If there is a single person who made Paul Ryan the Speaker of the House, it is probably Mark Meadows. Back in 2015, Meadows, a former restaurant owner who, in 2012, was elected to represent the most conservative district in North Carolina, set into motion the events that led to Speaker John Boehner’s resignation. Meadows, who had no legislative experience, filed an obscure parliamentary procedure known as a motion to vacate that would have forced a referendum on Boehner in the House. Boehner resigned rather than face the prospect of losing that vote, and Ryan emerged as the only Speaker candidate acceptable to all the factions of the House G.O.P.
Now it’s Ryan’s turn in the barrel. Last night, Ryan and two House committees released the American Health Care Act, their attempt to make good on the G.O.P.’s promise to repeal and replace Obamacare. It’s not anyone’s idea of a solution to the current flaws in the health-care system, but, rather, a rickety compromise designed to overcome the objections of conservatives like Meadows and several other ideological factions, interest groups, and parliamentary obstacles. The end result is a piece of legislation that critics on the right can credibly attack as too similar to Obamacare for them to support, and those on the left can assail as a giveaway to insurance companies that reduces the numbers of Americans who have coverage and contains no mechanisms to control health-care costs. It is fair to wonder what the point of the bill is at all. Despite all the delicate political calibrations that Ryan made, it still might not pass the House.
Meadows is now the head of the Freedom Caucus, a group of some forty right-wing Republicans who when they vote as a bloc can thwart any Republican legislation in the House. 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.
In this new era of trying to pass bills that a Republican President will sign, the Freedom Caucus is among the first groups that Ryan needed to mollify. Obamacare uses relatively generous government subsidies to help individuals purchase health insurance on the private market. 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. Meadows and several other Republicans attacked the idea as a new entitlement. Ryan’s response in the plan released last night was to scale back the tax credits for wealthier Americans. It didn’t work. Representative Jim Jordan, of Ohio, one of the founders of the Freedom Caucus, told Politico, “This is Obamacare by a different form.” Later today, the group is scheduled to hold a press conference pillorying Ryan’s plan.
Ryan’s problems are not just on his right. The other major mechanism Obamacare used to increase the total number of insured Americans was a large expansion of those eligible for Medicaid. Many Republican governors accepted a generous offer of federal money to expand the Medicaid rolls in their states, and after seven years of using the funds, they don’t want a disruptive reversal that would cause millions of people to lose health insurance. In the Senate, four Republicans wrote a letter yesterday demanding that some version of the Obama Administration’s Medicaid expansion be included in any repeal bill. Several Republican governors have been lobbying President Trump for the same thing. Ryan’s response was to leave the expansion in place until 2020, a decision that, like the tax credits, is already being attacked by the right as retaining a crucial element of Obamacare. 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. The mandate helped insurers afford Obamacare’s new regulations, which required that children be allowed to remain on their parents’ plans until age twenty-six and that Americans with preëexisting medical conditions not be denied coverage. 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. (If the new surcharge wasn’t enough of a sweetener for the industry, tucked into the bill is a tax break for insurance-company executives who make more than five hundred thousand dollars per year, a proposal that will be shredded by Democrats and Republicans alike.)
Finally, the Ryan plan was designed to navigate the Scylla and Charybdis of the congressional budgeting process. 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 the seventies, Congress mandated a rigorous process to estimate the costs of new legislation and created the Congressional Budget Office, which “scores” all bills. 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.” The Ryan plan was released yesterday and is scheduled to be marked up in two House committees tomorrow, long before the C.B.O. can analyze it. That means the most basic information about the plan—how much it costs and how many people will gain or lose insurance—will be unknown before voting on it begins.
The new budget system created in the seventies also set up the obscure parliamentary procedure known as reconciliation, which in the Senate is not subject to a filibuster. Using reconciliation, the Ryan plan can clear the Senate with fifty votes rather than the usual sixty. But reconciliation was not intended to be used for major legislation outside of budgets, and a Senate rule prohibits using reconciliation to make policy changes that aren’t strictly about raising or lowering government revenue. 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.)
Forced to navigate House Republican politics, the lobbying pressure from the insurance industry, and the obscure rules of the budgeting process, 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, and perhaps long before then. If his health-care-reform effort fails, Ryan himself may not survive as the House leader. Meadows and his colleagues catapulted Ryan to the Speakership, and they still have the power to bring him down.