House GOP health care plan is an empty backpack

Ryan's failed effort at a replacement for Affordable Care Act

THIS WEEK, US House Speaker Paul Ryan released a long-promised plan to replace the Affordable Care Act. Most of the plan, “A Better Way: Health Care,” developed by a House task force, includes familiar ideas that have been in Republican rhetoric even prior to the ACA. Coverage of the plan’s basics can be found here and here and here.  Is there anything new, important, or revealing in this? Yes. Here is my list:

First, Team Ryan does not want you to know the cost or coverage impact of their proposal. Team Ryan is plenty capable of producing a legislative draft that could be scored by the Congressional Budget Office, and chose not to do so because that would be telling. Indeed. The ACA repeal legislation they sent to President Obama’s desk (subsequently vetoed) this past January would have eliminated health insurance for 22 million Americans who got it via the ACA. Is this new plan better? Team Ryan doesn’t want you to know.

Second, Team Ryan wants to eliminate income-based subsidies in favor of a flat tax credit. The most important reason people lack health insurance is because they don’t have enough income to afford it. The ACA’s structure is based on income – the most assistance goes to those with the least means, ending at four times the federal poverty level, or $97,200 for a household of four. Team Ryan offers a flat tax credit for anyone who can’t get employer coverage that would leave most people under 300 percent unable to afford coverage. How many? It’s impossible to say because Team Ryan doesn’t indicate the size of the credit.

Third, Team Ryan believes Americans are not paying enough in health insurance deductibles. While widespread and justified criticism of the ACA involves high levels of cost sharing, especially deductibles, the Ryan plan proposes to expand high deductible health plans in the form of health savings accounts even for the Indian Health Service.

Fourth, Team Ryan surprisingly supports the ACA’s ban on lifetime limits in health insurance policies — with a big catch. The ACA bans lifetime and annual financial limits on health insurance policies. Team Ryan only mentions the former. Annual benefit limits are another way for insurance companies to achieve the same end. This is bait-and-switch.

Fifth, Team Ryan wants to bring back medical underwriting and pre-existing condition exclusions. Ryan endorses guaranteed issue (one of the most popular parts of the ACA), but only for consumers who maintain “continuous coverage.”  So if you are down on your luck, get sick, lose your job, and don’t have money to pay for health insurance, congratulations, you will get thrown into the newly revived pool of Americans subject to pre-existing condition exclusions and medical underwriting.

And get this: “Our plan provides a one-time open enrollment period for individuals to join the health care market if they are uninsured, regardless of how sick or healthy they are…the decision to forego coverage … will result in the forfeiture of continuous coverage protections and lead to higher health insurance coverage costs for that individual for a period in the future.” This is meant to replace the ACA’s individual mandate and, in truth, it is far more onerous and punitive than the ACA provision.

Sixth, Team Ryan wants to cap the deductibility of employer provided health insurance. Fascinating. Sen. Max Baucus, the Montana Democrat who was chairman of the Senate Finance Committee during the ACA’s crafting, badly wanted the same thing, couldn’t get it, and came up with a substitute called the “Cadillac Tax,” aimed at penalizing high cost health insurance plans to achieve the same end. Republicans unanimously oppose the Caddy Tax yet want to impose this more onerous version. Again, no details included. Good luck with that!

Seventh, Team Ryan proposes radical changes to Medicaid to incentivize states to cut or limit enrollment. Only states that expanded Medicaid by January 1, 2016 would be eligible for the ACA’s Medicaid expansion (tough luck, Louisiana – which expanded shortly after January 1 – and the 19 states still making up their minds, including Florida and Texas). States would have to choose between a block grant or a per capita enrollee cap that would limit federal reimbursement.  Republicans frequently complain that the federal government can’t be trusted to keep its Medicaid financial commitments – but the only folks who keep trying to renege are their party colleagues in Congress.

Here’s more of Ryan’s vision for health care for the nation’s poorest citizens: “…this proposal would allow states to adopt a requirement that able-bodied adults be seeking a job, employed or participating in an education, training, or approved community program … states would get broad new flexibilities such as the ability to charge reasonable enforceable premiums or offer a limited benefit package.  States could also use waiting lists and enrollment caps…”

We face a stark difference in values over health care in the November 8 election.  Democrats promote access to health insurance and medical care as a human right, and Republicans promote it as something only for those deemed deserving.

Meet the Author

Ryan says: “Our proposal is like a health-care ‘backpack’ that provides every American access to financial support for an insurance plan chosen by the individual and can be taken with them job-to-job, home to start a small business or raise a family, and even into retirement years.”

For too many Americans, the Ryan backpack – and Trump’s, too – is empty.

John E McDonough is a professor of practice at the Harvard TH Chan School of Public Health and blogs at