Defined contribution plans are dangerous unless there is a cap on how much patients pay. How much co-pay can be charged by the insurance companies in Ryan's plan? Is there any cap on how much is spent by patients?
Patients are buying private plans in everyone's framework, so the companies can do whatever they want with their co-pays, I would think. The Ryan plan places no cap on possible out-of-pocket spending by patients. The benchmark for reimbursement in Ryan's plan is either the second-least expensive plan offered by a state exchange or the FFS premium, whichever is cheaper. If the patient buys a more expensive plan, the patient is responsible for the difference, and if they buy a less expensive plan, they are refunded the difference. The level of subsidization depends on one's health status and geographical location and is adjusted over time by being indexed to the CPI. The Ryan plan makes an attempt to adjust for risk pools by penalizing plans that cover lots of low-risk seniors and giving tax incentive payments to plans with coverage of higher-risk populations. Low income beneficiaries who are not duel eligible for Medicare and Medicaid (the latter to be decided by each state) would have a medical savings account opened on their behalf with something deposited in it to help them cover out-of-pocket expenses, premiums and co-pays, but I don't know how all this is figured. All beneficiaries pay more for their premiums if the growth in Medicare spending exceeds GDP + .5% (odds, anyone?). The CBO told Ryan in their letter that they expected, if all his budgetary proposals were implemented and all targets met, that some seniors could see their out-of-pocket contributions toward premiums rise from 25% in 2022 to 68% in 2030. So, in some ways, I see the Ryan plan as an exercise as "how low can you go" in government premium-support. Good for federal budget outlays, of course, but for patients, not so much.
It's hard not to see all of this as an attempt to contain health care costs by having some people consume a lot less health care, with the people in question being poor, old, and sick. That's pretty blunt, but it does seem to be the net result of the plan.
