opinion

The size of his proposal is shocking, but it is proportionate to the size of our problem: According to the Congressional Budget Office, which examined a simplified version of his proposal, it would wipe out our projected long-term deficits.

Facing up to how he does this is a worthwhile exercise. It's not the privatization. His proposal to add optional private accounts to Social Security actually increases the program's cost. Similarly, his proposal to privatize Medicare increases costs.

Ryan saves his money after he privatizes the programs. Under his proposal, seniors stop getting Medicare, which is both government-run and pays for any procedures that can be shown to help improve their condition. Instead, the seniors get a voucher to buy private insurance, and that voucher grows more slowly than medical costs. That means the coverage that voucher buys is going to grow more slowly than medical costs. Seniors will be in the same position the rest of us are in: Either you can afford the coverage and care you need through savings or subsidies or both, or ... you can't.

Ryan's hopes are different. In his telling, his proposal unleashes market forces by pulling people out of Medicare, out of Medicaid and out of the employer-based market. He envisions insurance exchanges and better information on quality and cost. Combine that many consumers with that much money and that much transparency, and it'll have to reform itself into something we can afford. "This sector isn't immune from free-market principles," he says.

That may be so, but we don't necessarily want to treat health care the way we treat normal markets. The way markets deal with scarcity is by pricing some things out of reach. Are we comfortable with life-saving treatments being out of financial reach for the people who need them?

There's an argument to be made that we should be. Resources are limited, and they need to be apportioned somehow. This is rationing, and as Ryan notes, "It happens today. The question is who will do it? The government? Or you, your doctor and your family?" I think that's a bit off: The question is more about whether society should ration in consultation with voters and doctors and politicians and researchers, or whether your bank account should ration in consultation with pharmaceutical companies and medical-device manufacturers and hospital companies.

But Ryan is right that we will need to ration somehow, and along the way, we will need to change the health-care sector dramatically. His radical embrace of the free-market vision is one option. So, too, is the liberal vision of a nationalized system modeled off the far more affordable and efficient examples we see in France, Germany, Japan and elsewhere.

Liberals and conservatives may disagree over Ryan's solution, but I imagine most Americans would support his approach to the work.

"This is my 12th year," he says. "If I lose my job over this, then so be it. If you're given the opportunity to serve, you better serve like it's your last term every term."