care costs down and corporate America and competition will not do that. They have had forty years to succeed and have failed miserably. The consequence of their failure has been shouldered by hundreds of millions of once healthy Americans and for over 22,000 Americans every year it is medically preventable death. We spent trillions of dollars to prevent another 9\11 and bring the terrorists to justice but we ignore a number ten times that great that are allowed to die, frequently horribly, every year because of insurance company policies and profit margins. That isn't the America I am proud of. Ryan is ignoring a few basic facts in his arguments. We can never be as educated as we need to be to be affective health care consumers with out becoming doctors. Our health is frequently out of our control and to be denied health care because we aren't rich, because we didn't become bankers or wall street investors, is unjust. Ryans arguments are based on a free market ideology that doesn't really exist. No market that isn't regulated will ever be much more then a black market and in competition the powerful win and the majority suffer. Its a lesson the bankers and wall street investors just demonstrated to the world but seems to have been missed by some free market ideologues.

Posted by: tryreason | February 6, 2010 11:03 AM | Report abuse

Don't be fooled by Ryan's reasonable facade, it's a total sham. During his town halls this past summer, he removed anyone who disagreed, allowed attendees to boo school teachers and put out the call to all teabaggers to threaten and abuse any reform supporters. His staffers even set up a system for people to have small white pieces of paper in their hands during Q&A so he could safely call on them for friendly questions.

He's got one local paper running verbatim press releases with no rebuttal or comments like they do for every other elected official in the State.

This guy is a shark and his only obligation is to the big corporations and banks who fund him.

Posted by: kringleguy | February 9, 2010 4:56 PM | Report abuse

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