Swallowing the medicine depends on who prescribed it

“Rewind the tape two years to November 2009. Liberals had a very clear plan for the health-care system. The way to cut costs, they said, was to pit private insurers against a public insurer -- ideally, a public insurer that could use Medicare's bargaining power. Force the public and private options into the same system, they said, and the two would compete: private insurers would be forced to clean up their business practices and innovate aggressively or they would lose business to the public option. The public insurer would be forced to keep its costs low and its services smart or it would lose customers to the private options. Either way, competition between the two models would lead to better, cheaper health care. But Republicans and some conservative Democrats disagreed, and the public-option idea died in the Senate.

Now it's back. Only this time, it's Mitt Romney proposing it and Republicans enthusing over it.

Put simply, the public-option model is Romney's plan for Medicare. Taking his cue from the Medicare plan developed by the Bipartisan Policy Center's deficit commission, Romney's proposal would give seniors a lump-sum payment and let them choose between traditional fee-for-service Medicare and a slew of private plans. How big of a payment? Ah, that's the rub. Romney isn't saying. His campaign web site avers that he "continues to work on refining the details of his plan, and he is exploring different options for ensuring that future seniors receive the premium support they need while also ensuring that competitive pressures encourage providers to improve quality and control cost."

Whether a plan like this can work is almost entirely dependent on the size of the vouchers and the speed of their growth. So until Romney releases those details, little can be said about either the sort of health care Romney intends to provide for seniors or the sort of cost savings his plan will be able to ensure. But he's already winning some important supporters. In an interview with my colleague Jennifer Rubin, Paul Ryan was enthusiastic. "This is a great development!" he told her.

But it could, for Republicans, lead in an awkward direction. If Romney is elected and he manages to pass his plan and repeal the Affordable Care Act, the pressure to open the revamped, semi-privatized Medicare program up to younger and younger Americans will be immense. Romney forswears any intention of doing anything like this, of course. His plan actually calls for raising the Medicare retirement age. But with 50 million Americans uninsured and cost growth in private insurance options routinely outpacing cost growth in the Medicare program, something will eventually need to be done for the rest of the country. And Medicare will now look a lot like what Democrats originally wanted the Affordable Care Act to look like. Plus, it will have the GOP's stamp of approval on it, and there will be no questions about its constitutional legitimacy.

That's always been the great secret of the Ryan plan. In proposing that we could dramatically cut costs simply by forcing seniors to choose private options on competitive exchanges, it affirmed one of the ACA's central efforts at cost containment. Bowing to the unpopularity of that plan, Romney has now backed up to proposing we could dramatically cut costs by forcing seniors to choose between public and private insurance options on competitive exchanges -- an even more liberal approach to cost containment. This ideological overlap has always been tense for both sides. Liberals want to bring these ideas to the private-insurance system, not to Medicare, and conservatives want to bring their ideas to Medicare but not to the private-insurance system. But if either side succeeds in passing this model anywhere, and the model works, then the pressure will be overwhelming to implement it systemwide. Just as one possible outcome of the Affordable Care Act was that it would lead to Medicare reforms conservatives found congenial and liberals found upsetting, the irony of Romney's Medicare plan is that it could lead, in the private market, to the very system that Republicans spent almost all of 2009 attempting to kill.”