Lord, have mercy, I have said all of this before. Paul Ryan: the man whose plans to balance the budget do not balance the budget. Paul Ryan: somehow credited with being a deficit hawk despite having his fingerprints all over any number of deficit-busting policies. Paul Ryan: he will provide growth by closing tax loopholes, despite the fact that an insufficient amount of the same exist. Which is why he’ll never tell you which ones he’s aiming to close.
And now, he’s Paul Ryan ― the guy who doesn’t understand how health insurance works. This week, Ryan dazzled the media with a PowerPoint presentation in which he tried to lay out the nuts and bolts of his Affordable Care Act “replacement” bill, which almost everyone from across the political spectrum hated the moment it was let out of the closet in which he’d stashed it. One moment that caught everyone’s attention was this statement: “The whole idea of Obamacare is that the people on the blue side pay for the people on the red side,” he said, pointing to his slide before clarifying, “The people who are healthy pay for the people who are sick.”
This is not “the whole idea of Obamacare.” This is the whole idea of health insurance. This is the whole idea of insurance, period. President Barack Obama did not come up with this idea. If Obama had invented this concept, then we’d all have written stories back in 2009 about how a visionary president completely came up with the idea of the health insurance industry, entirely on his own.
Naturally, the Ryan camp thinks that this read is an unfair one. As The Washington Post’s Philip Bump reports:
What Ryan is arguing, his senior aide Brendan Buck said on Twitter, is that the balance of money coming in to money going out is out of whack in the Obamacare system. The fatal conceit isn’t broadly that healthy people should pay for sick people, as those unsympathetic might hear him saying. It’s that the Obamacare system isn’t yielding enough money from the healthy to pay for the sick. If you watch the video through that lens, Ryan’s comments sound different. He doesn’t explicitly say that the financing is broken, but “it’s not working” is easily understood as referring only to “pay for,” not the whole sentence, “The people who are healthy pay for the people who are sick.” That is, the people who are healthy paying for those who are sick is not working in this case. Whether you agree with Ryan in that regard, whether you agree that the economics aren’t playing out, you can see how that’s the point he’s trying to make.
So let’s concede this point and move on to the next, obvious question. By what mechanism does Paul Ryan manage to bring this balance back into whack? Because if I am going to accept this argument, my expectation is that Paul Ryan is going to find a way to bring more of that sweet, sweet young money into the system, to provide for the older, sicker, and poorer folks. At the moment, the Affordable Care Act does this through the individual mandate, which Ryan despises, along with the subsidies that the bill offers customers to help them pay for their insurance plans.
Critically, one of the things that Ryan wants to accomplish with this bill is to be able to say that he’s brought insurance premiums ― the money that pools so that blue can pay for red ― to lower prices for the individual consumer, especially the younger and healthier ones. Focusing on the sticker price of health insurance would provide Ryan with a positive-sounding talking point: “Hey, everyone, the cost of insurance under Obamacare was X, and now it is less than X!”
All of which sounds pretty good until you remember that (a) the money pooled to cover the sick is now less than what you started with, and (b) with Ryan’s watered-down version of the mandate, the young and healthy are more likely to simply stay out of the insurance market entirely, whether the premium costs are lower than ever before or not.
By now, you might be wondering how an insurance market filled with fewer younger and healthier people manages to keep premium costs down in the first place? Well, Ryan’s vision for health care is to keep the most costly insurance customers ― the aged and sick ― in high-risk pools. As The Huffington Post’s Jonathan Cohn and Jeffrey Young report, Ryan’s bill “provides states [with] $100 billion over 10 years to establish high-risk pools or other mechanisms to support people with high medical costs.”
The problem is that this is not nearly enough funding to make high-risk pools work. As TPM’s Tierney Sneed notes: “A Commonwealth Fund study estimated in 2014 that it would cost the federal government $178.1 billion per year to fund a national high-risk pool program that would cover the Americans barred from insurance due to pre-existing conditions prior to the ACA.” Other studies have suggested that number might be smaller, but still woefully inadequate. As the Urban Institute’s Linda Blumberg told Sneed: “They’re kidding themselves if they believe that this is enough federal funding to make care adequate and affordable for such a high-need population.”
But perhaps the only people Paul Ryan is trying to kid are those tuned in to his PowerPoint presentations. The broad strokes of his bill do not actually resemble “health care reform” at all ― and certainly not reform that’s uniquely concerned with finding the optimal mix of young-and-healthy money to bring the insurance market up to patch, thus shoring up the livelihoods of older folks and Americans with pre-existing health conditions. As Cohn and Young report, the bill will create higher premiums for older customers, roll back the Affordable Care Act’s Medicaid expansion, and then radically twist the existing Medicaid program into a weird parody of itself.
But the far weirder parody is the one that Ryan has wrought for himself. Somehow or another, Ryan has managed to pass himself off as a detail-oriented professor-cum-wonk and a master institutionalist. But he’s neither. Again, let me remind you that for a period of time, Ryan had this plan locked away in a basement hidey-hole, which prompted Sen. Rand Paul (R-Ky.) to set off on a seriocomic search for the thing, like it was the Treasure of the Sierra Madre. How is this not fundamentally unserious? This is, transparently, a charlatan act.
Beyond that, Ryan has now decided to rush this thing into existence, sending it to the relevant House committees for markup before the Congressional Budget Office has had the chance to weigh in on the plan. Naturally, it’s expected that when the CBO gets done scoring the bill on Monday, it could take a very dim view ― noting that the plan will fail to cover as many people as advertised, or that it will likely balloon budget deficits.
If Ryan was truly the legislator he’s advertised to be, he’d be ready to contend with this, do battle in the marketplace of ideas. Instead, he’s playing bog-standard political hack games, pre-emptively dismissing the CBO report ahead of its arrival, and trying to ram his vision down his colleagues’ throats before the independent budget wonks that are ostensibly there to help craft optimal policy outcomes have a chance to trigger their gag reflexes.
Ryan’s actions are a stark contrast to how he behaved when the Affordable Care Act was Congress’ going concern. Back then, he demanded that the CBO score the bill ahead of committee markups.
And the truth of the matter, Ryan doesn’t particularly want to delve down into any of the details of his plan beyond those that he proffers himself. This isn’t in any way a new thing with Ryan, either.
Ryan is actually not at all concerned with the details. He’s even said so! Consider this encounter Ryan had with Fox News’ Tucker Carlson, flagged by New York magazine’s Jonathan Chait, in which he says this out loud:
CARLSON: The overview here is that all the wealth [in] basically the last 10 years basically has stuck to the top end, that’s one of the reasons we’ve had all this political turmoil, as you know. Kind of a hard sell to say, ‘Yeah, we’re gonna repeal Obamacare but we’re gonna send more money to the people who’ve already gotten the richest over the last 10 years.’ I mean, that’s what this does, no? … I’m not leftist, that’s just, that’s true!
RYAN: I–I–I’m not concerned about it because we said we were gonna repeal all the Obamacare taxes, this is one of the Obamacare taxes. The other point I’d is, this dramatically helps tax reform.
As Chait notes:
So, asked about why his plan gives rich people a big tax cut, Ryan makes three points. The first is that he doesn’t care — “I’m not concerned about that” — is true, or a massive understatement. He’s not only not concerned, it is a major motivation. The third point, that it helps tax reform, is also true. As noted before, Ryan’s legislative strategy is designed around the goal of enabling a large, permanent tax cut for the rich. Obamacare repeal is being rushed in order to grease the skids for tax cuts later. But notice what Ryan is saying. Asked why his health-care plan (which massively cuts health care for the poor and middle class) includes a tax cut for the rich, Ryan explains that it will enable another tax cut for the rich later on!
So what is Ryan up to exactly? The Huffington Post’s Jeffrey Young, speaking on the “So That Happened” podcast, referred to Ryan’s health care bill in a different, but more honest, way: as “a huge tax cut bill financed through Medicaid cuts.”
“Universal coverage has never been a conservative goal,” said Young. “In other periods when Republicans had control of the entire government ... they never even attempted to tackle the uninsured or any of these things because it’s not been a priority for them.
“This is why I sort of half jokingly referred ... to this bill as a huge tax cut financed by Medicaid cuts, because tax cuts are something that they are unified about,” Young added.
And Ryan is unified in this as well. This is, in fact, the Rosetta Stone by which Ryan’s worldview is explained: Those who have achieved affluence have done so through proper moral choices and deserve rewards. Those who are struggling have made poor moral choices and require punishments to induce them back into prosperity. That’s the whole of it. And you can see how this is wholly incompatible with what “health care reform” seeks to achieve. In Ryan’s view, if you have come to the point in your life where you are incapable of simply financing your own health care, this is down to your personal failings, and you don’t deserve much beyond the barest of minimums.
So in the end, it’s not that Paul Ryan doesn’t understand health insurance. And it’s not that he doesn’t understand math well enough to know that the numbers don’t add up to a sufficient “replacement” for Obamacare. That’s because what Ryan is “repealing” and “replacing” isn’t a health care bill ― he’s swapping out the moral universe that gave birth to the Affordable Care Act with the one that he prefers. One in which the state rewards affluence and punishes those who fail to achieve it. One in which the very notion of redistributing money from the well-off to the poor for the purpose of health care provision is a mortal sin. Properly reconfiguring the universe along these moral guidelines is, to Ryan’s mind, an “act of mercy.”
Really, there is only one demand that I would make of Paul Ryan ― one that would also be an “act of mercy,” because it would preclude the need for me to write about him ever again. He could, at long last, simply start being honest about all of this.
Author: Jason Linkins