The most remarkable and revealing speech of the health care debate was delivered by Paul Ryan, the new right-wing idol. In the preceding weeks, Ryan had largely cast his opposition to health care reform in the wonkiest of terms, assailing the administration's claims to fiscal responsibility. This time he did so in the language of first principles:

Should we now subscribe to an ideology where government creates rights, is solely responsible for delivering these artificial rights, and then systematically rations these rights?

Do we believe that the goal of government is to promote equal opportunity for all Americans to make the most of their lives? Or, do we now believe that government's role is to equalize the results of peoples lives?

The philosophy advanced on this floor by this Majority today is so paternalistic and so arrogant.

This is the expression of a fundamental philosophical divide. Liberals do not believe in equality of outcome in most spheres of life. There are myriad punishments for the losers of the free market that liberals can accept: less money, less vacation time, lower social status, more uncomfortable, dangerous, or physically draining work. But the denial of medical treatment should not be among those punishments.

Conservatives generally haven't challenged this premise head on. They may object to Democratic health care reform on the grounds that covering the uninsured can be done more cheaply and efficiently using other (more conservative) means, or on the grounds that we can't afford to cover the uninsured until health care costs have first been reduced. Ryan was challenging this view. He believes that access to medical care is a matter of personal responsibility -- something we should have the opportunity to acquire for ourselves, but not actually to have as a matter of right. Medical care is like a flat-screen television -- a nice thing if you can get it, but not society's responsibility to provide.

A couple weeks ago, I wrote about the radical opposition to redistribution that sits at the heart of Ryan's worldview. Ross Douthat objected that I was engaged in "caricaturing and misrepresentation." Douthat's conceded my most important points, brushing them aside by restating them in weakened form. I pointed out that Ryan would transform the federal tax code from a slightly progressive instrument into a sharply regressive one, a change that would "amount to the greatest shift of resources from the non-rich to the rich in the history of the United States, by far." Douthat replies, "Ryan’s proposed changes to the tax code — his reduction in the highest rates, and his addition of a consumption tax — would shift the tax burden down the income ladder, just as Chait says." Yes, that's a fairly big deal, isn't it?

Likewise, I pointed out that Ryan has cited Ayn Rand as his primary intellectual influence, and boasted that he sees Rand's philosophical framework at the heart of every political battle he fights. Douthat sums this up as "Ryan has said kind words about Ayn Rand." That doesn't quite capture it. I've said kind words about Ross Douthat, but I've never credited this work as the primary lodestar of my thinking.

After brushing aside these fairly significant criticisms of Ryan, Douthat holds his ground on the question of Ryan's entitlement reforms. Ryan would privatize Social Security and voucherize Medicare. Now, on top of that, Ryan would slash the benefits of both programs heavily for the non-poor. Douthat notes that this would make both programs more redistributive than they currently are.

This is true. But my contention wasn't that Ryan was solely concerned with the elimination of financial transfers. It was that Ryan opposed  programs that mitigate against misfortune of all kinds:

The basic thrust of liberal public policy over the last century is to keep in places the market system but use government to slightly mitigate against risk--the risk of getting sick, the risk of outliving your savings, the risk that you just won't make much money in the first place. The downside of these policies is that, in order to mitigate the downside risk, you also have to mitigate the upside benefit. If you're unusually rich, you have to pay a somewhat higher tax rate than most people. If you're unusually healthy, you have to subsidize medical care for people who aren't. If you were able to invest well enough to cover your entire retirement, some of your good fortune will be siphoned off to those who weren't.

Progressive taxation mitigates the benefits of wealth on behalf of the less-wealthy. Ryan would turn that on its head. Medicare and the employer-based health care system mitigate the risk of chronic or severe sickness. Ryan would slash the former and eliminate the latter. Social Security mitigates the risk of outliving your savings. Ryan would return that risk to the individual.

Last week I linked to a video of anti-health care reform protesters taunting a man with Parkinson's disease, shouting their belief that they had no obligation to help him. They were expressing opposition to what many conservatives have taken to calling the "redistribution of health." Quite possibly the man, a former professor, earned more money than the protesters. But in the realm of health, they are the winners and he is the loser. Ryan, while surely less cruel on a personal level, shares their basic belief that government should not force them to subsidize him.

Yes, some elements of these changes cut against the grain of upward economic redistribution that characterizes his general approach. Dissolving employer-based insurance would help a healthy, low-earning 25-year-old at the expense of a diabetic high-earning 50-year-old. But each of his changes would make individuals bear more risk of different sorts of misfortune, financial or otherwise.