Monday, May 23, 2011

Guest Blog: The Ryan plan for Medicare

Richard Young, MD is a family physician educator and director of research at the John Peter Smith Hospital Family Medicine Residency in Fort Worth, Texas. The following post was originally published on his blog, American Health Scare.


It’s been interesting watching the political maneuvering since Newt Gingrich criticized the plan to reduce the federal budget deficit proposed by the House Budget Committee Chair Paul Ryan of Wisconsin. After receiving push back from fellow Republicans, Gingrich spent the week backpedaling from his earlier remarks.

Many pundits have recognized Ryan for his courage to present his ideas in the first place. I also applaud the fact that he was willing to put the issue of fiscal sanity on the radar screen in a concrete way few other politicians have been willing to. This comes against the backdrop of recent estimates that a 56-year old couple will pay $140,000 in Medicare taxes per person over their work lives, but will receive $430,000 of benefits. This is unsustainable welfare.

I have not read the entire plan myself, but I’ve read enough about it to feel like I understand the basic idea. Ryan proposes to not change Medicare at all for people currently age 55+. People aged less than 55 would be put into a voucher system where they would choose plans by applying the voucher amount to the premium, then pay the difference. As Ryan said recently on "Meet the Press," this would allow seniors to steer away from plans that are inefficient.

There are three big problems with this plan.

First, we have a huge budget deficit NOW, so to kick the problem down the road and not make difficult decisions now means we as a nation still aren’t willing to face facts, hoping that somehow our national character will change at some fuzzy time in the future when we will actually face facts. Highly unlikely.

Second, it puts too much faith in the ability of individual consumers to understand the complexities of the healthcare system. I know how intimidated I am to receive a dentist bill or vet bill. How in the world does anyone expect a person not in healthcare to shop around for medical facilities, physicians, drugs, and the rest? As one doctor writing in Texas Medicine this month put it, “How are they (patients) supposed to value shop for insurance coverage when I have to hire a broker and a couple of financial people to figure out how to get insurance for my own employees?”

Third, the plan calls for choice — which I’m all for — but doesn’t provide any mechanism to allow for meaningful differences in healthcare delivery models that actually break the cost curve. Currently, health plans and facilities try to attract customers with promises of expensive technology. Until some deeper understandings of the role of the healthcare system in our lives start to happen, consumers will continue to be sold on ideas that only raise the cost of healthcare.

Unfortunately, the culture of America must change for us to have significantly more affordable healthcare. The second most budget-busting phrase in America — after entitlements — is medically necessary. We must develop a new set of values and beliefs of what is truly important in healthcare. We can start by challenging the POEM assumptions:

Prevention saves money
Ologist care is best
Early detection prevents all bad outcomes
More treatments equal better care

These should be replaced with new and improved views of what is really important in creating an efficient, but caring healthcare system.

An ounce of prevention costs a ton of money
Family medicine-founded care is best
Early detection doesn’t always change bad outcomes
Aggressive care isn’t always the best care

I give Rep. Ryan credit for his efforts to save our children’s future by putting his political career in jeopardy with his proposals. Unfortunately, a real solution will be even more difficult.

For America to ever have reasonably affordable healthcare, the relationship between doctors and patients must change. The current relationship between doctors and the American public – that all possible healthcare services be provided no matter how rare the benefit or expensive the service – is unsustainable. Until we accept this reality, healthcare costs will continue to rise faster than personal incomes and soon health insurance will be available only to the very wealthy. The great American healthcare irony — we spend the most but get the least — will only get worse.

This reality is what we need to deal with.

- Richard Young, MD


  1. Thank you, Dr. Young for this great post!

    I believe that Paul Ryan's proposal is absurd. It is not practical and puts health insurance companies in a more powerful position than they already are. How is that going to cut health care costs?

    As a nurse, I worked in the non-profit sector where almost every decision the doctor made was based on cost. I worked as a civilian nurse in the military, where cost was never an issue. I also worked in the private sector for specialists who never even thought about cost.

    In my opinion, the doctors who provided care for non-profit gave excellent care with the resources they had available and our patients had good outcomes. I am not convinced the most expensive tests and procedures are best for the patient. That is one area that needs to be fixed.