Ryan has done two versions of his plan with prominent Democrats, and both involved a more generous formula for adjusting insurance payments than what he steered through the Republican-led House.
Q: What are the risks of Obama's approach?
A: If the government just keeps cutting payments, Medicare will start looking more and more like Medicaid, the much leaner program for low-income people.
Doctors will stop taking new Medicare patients. Many hospitals and nursing homes would start losing money, and some may have to shut down. Innovation would slow, as drug makers and medical device manufacturers think twice about bringing new products to market. Seniors would have problems getting appointments or face waiting times for elective surgery. Quality would decline.
That's why the administration has launched dozens of experiments to deliver quality care for lower cost. But it could take years to see results.
Q: So where do Romney and Obama actually agree on anything about Medicare?
A: There are four big points to keep in mind.
Both agree there has to be an overall limit on the growth of Medicare spending. (Obama would use a powerful new board created by the health care law to ratchet down payments. He has yet to name the panel; Republicans are calling it a "rationing board.")
Both agree that wealthy beneficiaries should pay more for their Medicare.
Romney and Ryan want to gradually increase the eligibility age to 67, instead of the current 65. In closed-door budget negotiations with Congress last year, Obama hinted he might be willing to do the same as part of an overall debt reduction package.
Both would shift additional costs to beneficiaries. Obama has proposed higher deductibles for outpatient care, new copayments for home health, and policies to discourage the use of "Medigap" policies that can lower out-of-pocket costs — particularly for newly joining baby boomers.
The boomers would do well to pay attention: Medicare will change no matter who wins the White House. Unless lawmakers cut spending or raise taxes, the program's giant trust fund for inpatient care will go broke in 2024.
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