Paul Ryan’s Health-Care Vise
As with the majority of House Republicans, most members of the Freedom Caucus have only ever served under a Democratic President. They were elected to oppose Obama and everything he stood for and they spent most of his Presidency attacking Republican leaders who they believed thwarted those efforts. They have no experience legislating.
.. An early version of the Ryan plan replaced these subsidies with less generous refundable tax credits, which many conservatives dislike because Americans who pay no taxes would still be eligible for the credits.
.. Ryan’s response was to leave the expansion in place until 2020
.. Proponents of the Medicaid expansion see the deadline as creating a health-insurance time bomb that will detonate in a few years.
.. Health-care reform has long been stymied by the insurance industry. Bill and Hillary Clinton took on the industry in 1994 and were badly defeated. In 2009, Obama decided to buy the industry off by including a provision forcing every American to buy its product—the dreaded individual mandate.
.. Ryan and Trump have insisted they would keep those popular regulations while killing the mandate, which forces the uninsured to pay a tax penalty. Their solution is that the uninsured would pay a penalty to insurance companies. Specifically, insurers would be allowed to charge anyone with a two-month gap in coverage up to a thirty-per-cent surcharge on a new policy. For many Americans, the surcharge in Trumpcare could end up being more than the current tax penalty in Obamacare.
.. When Lyndon Johnson created Medicare he essentially made up and lowballed the long-term costs of the program. Without a true estimate, it was difficult for fiscal conservatives, medical groups, and other opponents to attack the plan, and it sailed through Congress.
.. In 2009, Obama became so frustrated by the C.B.O., whose cost estimates had an enormous impact on the health-care debate, that during an Oval Office meeting he said he didn’t want to hear the C.B.O. mentioned, so his aides referred to it as “banana.”
.. Ryan needed to shape a bill that would survive this process, and as a result, he left out some of conservatives’ most long-standing health-care-policy ideas. (For instance, most conservatives support changing a law that prevents insurance from being sold across state lines, arguing it would make markets more competitive and bring down costs, but Ryan didn’t include the change in his plan.)
.. Ryan has produced a bill that nobody would ever propose as a sane solution to the problems with Obamacare. Its only chance is speed. If Ryan can rush and muscle it through the House and Mitch McConnell can do the same in the Senate, it might end up on Trump’s desk. But the more scrutiny this House bill is subject to, the more likely it is to share the fate of most efforts at health-care reform and die somewhere on its journey to the Senate