The Evolution of Paul Ryan's Medicare Plan

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To hear his communications director tell it, Paul Ryan came to Washington as a man with a vision. He knew that the nation's fiscal prognosis was deadly, and that vital entitlement programs would capsize without drastic changes.

In May of 2008, with a presidential election on the horizon, Ryan introduced his Roadmap for America's Future, a document that laid out those radical changes and drew criticism for one of its most drastic: the voucherization of Medicare. At this point, Ryan fancied himself a "consensus of one."

Since then, he's laid out several iterations of that initial plan for Medicare. In January of 2009, he tweaked it, reintroducing it as his Roadmap 2.0. Last year, along with founding Congressional Budget Office director Alice Rivlin, he proposed the similar "Rivlin-Ryan" plan to President Obama's fiscal commission (the commission did not accept it). Ryan moved on to a "consensus of two."

His latest effort on Medicare, contained in the Path to Prosperity -- the catchy name for his 2012 budget proposal, introduced this week -- constitutes a similar plan to the first two. Now, he's trying to win the consensus of 218 House members, plus the Democratic Senate, plus the president.

The plans aren't all that different.

They all revamp Medicare as we know it, eliminating a government system of direct payment to health-care providers: In each of them, Medicare is transformed into a body that pays citizens directly, then requires them to pay for health insurance on their own. In each of them, Medicare would pay citizens the equivalent of its average payment to beneficiaries (now $14,900), but would grow that payment at different rates. Poorer and sicker people would get more; richer and healthier people would get less. Everyone over 55 would be grandfathered into the current Medicare system, so Ryan's solution would be the only Medicare option beginning in 10 years.

Ryan's plans have evolved, however, on what kind of insurance you can buy, and how government-payments grow.

Roadmap (2008)

How fast the payments grow: A blend of inflation (Consumer Price Index) and medical inflation. Comparing the three plans, speed of growth for the Roadmap falls in the middle.

Insurance plans you can buy: A list of plans approved by Medicare, or private insurance on the open market.


Rivlin-Ryan (2010)

How fast the payments grow: Growth rate of GDP plus one percent. This is the highest growth rate of the three.

Insurance plans you can buy: List of approved plans.


Path to Prosperity (2011)

How fast the payments grow: Rate of inflation (Consumer Price Index). This is the lowest rate of growth, among the three plans.

Insurance plans you can buy: List of approved plans.


Ryan's thinking on Medicare hasn't changed much, but, if it has been shapes by politics, Ryan was at his most willing to compromise last year, while working with Rivlin. At that time, he moved to restrict insurance purchasing to a list of government-approved plans, similar to an "exchange," giving the federal government more regulatory control.

The most significant variable among Ryan's plans, in terms of what people get, seems to be the rate at which payments to beneficiaries increase, year by year. In the plan he issued earlier this week, people get less than they would under his previous two iterations.

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Chris Good is a political reporter for ABC News. He was previously an associate editor at The Atlantic and a reporter for The Hill.

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