Paul Ryan, Former Speaker of the House and Founder of the American Idea Foundation
Today’s healthcare delivery system has too little competition and too much regulation, but could we see a fix if both sides of the political spectrum lay down their proverbial swords and agree to key pillars such as universal coverage and broader competition? Paul Ryan, former Speaker of the House and founder of the American Idea Foundation, thinks so, and sees a specialized role for Congress to bring the U.S. healthcare system into the 21st century by protecting patient privacy rights, increasing choice, and aligning incentives.
Paul Ryan was the 54th Speaker of the U.S. House of Representatives. In office from October 2015 to January 2019, he was the youngest speaker in nearly 150 years.
During his tenure as Speaker, Ryan spearheaded efforts to reform our nation’s tax code, rebuild our national defense, expand domestic energy production, combat the opioid epidemic, reform our criminal justice system, and promote economic opportunity.
As chairman of the House Ways and Means Committee he worked to protect health care choices, advance free trade, and strengthen the economy. Before that, Ryan served as chairman of the House Budget Committee where he outlined revolutionary blueprints to balance the federal budget and pay off the national debt.
In 2012, he was selected to serve as Governor Mitt Romney’s Vice-Presidential nominee. Ryan was first elected to Congress at age 28 and represented Wisconsin’s First District for two decades.
In 2019, Ryan launched the American Idea Foundation, a non-partisan, not for profit organization that expands economic opportunity by partnering with local organizations and academics to advance evidence-based public policies.
In 2020, Ryan was named as the Chairman of the Board of Directors of Executive Network Partnering Corporation and in 2021, he was named as a Partner at Solamere Capital.
He is a member of the Board of Directors of the Fox Corporation, of SHINE Medical Technologies LLC, and of UniversalCIS. Ryan also serves on the Advisory Board of Robert Bosch GmbH and is a senior advisor with Teneo.
He is a Professor of the Practice at the University of Notre Dame and a visiting fellow in the practice of public policy at the American Enterprise Institute. Ryan serves on the Board of Trustees of the Ronald Reagan Presidential Foundation and Institute and on the Board of Directors for the Center for Strategic and International Studies.
Paul and his wife Janna have three children: Liza, Charlie, and Sam. He holds a degree in economics and political science from Miami University in Ohio and was also awarded an honorary doctorate by the University.
Show Notes
Paul Ryan shares his background in Congress and his accidental journey into the health care system. [04:31]
A vision of health care that pushes ideological differences aside to create a center-based system that has innovation, choice, and universal health care coverage. [06:39]
How can health insurance change now, so we don’t end up with a debt crisis in 2049? [10:41]
What key things do we need to create an efficient healthcare delivery system for both patients and providers? [20:48]
What role will technology play in health care? [24:26]
How can we allow for innovation and protect individual rights? [26:36]
New innovations are extending life expectancy beyond 100, how will this affect Social Security and Medicare? [28:22]
How likely will it be that the Democrats and Republicans put aside their idealogical differences to come together for a solution that will benefit the country? [32:59]
Transcript
Jason Helgerson 0:04
I'm Jason Helgerson, and you're listening to Health2049.
Paul Ryan 0:08
We spend two times what anybody else spends per person on health care in the world, but we don't have a system twice as good as anybody else, if that, it's nothing close. So I think we can get that. And I think we spend enough money. I think it's the way we spend our money that needs to be changed. And I think we need to have a system that accommodates and encourages competition and choice. And that just means we have to put the ideological sabers aside. From my side, let's accept universality, let's accept, government's going to be involved and on the left, let's accept the private sector is going to be involved as well. This cannot be a government granted right where the government decides, controls and rationalizes healthcare. So I think both sides of ideological extremes need to be pushed to the side. And I think there's a center, I'd like to say center right, but a center-based system that can be had full funded that can avoid a bankruptcy, and one in which we're proud of that has innovation choice, and universal healthcare coverage.
Jason Helgerson 2:17
Today's guest is a true ideas person that has been an active combatant in some of our nation's most important public policy debates regarding the future of health and health care. Paul Ryan was the 54th Speaker of the House of Representatives after nearly two decades in the house during which he held some of the body's most important chairmanships. In addition to that, Paul was Governor Mitt Romney's vice presidential nominee during an election in which the future of American health care was hotly debated.
Since leaving office, Paul has launched the American Idea Foundation, a non-partisan organization that expands economic opportunity by partnering with local organizations and academics to advance evidence-based public policies. Lastly, I must note, that Paul truly advanced a positive vision of health during the 2012 presidential election campaign, during which he was photographed working out in his home gym had said photos prominently featured in the pages of Time Magazine, truly inspirational.
I'm Jason Helgerson, and you're listening to Health2049. And it's my pleasure to welcome Paul Ryan to the program. Paul, welcome.
Paul Ryan 3:26
Thanks, Jason. You left out a couple things in my bio, number one, I was the neighbor to a Jason Helgerson, Janesville, Wisconsin, when he was the director of the Medicaid program in the state of Wisconsin. I think that's part of my bio you left out, and as part of those Time Magazine photos, at that photoshoot, I did three photos, said this is not me, I don't want this, I'm going to do something different. They said, No problem, those photos will never see the light of day, we'll do something else. And then the day I'm debating Joe Biden, in the 2012, election Time puts those photos on the web, just to mess with my head. So there's always a backstory to every one of these stories.
Jason Helgerson 4:11
Well, Paul, thanks so much for taking the time to be with us today. And really excited to have your perspective on what the health and health care of the future really is going to be like, not only for Americans, but for people potentially around the world. And so before we get started, maybe you could tell us even a little bit more about your background and your interests in health and health care.
Paul Ryan 4:31
Yeah, my interest. I got elected to Congress in '98 and served 10 terms, so '98 through 2018. And I was primarily a fiscal policy guy concerned about debt, deficits, the dollar as the world's reserve currency. And when you dig into those issues, it basically takes you to the entitlement programs. And when you dig into that, it takes you to health care. So I sort of walked into the health care issue a little later about two terms into my tenure in Congress because it became very clear to me, this was the biggest fiscal challenge of our country. And then just representing southern Wisconsin, this was a big concern, a big problem with my constituents, the people I represented. So it became really clear to me, you need to learn more about health care is what I kept telling myself.
So I spent a number of years just trying to learn about health care from providers, from consumers from economists. And then I spent a lot of time with the committees, with Joint Committee on Taxation, with the Congressional Budget Office, the Think Tanks, and in Budget Committee. And then I was chair of Budget and chair of Ways and Means, which are primary health committees. I spend a great deal of my time on this issue. And so it's one of those issues that I sort of nurtured a love for, after getting elected to Congress, realizing just how important this was to the people I represented, and to the fiscal health of the country, and to the health of the country. So that's kind of how I got into the issue of healthcare. And then I produced a number of different bills, some passed, many didn't. I had basically withTom Coburn, the alternative to the Affordable Care Act in 2010, when that passed. And then I built budgets around health care proposals I've had over the years. I'm working on something right now with Jim Capretta at the American Enterprise Institute, to be released later in 2022. So still spend some time on the issue.
Jason Helgerson 6:24
Excellent. So now, as we'd like to do with our guests is ask them to look into the future, roughly 30 years in the future and to the year 2049 and please tell us what you hope health and healthcare will look like in the year 2049.
Paul Ryan 6:39
I hope that we have a full funded system that does not have trillions of unfunded liabilities so that it's not saddling the next generation with insurmountable debt. And I hope this system is characterized by one of which everyone has healthcare coverage. And you have a system where the health inflation rate is nothing like what it is now and it's closer to the actual nominal inflation rate, which, frankly, is kind of high right now. And it's a system known for and driven by innovation, choice and competition, where markets work. And markets are designed in such a way to protect those with pre-existing conditions, and that the preferences and fiscal policy are aimed toward the sick and the poor, but that everyone has access to a system where they are guaranteed coverage, also a system where those with tough health conditions don't go bankrupt if they get sick. And I believe that that's absolutely achievable. A lot of folks would argue that we have that right now.
Well, I think we have a system right now that is a fiscal train wreck. And we are piling on top of the system unfunded liabilities, which will make for a very, very difficult moment fiscally, in about this time actually. So I look at 2049, I see either a fiscal train wreck where we lose the dollars reserve currency, and we have to do immediate budget surgery to the budget where we have to cut benefits back in real time for real beneficiaries, dependent on these programs who organize their lives around these promises. Or, and this is the glass half full side of things that I think and hope will happen, we have a system that doesn't have a fiscal train wreck, that doesn't bankrupt the country or our entitlement programs, that is market-based, and takes taxpayer dollars and puts them where they ought to be, the sick and the poor, as I mentioned, and has a system where you have legitimate health insurance competition and innovation. And is a system where the American system of innovation is alive and well. And we come up with new drugs and new therapies to make our lives healthier, happier, longer, and I believe that that's eminently achievable.
We spend two times what anybody else spends per person on health care in the world, but we don't have a system twice as good as anybody else, if that, it's nothing close. So I think we can get that. And I think we spend enough money. I think it's the way we spend our money that needs to be changed. And I think we need to have a system that accommodates and encourages competition and choice. And that just means we have to put the ideological sabers aside from my side, let's accept universality. Let's accept the fact that government's going to be involved. And on the left, let's accept the private sector is going to be involved as well. This cannot be a government granted right, where the government decides, controls and rationalizes health care. So I think both sides and our ideological extremes need to be pushed to the side and I think there's a center, I'd like to say center right, but a center-based system that can be had, that can be full funded, that can avoid a bankruptcy, and one in which we're proud of that has innovation, choice, and universal health care coverage. And I can give you my sense on how would I go about achieving that, I suppose that's your next question.
Jason Helgerson 10:04
Yeah, and there's a lot there, that one, talk the depth and breadth of your vision and the clarity of it, I think is very admirable, is there's a lot to unpack there. And I guess one of the questions that sort of jumps to mind is, before we get into how, what role do you see insurance playing? You use words, coverage, you use the words, certainly, access to services to health and health care. But maybe you could talk a little bit about, do you see health insurance as it is today or will that fundamentally different?
Paul Ryan 10:41
I think it needs to be a bit different. So to get into the regulatory stuff, you load up these central health benefits so much that people are going to buy things they don't need or want. You have such tight banding on your community rating that you're making young, healthy people pay for older, wealthier people, and there's very little competition in there. And so I think the regulations are too tight, and the mandates are too great right now. And this is where politics breaks down, but you have to find what is basic health insurance, and have a legal definition of that. You can't let Congress or even state legislatures, in my opinion, get in the business of defining what are central health benefits, because everything's gonna be in, and then everybody's got to buy everything, it's gonna be cost prohibitive. So I think we have to get past that fight. And that's easier for the right and harder for the left. What's easier for the left and harder for the right is, I think we should have guaranteed issue. But I think we need to relax our community rating bands, and I think it's too tight, I think you need to loosen those bandings on a five to one or four to one. I don't really have a strong opinion on that other than if you loosen up community rating, if you reduce the central health benefits to a core package, so that's a regulatory statement to allow for competition within the system.
And then I've always been a believer that we should have state high risk pools financed by the state and the federal government, you can do a combination to, in a smart, competitive-based way, finance that health care for people with more than two comorbidities people were prohibitively expensive, and that will make the rest of insurance. The last time I talked to an actuary, I think was Millman and Alou and Guy, it was something like 92% of the under 65 population, were not people with pre-existing conditions. And that 8%, you just subsidize so that when they have surgery or cancer, it's covered. And it's covered in a smart, intelligent way. But so that you are capping the catastrophic limit on an insurance for everybody else, with loosening your banding you can basically have better competition. And younger people who don't have very high cost health insurance can pay for cheaper health insurance, and they're at the stage of life that they don't make as much money as an older person. But you have respectable limits.
On the fiscal policy side, and I know I'm rambling here a little bit, but the biggest thing that got away, I have a few white whales in my career that I wanted to slay, that I could never get, one of which is the tax preference for health insurance. The tax exclusion is upside down, we give the biggest tax benefit to the highest income earner and the lowest tax benefit, the lowest income earner. By excluding health care benefits from your job from taxation, the higher the tax rate you are, the bigger the subsidy you get that is completely wrong. It is the biggest tax expenditure in the tax code. I've always tried to get rid of it. I tried to cap it when I was Speaker and I couldn't even get the votes for that among Republicans. And the Democrats tried it with the Cadillac Tax, which is very controversial on their side as well and keeps getting pushed around. And so I think Obama was going at it the wrong way with the right idea with the Cadillac tax.
What I wanted to do, and I still believe, is repeal that tax exclusion, convert it to a fixed, refundable tax credit so that more of the money goes to low income individuals and families, less to upper income individuals. Throw a deduction on top for those people and allow people to take that refundable tax credit to buy health insurance, health insurance in a guaranteed issue climate with basic health insurance, affordable, and your community rating banding at a smarter way so that the young person coming out of college or once they're 27 or 28 and buying their own health insurance can buy affordable insurance. And a 48 year old who's making more money, who's still pretty healthy will pay what they should pay for that health insurance. So from a regulatory and tax perspective, I would do those two things, which would equalize the tax treatment of health care make it more fair from an ability to pay standpoint, throw state-based risk pools with federal subsidies on top of it. And then with those kinds of insurance relaxations would still have basic packages and guaranteed issue.
I think you'll have a better system that can have choice and competition, and innovation, and incentives for not just insurers, but for healthcare innovators, for ACO models and the rest to prove themselves. That's the kind of system I think we ought to have. And then when you roll into retirement, I'm a big believer in a premium support model for Medicare. They should be set on a bid based pricing system so that market wait bids are what set the rates. Even CBO, under Doug Elmendorf built a model that showed that that's the smartest way to reform Medicare. And I think that takes Medicare on a much better footing, it reduces the unfunded liability and going to a premium support model with Medicare, more for the poor, more for the sick, less for the healthy and the wealthy within the Medicare system, where you have a number of plans to choose from, to a premium support model, much like the federal employee health benefit plan, I think you can mitigate or avoid a debt crisis.
The fee-for-service system, as we now know it, which is more than half debt financed, is tumbling us toward a debt crisis in about the year 2049, frankly, and if you would convert our system to a premium support system, with the kind of system for the under 65 population that brings choice and innovation, and hopefully a mitigating effect on inflation, then I think you'll have a system for under 65 and over 65, that works quite well. I will defer to you on Medicaid, you will forget more over this podcast about Medicaid that I'll ever know, federal guys don't know Medicaid too well, but ways and means guys like me, I don't know it as well because it's a Commerce Committee issue. I would probably add on top of the tax credit, I would voucher out Medicaid, and just double the tax credit or make it make it larger for the Medicaid population, so they can get really comprehensive care is what I would do. But I know that's not viable. But that's the kind of system that I would envision for 2049.
And what that does in my mind's eye, and I'm giving you just the top level here, is it creates a system of incentive, it creates a system of choice, it creates system of competition so that new products are developed and new drugs and therapies are developed because because their property rights are still in place and there's a huge incentive to create new therapies. Rick Foster is a guy I used to spend a lot of time with, love the guy, he was the Chief Actuary at CMS for many years and he left when I was in government. I asked him to come by before he left, I just wanted to get some last pearls of wisdom from him. And I told him the biggest concern I had was this notion that health inflation is always going to be really high, there's nothing we can do about it. And that it's going to bankrupt the country. And I asked him like why, when everything else we look at in our economy, take tech, for example, new innovations can bring down costs. New innovations can increase quality, increase capacity and reduce costs in tech, look at my iPhone, look at what it was 10 years ago, look at the fact we didn't have an iPhone 20 years ago. Why can't this be in healthcare? And he said, You know what, I actually think it can be and all these actuarial assumptions we've baked into the cake, assume that that's not the case, but if you have, I'm just paraphrasing what he said, if you have the right incentives in place that allow tech and innovation and an incentive to innovate within healthcare, to enter the system, the new devices and the new technologies and the new therapies can, not will, but can have the effect of making things better and reducing prices. So I'm hoping that we can bring that kind of market dynamic to the healthcare space by the year 2049.
Right now, it's nothing but partisanship and ideology on my side of the aisle, let's just get right with the idea that we want universal coverage. We want everyone to have health care. And we think the government, through taxpayers and tax policy should pay for it, then let's get on with the left conceding, there will be private sector involvement, there will be private property rights, there will be innovation, and there will be innovators that need to recoup their gains and make money on their innovations. And if we can all accept those basically twin premises, then let's get on with designing a system that works.
I used to go around the world looking at these systems. Actually, I thought the Swiss system was pretty darn good. I think they did a pretty good job with their system. It's a private system with a public payment mechanism with important regulatory guardrails to protect people from from being screwed basically, by health insurance companies. That's what we should seek to achieve. And I believe if we can get the political pendulum to sort of settle in the middle, which right now it's not, I think Joe missed the boat on that. But if we can get the political pendulum to settle in the middle, I think we can get this done. And we can do it before 2049 which is the year, you asked me to demonstrate or identify what this will look like, so right around the time the debt crisis will get us if we don't do something about it. So how's that?
Jason Helgerson 20:06
I think it's very clear, especially your description of what the payer environment, how will we actually pay for health care, I think you're very clear about efficient health insurance markets, the role of the government, what Medicare would look like, what Medicaid would look like, how you would see universality achieved, but I also want to go now one layer below how we pay for it, and get you to sort of tell us a little bit about what you actually think healthcare delivery could and should look like in the year 2049. If we get those financial incentives right, what is the healthcare system that all of us experience here in the United States, what does that look like and feel like for patients, providers, and just citizens in general?
Paul Ryan 20:48
Yeah, that's why I have a little bit more concern. It's not that I had this great nostalgia, like my grandfather was the first cardiologist in Wisconsin in Fond du Lac, and at this neat private practice, and I want to go back to those days of private practicing physician groups and small hospitals, I'm not trying to suggest that that's what I want to get back to. But I am a bit tired of sort of, oligopoly healthcare.
I remember one of the reforms I tried passing, I couldn't even get it out of the Ways and Means Committee Republicans, was to end this ban on physician on hospitals, which I think are pretty good, they're pretty efficient, they have great customer satisfaction, they have good outcomes. And yeah, the doctor makes some money, but just disclose, make sure everybody knows who's doing what and where the money is being made and let the market settle that. I couldn't get that out of the committee because the hospital lobby is so powerful. And these full service hospitals don't want competition.
And so I think we've got a bit of an interest group problem there, where you have barriers to entry against innovation in the healthcare delivery system. And big is established and smaller, more innovative things that we haven't even thought about yet have a hard time getting a foothold in the marketplace. I'd like to think the market will overcome these challenges. But right now, there is a real regulatory competitive moat formed around the healthcare delivery system. Am I enamoured with the ACO concept? Yeah, of course I am. I think it's a wonderful concept. But let lots of experiments happen, not just something through CMS or CMMI, don't make it just a government experiment. Build an incentive structure so the lot of players can come to this.
I advise a company called Devoted, which I think is a really interesting Medicare Advantage tech-enabled company that's just crushing it. And it's doing it within the existing rules. But I think if you can have more innovation, especially from Palo Alto and people like that, with their innovation coming to the healthcare delivery system, I think, especially with telehealth being fast forwarded because of COVID. I think there's a lot of innovation in the healthcare delivery system that can be really improved.
Where Congress needs to get involved, and it's a little early, it's making sure that people's rights and privacy are protected, especially when we get to immunotherapy and gene therapy. So it's extremely important. Look, my wife as you know Jason, has a history of cancer in the family and went through the whole screening to see if she has these genes that could get the kind of cancer her mom had, that stuff needs to be protected and protected from insurers and others. So I think Congress is gonna have to get involved in a smart way, not unlike what HIPAA did back when I was a staff guide working on that bill, for the 21st century, customize immunotherapy, drugs, but we need to have a get better incentive system. And as far as delivery, I just think that we need more choice and competition in the delivery system. And right now, the incumbents basically write the rules. And I think that's got to change.
Jason Helgerson 23:49
So let's go drive it a little bit more in innovation, and particularly technology-driven innovation. And on the show we often have guests who come at this question of what should health and health care look like in the year 2049, very much through the technologist lens. And we often debate or discuss how much technology, what role it will play, will it play a positive role overall in health and health care in the year 2049? Are you optimistic about technology? How transformative do you think it's going to be in health care 30 years in the future? If you could talk a little bit about that.
Paul Ryan 24:26
This is what I'm most excited about. And this is why I want to make sure that we get the fiscal parts in place, when I mean fiscal parts, paying for health care for people who can't afford it, who need it, rules that allow everybody to get health care, and then an incentive structure so that innovation can keep going.
I'm on the board of a nuclear technology company that you're probably familiar with Shine, which is in Janesville, actually, and there are these physicists in Madison who designed these new kinds of particle accelerators that create medical isotopes and we're building one of its first of its kind, generation plant with eight particle accelerators to produce Molly 99 for diagnostics, but basically we're gonna be able to produce a bunch of medical nuclear isotopes like Lutetium177, and others, for cancer immunotherapy which will be able to target people specific cancers in their bodies, customized they themselves for the kinds of cancer they have, which can eradicate their cancer. I think we are just a single digit handful of years away from effectively killing, treating and curing cancer. And that is, all this immunotherapy direction with things like nuclear isotopes is very exciting. Novartis is just almost done with their last trial on this prostate drug.
So I just think there's great breakthrough technologies that are out there. And these technologies are happening because we have a decent private property right protection system that allows that innovation to occur. And as we get down this road of customizing our healthcare, so that we can cure our diseases, enhance our lifestyles, you got to make sure that you have a payment system, a privacy protection system that is fit for the 21st century, and we're not quite there yet. But I'm really excited about this innovation. It's just incredible. CRISPR I mean, you can go on and on about this stuff.
Jason Helgerson 26:09
Yeah, I share your excitement for it. And I also appreciate the potential problems, particularly the ethical problems, the information protection challenges that we're going to be facing, and are going to have to grapple with as a society in the future in order to be able to make sure that these advances are in fact advances and don't lead to a new form of discrimination.
Paul Ryan 26:36
Huge ethical conundrums await us whether it's discrimination, or what other countries irresponsibly are doing to try and genetically modify people. And whether it's machine learning, AI, immunotherapy and all the gene editing, CRISPR, everything like that, we've got big, ethical and moral conundrums ahead of us. And that's why frankly, I think the smarter way, look, I'm a Congress guy who never liked kicking things to blue-ribbon commissions because that's Congress not doing its job. This is an issue where you need to have big time stakeholders and experts, bioethicists, on a commission to help determine what are the right rules for the road, and not just for America, but for the world. That's an area where I think legislation in regulation is going to have to happen. And it's got to be done in such a way that allows for the innovation but also protects individual rights individual people.
Jason Helgerson 27:29
So taking some of what you talked about today, innovation, one of the, I think potential outcomes of curing cancer, or some of these new treatments to address rare diseases, is extending life, the opportunity for life expectancy to exceed 100 years. Life expectancy, could within our lifetimes achieve maybe 100 to 125 years. That's all wonderful and exciting to contemplate, but then, does it not also worry you a bit about the other large entitlement program in the United States, Social Security or the cost to government and society, potentially this aging population that thanks to technology is now possible, but it in itself would also potentially create some challenges to the country to the world?
Paul Ryan 28:22
Yeah this sort of what I meant in my opening riff when I meant full funded system. What fiscal policy people mean when they say that, like me, full funded system means we have to go from the pay-as-you-go system, which is demographically destined for the ash heap.
We started Social Security with I think, 35 FICA tax payers for every senior beneficiary, then we started Medicare with 16 people paying their FICA taxes for one beneficiary. With the boomers now, getting deep into retirement, we're going to two FICA tax payers for one beneficiary. And those numbers with the current debt trajectory don't even account for this take off in life expectancy. So when I say go to a full funded system, we have to go from this pay-as-you-go system, where someone's paying for someone else's health care, basically, on a demographic generational basis, to each generation pays for its own health care system.
Now, I do believe this is one of those cases where you have to have a safety net, more support for the sick and the poor, less for the healthy and wealthy, as I've said a number of times, but I don't think we can continue to have one generation cashflowing the next generation because of just birth rates and life expectancies. Those numbers are so bad that those numbers compound so viciously, that it's really not viable. So you have to transition over to a full funded each generation, like you do for your retirement, like you do for whether it's a defined benefit or defined contribution program, you are paying for your own retirement we need to do the same sort of thing for these entitlement programs. And so I think we do have to gravitate over to that. That's really hard.
I don't see any political viability for that idea, presently. But I think mid century, it's going to dawn on us that we don't really have a choice and that's where we have to go. On the under 65 healthcare, I think that's pretty easy to do. It's the over 65 stuff. I always embrace something called longevity indexing for for the age limit for Medicare and Social Security. I put it in every one of my budgets, if you follow the Social Security actuarial tables, it goes up one month, every two years. So I think the retirement age goes to 70 in the year 2103, if I'm doing the math right, and you could do that, and that would help a lot. But Social Security longevity tables probably are going to be a little behind the times with what you just described. And I think we could have dramatic increases in life expectancy, therefore there's no way the Social Security system will be able to pay for that person's retirement or the Medicare benefits.
That's why I think we're going to have to convert over to a system. And it's a system, frankly, where I think as a society, we should decide, if you're wealthy enough to be able to afford it, you should pay for it yourself. You have these rules, guaranteed issue and all of these other things that will protect you, so that you can't get cherry picked out of being able to buy the insurance. But I do believe in the safety net. The left will hate the fact that it's less universal, but I just don't see where we have a choice with respect to being able to afford all of this and still have a free society and a free economy. I think Social Security, I'm a big believer in personal accounts, I think we should switch over to a personal account system, where at least half of your FICA taxes are going to your personal retirement, invested in a smart way in index funds, age adjusted, so that you get a better rate of return.
So that's what I mean, when I say full funded system on Social Security. And on Medicare, you could do something from a from a payment mechanism in a similar way, where your FICA taxes are going toward your Medicare and a bunch of it is basically cross subsidize for the rich to the poor.
Jason Helgerson 31:53
All right, so Paul your vision for 2049 presents a lot of opportunities, but also challenges. And I think one of the challenges that you've highlighted several times is this political divide that we have in this country right now, and not that we haven't had political divides in the past, but at least it feels quite severe at the moment. And you were a member of Congress for for two decades and obviously the Speaker of the House, how confident are you that Republicans and Democrats, people from multiple sides of these complex issues, how confident are you that they can overcome their historic positions to coalesce around to finding answers to not only some of the quite challenging questions we've been debating around, say, over the Obamacare debate, but some of these even more complex issues that you described that we're going to be facing in the next couple of decades, how optimistic are you that people are going to able to put down their swords and come together with solutions that work for the country?
Paul Ryan 32:59
I'm relatively confident. Right now, of course not. And I always think it's going to be better tomorrow. Well, I think it's still going to be ugly for a while, politically speaking. But I think just the math is going to get us. And I think the realization that these programs are running into fiscal reality, which jeopardizes their own viability. The social contract is an important concept. It's very important. Two decades of going through all of this stuff, my own views have matured through all of this. I see the social contract as extremely important, a viable safety net for the poor, health and retirement security for old age. And then all the other things we talked about in between, that is important.
And for that to be sustained in this century and on, it will have to change. These were designed in the 20th century with 20th century economics, 20th century debt demographics, all of that is changing for the things we just discussed. And I think Congress will get there, because they will have no choice but to get there and the bond markets will make them do it.
I think the only real viable way in the midterm, not this year, this session, or even probably the next session, is a commission. I hate, like I said, I was on Bowles-Simpson, I served on some of these commissions, I'm not a big fan of them because I think it's Congress sort of ducking its responsibility, but I don't think Congress is ever going to, it's just too broken to think that Congress is going to be able to take all of this on on its own. You know, my buddy, Mitt Romney has a commission where I think he has an equal number of Democrats and equal number of Republican co-sponsors to take on these entitlements and to have a forced up or down vote like the base closing commission. Bowles-Simpson didn't have that. So in both Bowles-Simpson didn't even tackle health care. Alice Rivlin and I had an amendment to it which was defeated by the Democrats. But I think there are seeds of what I just described in sort of the Brookings Institution left in the AEI right, and I think, I'm describing center left and center right, I believe the right formed commission in the right Congress with the right President can put before Congress a solution to this problem that can buy us decades and really chip away at this problem and pass Congress in the medium term. And I think that's probably the best and easiest most viable path forward to solve this problem.
Jason Helgerson 35:22
All right. Well, on that optimistic note about the not too distant future in terms of solving some of our biggest challenges and how do we get to a positive future, I want to thank Paul Ryan for being our guest today.
Paul Ryan 35:35
Go Packers!
Jason Helgerson 35:36
And that was Paul Ryan's vision for health in the year 2049. As always, thank you for listening to Health2049. If you enjoyed what you've just heard, please subscribe to us on Apple Music and Spotify and share this podcast with a friend. Thank you and see you next time.
