What Paul Ryan’s Election to House Speaker Means for the Affordable Care Act

In a recent interview on CBS’ “Face the Nation,” newly elected House Speaker Paul Ryan (R-Wis.) signaled a need for change in the House leadership, saying he will redesign the job and return the House to “regular order.”

Despite his stated desire for change, the top issues Ryan plans to address — tax reform and the Affordable Care Act — are similar to those ardently pursued by former House Speaker John Boehner (R-Ohio). During Boehner’s reign as speaker, the House voted more than 60 times to repeal all or parts of the ACA.

House Strategy on ACA

During the interview, Ryan said that Republicans need to take “policy risks,” such as creating a health care reform plan to replace the ACA.

He said, “People don’t like Obamacare. Members of Congress don’t like Obamacare. … But I think if you take a look at the premiums, if you take a look at the fact that decisions are being taken away from patients and their doctors, the people are starving for an alternative to this vision.”

While Boehner targeted the law through repeated, and inevitably fruitless, repeal efforts, Ryan appears focused on creating a viable alternative to the law. Both strategies take different paths, but the end game is the same: doing away with the ACA.

Edwin Park, vice president for health policy at the Center for Budget and Policy Priorities, said, “The same dynamic is still in place. Both before Speaker Ryan and with Speaker Ryan the GOP is still seeking to repeal the ACA.” He noted that the House’s budget reconciliation bill (HR 3762) — negotiated under Boehner — contains provisions to repeal major parts of the ACA, including the:

  • “Cadillac” and medical device taxes; and
  • Individual and employer mandates.

However, most health policy experts say it is unlikely that any effort to change, replace or repeal the ACA in a significant way will be implemented while President Obama is in office. Park said, “President Obama will veto any legislation” that seeks to drastically change or repeal parts of the ACA.

The 2016 Presidential Election

The 2016 presidential election could be a game changer for the ACA, potentially giving Ryan the political backing needed not only to pass new health reforms, but to sign them into law.

Tim Garson, director of health policy at Texas Medical Center, believes that Democrats and Republicans agree on more ACA principles than most people think. He said, “There is tremendous ability to compromise [on health care reform] moving forward” and there is plenty that Ryan, as House speaker, could do, but it all depends on who wins the 2016 presidential election.

ACA Replacement

While the election has the potential to make enactment of an ACA replacement plan more realistic, Republicans must first agree on a proposal.

“The House has been unable to coalesce around a single ACA replacement plan. There has not been consensus among the caucus,” Park said.

However, such a plan “could be possible,” he said, noting that several Republicans — including Ryan — have talked about replacement proposals in the past.

Garson said a key question is whether Ryan’s views on health care reform have changed since the 2009 Patients’ Choice Act, which he co-sponsored. Garson noted that the foundation of the 2009 plan is very similar to the ACA, but it differs in the execution. For example, he said the Patients’ Choice Act would have created state health insurance exchanges, suggesting that a new Ryan plan could get rid of the federal insurance exchange and allow for more state innovation.

Garson also noted that depending on who is in the White House, the ACA’s individual and employer mandates “could go away.” But, he said they would have to be replaced by something that really works and encourages people to purchase coverage.

Meanwhile, Park expressed some concerns with the health care changes included in budget plans proposed by Ryan during his time as House Budget Committee chair. Park said, “It is important to remember that those plans repealed the ACA coverage expansions and made deep cuts to low-income programs, such as Medicaid.”

According to Garson, the missing piece in Ryan’s health reform proposals is ensuring that coverage is both accessible and affordable. He said, “There needs to be a basic health plan that is affordable at all levels of income.” He added, “The problem right now is the ACA is not affordable in some situations.” For example, an individual may be able to afford the premium, but factor in other costs — deductibles, copayments, etc. — and the out-of-pocket costs grow.

While much remains up in the air surrounding the future of the Affordable Care Act and Ryan’s plans for a replacement, Ryan’s comments on the ACA so soon after his election suggests he will continue to wage the GOP war against the ACA that Boehner is leaving behind.

Around the Nation

Unforeseen consequences. A new study published in the British Medical Journal suggests that reducing excess health care spending, a main goal of the Affordable Care Act, could prompt a rise in medical malpractice lawsuits, the Washington Post‘s “Wonkblog” reports.

Behind the scenes. The Hill reports that Senate Minority Leader Harry Reid (D-Nev.) and House Minority Leader Nancy Pelosi (D-Calif.) are working behind the scenes on a bill that would repeal the Affordable Care Act’s “Cadillac tax” on certain employer health plans. 

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