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Ryan Budget Proposal Echoes Obamacare While Rejecting It

House Budget Committee Chairman Rep. Paul Ryan, R-Wis., holds up a copy of the 2014 Budget Resolution as he speaks during a news conference on Capitol Hill in Washington, Tuesday, March 12, 2013. (AP)

Health policy watchers might have been amused reading the latest blueprint for the federal budget, out Tuesday.

That's because once again House Budget Committee Chairman Paul Ryan proposes a full repeal of the Affordable Care Act, which Republicans refer to as "Obamacare." But this time, the proposal describes the changes it envisions to the Medicare program in very Obamacare-like terms.

Ryan's "Path to Prosperity" for fiscal 2014, like its two predecessors, would transform the current Medicare program from one that offers a guaranteed package of benefits into one that offers patients a set amount of money to purchase a health insurance plan, either the current Medicare or private coverage.

The idea, known as "premium support," aims to limit what the government spends on Medicare in the future by allowing that contribution to grow more slowly than health inflation has in the past. That would either convince health plans to find a way to economize (as backers hope) or pass more costs on to patients (as opponents fear).

"Chairman Paul Ryan's proposed budget fails to address the high costs of health care and instead shifts costs onto seniors and future retirees," said Nancy LeaMond, executive vice president of AARP, in a statement.

The proposal has passed the House twice, in various forms, in 2011 and 2012, and has never been taken up in the Senate. And while it was severely pummeled by Democrats on the campaign trail last year, when Ryan was running for vice president, he insisted in an interview on last week's Fox News Sunday that it enjoys strong backing among older voters.

"I would argue against your premise that we lost this issue in the campaign," Ryan told host Chris Wallace. "We won the senior vote."

That's true, according to exit polls. Among voters over age 65, 56 percent voted for Romney-Ryan, compared to 44 percent who voted for Obama-Biden. But what Ryan didn't say is that those votes hardly represented an endorsement of his (and Romney's) Medicare plan. Some 53 percent of voters said they preferred Obama to Romney when it came to handling Medicare.

Yet the Fiscal 2014 document, while again proposing to jettison the Affordable Care Act entirely, uses even more of the language Obama officials have been using to tout the Medicare changes in their plan.

For example, it describes the choices seniors would have as part of a "new Medicare exchange," presumably similar to the insurance exchanges now being built under the ACA. Seniors who choose less expensive plans would "receive a rebate for the difference," between what that plan costs and what the government would pay. That echoes the ACA requirement that health insurers provide rebates if they spend too much of customer premiums on non-medical purposes.

The Ryan budget document also refers to Medicare "premium subsidies," though those would be considerably different from the ones available to people with low and moderate incomes under the health law. And it notes that every health plan in the new Medicare exchange would have to "offer guaranteed issue and community rating" and that "insurers would be unable to deny coverage based on pre-existing conditions."

Those are, not so coincidentally, among the more popular aspects of Obamacare, since they make insurance more widely available to people regardless of their health status.

To be fair, similar language appeared in last year's version of the Ryan budget.

But Ryan at his news conference Tuesday refused to acknowledge any irony in juxtaposing his vehement opposition to the ACA with his support for creating quite such an ACA-like structure for Medicare.

"We want to prevent this law," he said of the health measure, "which we really do believe will do great damage to families and the health care system of America."

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