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However, the Republican proposal does nothing actually to cut the cost of health care. Instead, it transfers the burden to the states, in the case of Medicaid, and to the elderly themselves, in the case of Medicare. Medicaid would be transformed into a “block grant” to the states, allowing them much more discretion over how the money is spent. But the size of each state’s handout would be tied not to runaway medical inflation, but to the much more sedate general price index. This would trim the federal government’s projected outlay by a third within a decade and half within two, obliging unfortunate state governments either to cough up far more themselves or to reduce coverage.

然而，共和党人的建议对于削减医疗改革支出毫无实效。相反，在医疗补助项目方面，方案将负担转移到了各州政府身上；在医疗改革项目方面，方案将负担转移到了老年人个人身上。医疗补助项目将以“整笔补助金”的形式转移到各州政府，允许各州政府自行决断如何支配该项资金。但各州发放补助的大小并不与失控的医疗通胀挂钩，而是与更加稳定的基本物价水平挂钩。在十年内联邦政府预计开支将因此削减三分之一，在二十年内则削减一半；而不幸的各州政府要么被迫交出本不该交的资金，要么缩小医疗补助覆盖范围。

By the same token, under the Republicans’ plans for Medicare, the federal government would subsidise private health insurance for the elderly, instead of itself paying most of the cost of treating them directly to hospitals and doctors. Mr Ryan claims that the resulting competition among insurance firms would lower the overall cost of treatment. But the non-partisan Congressional Budget Office disagrees, arguing that private coverage tends to cost more than public, and that both would continue to suffer from cantering inflation. This would have a doubly pernicious effect for patients: not only would the overall cost of treatment rise, but so would the proportion of it they have to pay.

出于同样原因，在共和党人的医疗改革方案中，联邦政府将为老年人向私营医疗保险公司提供补贴，而不是政府直接出资，为老年人住院看病买单。瑞恩先生声称改革将使各保险公司相互竞争，从而降低治疗的总体费用。但无党派的国会预算办公室持不同意见，认为私营公司的支出将比公共支出还高，双方应继续忍受长期通货膨胀的折磨。这对病人来讲有双重恶性影响：不仅治疗的总体费用会上升，而且病人承担的比重也会增加。

Such measures would be devastatingly unpopular. In a poll last month by the Pew Research Centre, two-thirds of respondents opposed any changes to Medicare and Social Security. Republicans themselves made hay at the last election with the much more modest cuts the Democrats’ health-care reforms made to Medicare (remember “death panels”?). Democrats are returning the favour by depicting the Republican plan as the complete unravelling of America’s Great Society safety net. That is not so far from the mark: two-thirds of the proposed savings would come from programmes to help the poor, according to the Centre on Budget and Policy Priorities, a think-tank. Among the casualties of Mr Ryan’s axe would be Mr Obama’s health reforms, aimed at helping the uninsured get health cover.

这类措施定会受到民众的强烈反对。上个月Pew Research Centre 发布的一项民调显示，三分之二的受访者反对对医疗改革方案和社会保障制度做任何改变。共和党人在上次选举中充分抓住了机遇，提出了更为谨慎的削减支出方案，正如民主党人充分利用机会提出针对医疗改革的方案（还记得“死亡小组”吗？）。民主党回敬共和党称共和党人的方案目的是建立“完全分散”的美国大社会安全网络。这还并未偏离标准太远——根据智库预算和政策优先事项中心的数据，三分之二的预期收入将来源于旨在帮助穷人的项目。瑞恩先生改革大斧砍伤的将是奥巴马总统的医疗改革方案——该方案旨在为未加入医疗保险的人提供援助。

Mr Ryan’s plan also ignores the received wisdom in Washington that any grand deficit-reduction package will have to include bitter medicine for both parties, in the form of cuts to the entitlements particularly cherished by Democrats and revenue-raising measures that are anathema to Republicans. Instead, it would use the savings it would garner by eliminating many of the loopholes and exemptions in America’s tax code to pay for big tax cuts, not deficit reduction. These will mainly help the better-off.

瑞恩先生的方案也忽视了华盛顿政客们公认的看法，即任何大型的赤字削减一揽子计划都是让两党服苦药——削减民主党人尤为珍视的应得利益，采用共和党人深恶痛绝的增加收入之措。实际上，按照该方案，通过堵住美国税收制度的漏洞和取消众多免税权这两种方法增加的收入将用于为大型减税项目买单，而不是为削减赤字买单。这主要是肥了富人。