Opinion: Paul Ryan’s Problem with Medicare

Mar 15, 2017

Credit Courtesy / Abraham Schwab

Several months ago I wrote that Paul Ryan, in his arguments against Obamacare, was showing his hand that he also wants to do away with Medicare. In the last week, he was trying to defend his recent health care proposal, which I’ll call Republicare, and provided more evidence for this view.

Before I get into that, however, I need to say a few things about how insurance works when it’s working well. The basic idea of insurance is that everyone pays into a pool so that no one, should catastrophe fall, ends up in the gutter. For example, I have paid thousands upon thousands of dollars in homeowners insurance, far more than I have received in benefits. But that may not always be the case. It may happen in the next week that my house burns to the ground. At that point, because I have insurance, I will not have to pay for the entire cost of replacing my home out of my own pocket. Instead, I will draw on the money that myself and other homeowners have pooled together to pay for the replacement.

To put [Ryan's] point a different way, tragedy is going to befall some of us. We don't know which ones, and we don't know when. But tragedy will happen. The point of an insurance system is to limit the harms of those tragedies.

Of course, some of us who buy insurance will end up paying more into the pool than we get out of it, and others will end up getting more out of the pool than they pay in. That is, I could lead a charmed life and have nothing particularly bad happen to me. My roof may never be damaged, my home may never burn down, my children may never contract a serious illness, and I myself may die peacefully in my sleep before I require assisted-living. If all that turns out to be the case, then the money that I will have paid for my health insurance and my homeowner’s insurance will have gone to pay for those who are less fortunate than myself. 

Am I the lucky one who never has tragedy befall me, or am I the unlucky one who requires help and assistance to avoid the worst effects of my tragic life? Because I don’t know, and because you don’t either, buying insurance is the rational thing to do.

It's this basic structure of an insurance system that Paul Ryan has demonstrated he is opposed to. That is, based on what he said last Thursday, he doesn't believe the insurance system should exist at all: 

“So take a look at this chart. The red slice here are what I would call people with preexisting conditions. People who have real health-care problems. The blue is the rest of the people in the individual market — that’s the market where people don’t get health insurance at their jobs where they buy it themselves. The whole idea of Obamacare is the people on the blue side pay for the people on the red side. The people who are healthy pay for the people who are sick.” —Paul Ryan, March 9, 2017

Aside from questions of the rights of individual to health care, the responsibilities of human beings to care for the less fortunate, and the core responsibilities of civilized society, Ryan’s arguments indicate a perverse world view. Specifically, this suggests that insurance would work best if the individuals who tragedy befalls, who are most in need of help in paying their healthcare bills, are also the ones who are not helped by the insurance system. This would be an insurance system that would take care of those who are healthy and fortunate and leave the sick and unfortunate to fend for themselves. 

And this argument is an argument against Medicare. 

The structure of Medicare is such that it depends upon individuals who are not currently using healthcare resources (e.g., me, you, and other healthy individuals paying a Medicare tax) to pay for individuals who need it (Medicare recipients). The uncomfortable truth is that as we age, we are more likely to require healthcare resources to maintain our daily lives. If the costs of that healthcare rest solely on the shoulders of the individual who needs it, then the very idea of Medicare is problematic and, on Ryan's view, should be rejected outright.

If asked, I'm sure that Ryan would say that he is not opposed to Medicare, and has no intention of getting rid of it. But the arguments he offers against Obamacare, and the insurance industry as a whole, suggest that Medicare should also be abandoned. And this leaves us with a bit of dilemma. Either Ryan doesn't believe what he is saying about Obamacare and the insurance system, and is just making things up because he’s ashamed or unable to articulate the real reasons he's working against Obamacare. Or he really wants to get rid of Medicare and he's just afraid to say so. Either way, Ryan and anyone else who makes these kinds of arguments in favor of Republicare, can't be trusted.

Abraham Schwab is a Fort Wayne associate professor of philosophy and medical ethicist.

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