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Congressman Ryan, to the extent he's known at all, has earned notoriety as the author of a controversial budget plan that would dramatically make over the nation's two largest health programs. And as NPR's Julie Rovner reports, his addition to the ticket will present the public with a dramatic choice about the roll the government should play in health care.

JULIE ROVNER, BYLINE: One thing Paul Ryan never does is apologize for thinking big. Here he is on ABC's "This Week" back in February.

PAUL RYAN: We also think we have a moral obligation to try and fix this country's big problems before they get out of our control.

ROVNER: Ryan is referring, among other things, to the budget plan he wrote and helped muscle through the House, twice. It would cut taxes, create private accounts for Social Security and, perhaps most notably, make major changes to the Medicare and Medicaid health programs. The Medicare changes in particular are dramatic. Starting a decade from now, seniors would get a set amount of money rather than automatic coverage. They could use that to choose from a range of health plans.

Here's how Ryan explained it at a news conference with Democratic Senator Ron Wyden last December.

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RYAN: Doing it this way harnesses the power of choice and competition. Our goal here is to have the senior citizen, the beneficiary, be the nucleus of this program.

ROVNER: But the amount of money the senior gets wouldn't necessarily go up as fast as medical costs. Ryan and those who support his idea say that choice and competition would maintain the benefits. Others, including President Obama, aren't so sure. Here's the president from a speech last spring, in which he blasted Ryan's budget plan.

PRESIDENT BARACK OBAMA: It says instead of guaranteed health care, you will get a voucher. And if that voucher isn't worth enough to buy the insurance that's available in the open marketplace, well, tough luck, you're on your own.

ROVNER: On Medicaid, Ryan's proposal would give states far more flexibility to decide how and who to cover, but also less money to do it with. Here's how he explained in on the PBS "NewsHour."

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RYAN: We are trying to do here is to couple Medicaid reforms with food stamp reforms, housing assistance reforms, education reforms, for job training. We are trying to couple these things by sending them back to the states in block grants so the states can combine these dollars to reform the tattered social safety net.

ROVNER: But most analysts say the cuts would be so large - about a one-third reduction over 10 years - that states would have no choice other than to cut benefits or drop people from the rolls. Here's President Obama describing who could be at risk.

OBAMA: Many are somebody's grandparents, maybe one of yours, who wouldn't be able to afford nursing home care without Medicaid. Many are poor children, some are middle-class families who have children with autism or Downs syndrome.

ROVNER: At least one thing that's clear about Ryan's vision for health care compared to President Obama's...

AARON CARROLL: The direction they'd like the county to go is very, very different and no one will be able to mistake one for the other.

ROVNER: Aaron Carroll is a pediatrician and professor at the Indiana University School of Medicine and a health economics blogger. He says this campaign should give voters a clear choice.

CARROLL: I think what Ryan puts forward is a vision of much less government involvement in things like Medicare and Medicaid, especially from the federal level.

ROVNER: What's less clear, however, says Carroll, is whether the nation really is ready to have what Ryan likes to refer to as an adult conversation about how to control entitlement spending.

CARROLL: Well, we probably can, but not in politics because in politics, of course, people want to win, and you win by scaring people into thinking what the other side will do.

ROVNER: In 2010, Republicans tried to scare seniors about President Obama's health law and Medicare. This time around, it will be the Democrats who will try to turn the tables. Julie Rovner, NPR News, Washington.

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