He left out Medicaid, I think, because he recognizes that he couldn’t commit to preserving funding levels for it because it’s unrealistic as a fiscal matter. Unless we address Medicaid’s spending trajectory, we won’t be able to address our fiscal problems.
In other words, if he folds Medicaid in with other anti-poverty programs, he either has to cut the total amount spent on poverty or leave in place a fiscal doomsday machine. I’ll have to think about that argument.
I suppose one could always work backwards from a fixed budget for things like Medicaid and, indeed, health-care spending in general, setting the figure at whatever the ‘sustainable and affordable’ level is perceived to be. Some arbitrary fraction of GDP close to current levels, perhaps. It’s very hard to answer the question of what the ‘right’ amount of spending is, which is a tricky problem outside the context of purely individual choices.
Then one must set up a system that attempts to allocate the funding in some intelligent effort to do as much ‘good’ as it can within that constraint. But that’s where we get things like the IPAB, “Death Panels”, NICE in the UK, and so forth.
Demand is theoretically infinite, and so if a third party pays the bills then someone at sometime has to say no. I really don’t see anyway around leveraging such a system to control costs, and I suspect Ryan knows that. But talking about it explicitly is so politically difficult – especially for a Republican – that he simply can’t be explicit about it.
If this is true, then it would make sense for him to set Medicaid aside, as if there could be a way to control costs there too, but that he can’t take the additional hit of talking about it when he’s probably already reached his political risk quota with his current set of proposals.