1. "The budget deficit is overwhelmingly about Medicare. It’s overwhelmingly about the fact that most Americans will pay much less in Medicare taxes than they will get in Medicare benefits – even though people don’t always realize that. They think they pay for their Medicare, but the typical person does not come close to doing so. So neither party has a plan to get it into balance.

    "But both parties have a plan that — if you think about it – philosophically would make a difference, would reduce the long-term Medicare deficit. And so we don’t have to get too precise and say, ‘Well, neither of them has a plan that works and thus, neither one of them has a plan that is meaningful at all.’ They do each have meaningful plans.

    "The Democrats’ plan is to make much less of a change to Medicare than Republicans would. It is to say, through a variety of ways, we want to reduce the growth rate of Medicare spending. We want to say, if there is scientific evidence that suggests that this expensive new treatment doesn’t actually make you healthier, well, over the long term Medicare may not reimburse for that treatment, as much as it would for a treatment that there is scientific evidence. You could still get it, but you’d have to pay for it. It takes baby steps in that direction. Many health experts wish it would go farther, but when you think about the whole debate over death panels, you realize why this is tricky terrain. …

    "In a sense, they try to take Medicare and they try to say, we’re going to make it more efficient. We’re going to have it so the government is not so often paying for healthcare that doesn’t make people healthier. And the government needs to make those decisions because Medicare is a government program.

    "The [representatives] say, ‘No, no, no.’ The whole thing, to some extent, is broken and what we need to do is turn it over to the private market. And competition will take care of this problem. And so the government will give you a chunk of money. You can go out; you can buy your own plan. And by competing for your business, the plans will get rid of those inefficiencies in Medicare. The Republicans have backed off a little bit from some of that.

    "In the original Paul Ryan plan, you had to move to that if you were 55 and under – everyone 55 and older got to remain in Medicare. In the new plan, it’s sort of an option. But I don’t think there’s any doubt that philosophically that’s what the Republicans want to move more toward. And you can make an argument that it will make a big difference. There’s always some reason to doubt that it would because historically, the record of market competition working in health care is very mixed. It’s worked for things like laser surgery. It hasn’t worked so well for things like heart surgery or cancer care."

    David Leonhardt on how Democrats and Republicans differ on Medicare

  2. David Leonhardt


    2012 election