Since Donald Trump stunned Washington and won the White House earlier this month, Republicans in Congress have been frantically dusting off their legislative wish lists and prepping for the new era in which their party is in the driver's seat.
For House Speaker Paul Ryan (R-WI), overhauling and privatizing Medicare – the popular, single-payer health insurance plan for senior citizens – is a top priority. What exactly the House's plan would look like remains unclear, as Republicans have just begun ruminating about overhauling Medicare. But there is a treasure trove of past Medicare ideas and blueprints from Ryan that give us insight into what his plan might look like.
Ryan has been pushing his privatization plan – or what he calls "premium support" – for years. It's been part of his annual budget blueprints, and it has evolved over time. The basic idea is that Ryan would give the elderly a set amount of money to buy health insurance rather than Medicare's fee-for-service system where the government pays doctors and hospitals based on the services they provide.
How much money the elderly would receive to buy insurance, the quality of the plans available, how the government would regulate them and the rate at which the benefits would increase have varied over the years and sometimes have been unclear.
As Medicare is currently configured, American workers and employers contribute equally to the public insurance program via the Medicare payroll tax. When people turn 65, they become eligible for Medicare's guaranteed coverage, pay premiums and receive a robust package of benefits.
Looming as the biggest unknown is whether Medicare – in its current form as a single-payer, guaranteed-coverage, fee-for-service system – will remain intact.
Will Medicare be eliminated explicitly, as it has in past Ryan plans? Will it be changed so substantially that the long-term effect will be to weaken it so that phasing out it out is inevitable? Or will Ryan seek to change Medicare in fundamental ways while still preserving its most important protections?
How committed President-elect Trump and Rep. Tom Price (R-GA), his nominee as secretary of Health and Human Services, are to Medicare privatization is another wild card in the mix.
"It is quite clear at this point that Ryan and Price would say they are retaining traditional Medicare as an option, but the question is under what terms. Is it provided under terms that would allow traditional Medicare to continue and flourish? Or is it conversely under terms that would cause it to wither and perish?" said Paul Van de Water, a senior fellow at the Center on Budget and Policy Priorities.
Over the years, Ryan's plans have evolved, in part because of pressure from his own members. Ryan told the New Yorker in 2012 that he recognized his plan needed to be accepted by more than just a few conservatives in the House. He needed to develop a plan that met the vision for the broader Republican conference.
He told the New Yorker in 2012, shortly before he became the Republican Party's vice presidential nominee, that his early plan "was just me, unplugged.”
"When you’re writing a budget you’re representing an entire conference, and so you have to get consensus," Ryan said.
But the underlying principle for Ryan's plans comes from the conservative idea that private businesses are more efficient at managing health care than the government would be. That, some experts argue just isn't true. Medicare, by and large, is a fairly efficient program. Seniors manage to get a lot of health care they are happy with for a decent price.
"Medicare is more efficient than private insurance for two main reasons. One it is able to pay providers less and second it also because of its size, it has lower administrative costs as well," Van de Water said.
Health care experts who have spent years analyzing Ryan's plans note that there are still a lot of questions to be answered. Here's what we do know:
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