Steve Chapman

"Health plans that choose to participate in the Medicare exchange must agree to offer insurance to all Medicare beneficiaries, to avoid cherry-picking and ensure that Medicare's sickest and highest-cost beneficiaries receive coverage," says the committee's report.

Among those favoring such changes is Alice Rivlin of the Brookings Institution, who was President Bill Clinton's budget director. The premium support model embraced by Ryan, she testified before Congress in April, "seeks to combine the tools of market competition and cost-effective regulation in hopes of maximizing the chances of improving health care for seniors at a sustainable cost."

It's easy to improve health care if cost is no object. It's easy to reduce costs if you can tolerate worse health outcomes. The trick is to balance the two needs. The Ryan plan is a credible attempt.

Not that he has a stellar record in this or other areas of the budget. In the past, he's been the fiscal equivalent of a chicken hawk: tough until it's time to put his own survival on the line.

He voted for President George W. Bush's plan to furnish prescription drug coverage to seniors, adding $8 trillion to the government's unfunded obligations. He voted to bail out General Motors. He voted for TARP.

He did more than his share to help Bush add $5 trillion to the national debt. But if the prodigal son wants to redeem himself with a politically dangerous blueprint to make Medicare affordable, more power to him.

Democrats have a point in saying what Ryan offers is not as good as the current version of Medicare. It's also not as good as the Big Rock Candy Mountain, the pot of gold at the end of the rainbow or the valley of Shangri-La.

His option does, however, have the virtue of a connection to the real world. It's a place his critics can't avoid forever.

Steve Chapman

Steve Chapman is a columnist and editorial writer for the Chicago Tribune.

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