After All That, Paul Ryan Got the Cruel, Radical Health Reform Bill He’s Always Wanted

The man’s bursting with joy because he’s winning at halftime.

Carlos Barria/Reuters

If there is a single comforting thing about the American Health Care Act, which House Republicans passed Wednesday after a bewildering week of negotiations, it’s the possibility that the bill may never have been meant to become law. In order to keep the gears of Capitol Hill turning, the generous interpretation goes, House Speaker Paul Ryan had to move some sort of Obamacare replacement up to the Senate, where it is sure to be rewritten. At least a couple of rank-and-file members have suggested as much while trying to explain their own votes. “This thing is going to go to the United States Senate. It’s going to change in my view,” Oklahoma Rep. Tom Cole told NPR. “At some point you just have to move, and we think this is it. This will create some momentum.”

The Senate GOP seems to agree. The Washington Examiner reports that the chamber’s Republicans aren’t planning to vote on the House bill. Instead, they’ve created a working group to craft from scratch their own legislation, which may incorporate some of the AHCA. “It was kind of a moot issue if the House wasn’t going to be able to pass a bill and now they have and I’m proud of them for doing it,” Senate Majority Whip John Cornyn told the Examiner. “Now it’s up to us to pass a bill 51 senators can agree to.” As of this moment there’s no deadline.

It’s relieving to think that the AHCA was never truly intended to land on President Trump’s desk, because every aspect of the bill is repugnant, from the farcical process through which it was crafted to its cruel and sometimes incoherent mix of policies. The president appears to have no idea what’s actually in the legislation he celebrated this afternoon in the White House Rose Garden; just this week, he told Bloomberg it would let Americans buy insurance across state lines, which, no, it would not. Meanwhile, House Republicans can’t say what it might do, because the Congressional Budget Office never got a chance to score their final bill.  We do know that their original legislation would have financed roughly $600 billion in tax cuts—overwhelmingly targeted at the wealthy—with almost $1 trillion in cuts to health programs, and eventually left 24 million additional Americans uninsured. It was, and still largely is, a tax giveaway to the rich masquerading as health policy.

So the Potemkin bill theory is pretty appealing. How many people would actually want a bill like this to become law?

Well, Paul Ryan, for one. Last summer, the speaker and his fellow House leaders released their own outline of an ideal Obamacare replacement as part of their Better Way series of white papers. And as it turns out, the monstrosity that just passed the House isn’t all that different from what they sketched out back then.

Consider: The Better Way plan was designed to bring down the cost of insurance for younger, healthier Americans by letting insurers charge more to the sick and old, while offering Americans universal tax credits to buy coverage. (I’m sure there’s a Bible verse that justifies this approach to health policy, somewhere). It would have eliminated the Affordable Care Act’s individual mandate to buy insurance and its market regulations, such as the rules that required plans to cover certain essential medical services and barred insurers from charging more to patients with pre-existing conditions. It offered two bits of consolation to the sick: First, they would be protected from discrimination as long as they maintained their coverage (unfortunately, Americans end up dropping their insurance all the time). Second, the government would fund high-risk pools of subsidized insurance to cover those otherwise shut out of the individual market (unfortunately, high-risk pools have a terrible track record, as they tend to be underfunded).

Meanwhile, Ryan would have put a cap on Medicaid spending and slowly throttled the program, while slashing taxes.

And what does the American Health Care Act do?

Well, it lets insurers charge older customers more relative to the young than they can currently, while offering not-quite-universal, age-based tax credits to help Americans buy coverage (poorer Americans will get less help now, while some higher-income Americans will get more). It lets states opt out of the Affordable Care Act’s individual mandate to buy insurance and its market regulations regarding essential benefits and pre-existing conditions. In those states, it offers protection to sick people if they can maintain continuous coverage or tosses them into a (probably) underfunded high-risk pool. It caps Medicaid while slashing its funding by more than $800 billion over a decade. And it torches a bunch of taxes. Unlike the Better Way outline, it doesn’t let Americans buy coverage across state lines—a concession to letting states pick their regulatory schemes. But that’s relatively small potatoes

What’s remarkable is that it took the intransigence of the Freedom Caucus, which scuttled the first version of the AHCA, for Ryan to more or less get the House to pass his ideal bill. The original AHCA contained a number of compromises meant to win over moderates, which left it looking like a more dysfunctional version of Obamacare. Those consolations mostly fell by the wayside during negotiations. Of course, rushing the bill to passage left it laden with bizarre inconsistencies and set the stage for some awful unintended consequences. Parts of it encourage Americans to keep continuous coverage, while others do the opposite. Its tax credits are structured so that, in states that waive Obamacare’s market regulations, insurers might be able to scam money from the government by offering customers “free” coverage that doesn’t really cover anything. Because of how its rules interact with a previous Obama-era regulation, the law may allow employers to offer worse coverage than before. The list goes on. But the outcome is ultimately a fairly pure expression of Ryan’s extreme ideological preferences.

Unlike Ryan, who couches his policy goals in gauzy language about individual choice and improving “access to care,” the Freedom Caucus members have been pleasingly blunt and upfront about their ultimate aim of making cancer survivors and heart patients pay more for their care. “The fundamental idea is that marginally sick people would pay the risk associated with their coverage,” Freedom Caucus Chairman Mark Meadows said. Alabama Rep. Mo Brooks, perhaps the most horrifyingly forthright man in Washington, said he hoped to to reduce costs for people “who lead good lives”—which presumably does not include people with childhood leukemia or who have rheumatoid arthritis.

Even if the American Health Care Act disappears into the Senate mists, I fear it could still do damage. The American Health Care Act has set such a low bar for compassion and competence that the media and public may give Senate Republicans credit for writing an even marginally better bill. Senators from Ohio or West Virginia could wring credit from cable-news pundits by negotiating a compromise that cuts Medicaid by $400 billion instead of $800 billion or by creating a subsidy structure that prioritizes the poor but still cuts their aid. If the House’s bill becomes an anchor on the public’s expectations and sets the stage for something just slightly less grotesque to pass, that would be almost as much of a tragedy as this thing actually getting signed. And it would all be thanks to Paul Ryan, who stumbled his way toward the cold, cruel bill he’s always desired.