Paul Krugman spends time today ripping Paul Ryan once more. Ryan’s plan is to limit government spending way off into the future (starting with people who are now 55) by giving them a flat Medicare voucher and then telling them to try it on for size in the individual insurance market. The joke is that there is a rational way to try to introduce some consumer-choice competition into Medicare. Essentially there are two alternatives to dealing with the mess that is Medicare. One–try to manage Medicare spending both with a global budget (the IPAB) and with specific restrictions on care that’s delivered that’s wasteful or unnecessary (via changes in FFS payment). That’s essentially the route the ACA goes. Two, give recipients a voucher that lets them choose between competing entities that can’t charge more than the value of the voucher and actually are mandated to compete on the correct things (outcomes, service, etc) like they do in Holland and in Alain Enthoven’s theories. That’s rational managed competition under a global budget, and the winners in that would look more like Kaiser and Group Cooperative than today’s insurers. Ryan’s idea is just to subsidize the dysfunctional private marketplace and to repeal the minor restrictions the ACA puts on health insurers while he does it–a sure-fire recipe for disaster.

There is of course another alternative. Just to let Medicare continue to spiral out of control on both costs and the quality of services it provides, and Ryan’s plan basically does that without a safety net