This last week Congress has been recessed for the Presidents’ Day holiday week. Paul Ryan accurately anticipated that many of Republican members of Congress would be having town meetings with their constituents and would face angry voters who wanted to talk down the plans to “repeal and replace” the ACA. Ryan met with his troops on the Thursday before they left Washington for their week of hometown meetings. Like a good general, Ryan’s send off included last minute advice and some information that they could use to deflect the anger they were sure to encounter.


The report in the New York Times (frequently number one on President Trump’s list of purveyors of “false news”) gave us a very informative report of that meeting. In the article Robert Pear and Thomas Kaplan reported that Speaker Ryan, flanked by two House committee chairmen, and the new Secretary of Health and Human services, former Representative Tom Price of Georgia, presented the plan in the form of talking points and a policy brief. Pear and Kaplan point out that the “plan”…


  • Was heavily weighted toward tax credits.
  • Would reduce payments to the 31 states that expanded Medicaid eligibility.
  • Did not say how the legislation would be financed.
  • Laid out the benefits without the more controversial costs and collateral damage to the economy.
  • Included no estimates of the number of people who would gain or lose insurance under the plan.
  • Did not include comparisons with the Affordable Care Act, which has extended coverage to 20 million people.


In a companion article in the Times Margot Sanger-Katz reported on the immediate concerns that the plan elicited from the states that have expanded Medicaid through the ACA. The key thing to notice here is that the discussion began with the the concept of repealing and replacing the ACA, but it has become a much bigger discussion of Medicaid. “Welfare spending” is the largest item in the federal budget and Medicaid is one of the largest federal welfare programs. If your agenda is to reduce federal spending, Medicaid is a richer target than the ACA, and reducing Medicaid spending undermines the ACA. The Commonwealth Fund has published an excellent tool that is a map that allows you to click on a state to see its total Medicaid population, the Medicaid growth since 2013 under the ACA, and an analysis of how many jobs would be lost if the ACA were repealed.


I clicked on Pennsylvania and New York, since I am on the board of Guthrie Health which has hospitals and ambulatory sites in both states, as well as my home state of New Hampshire. Pennsylvania has added almost 500,000 Medicaid patients since 2013 and would lose about 91,000 jobs by 2019 if the ACA were repealed. In New York there are 750,000 new recipients and potential job losses are estimated to be about 89,000. New Hampshire is a small state, but we still added more than 62,000 lives to Medicaid and our economy could lose as many as 8,000 jobs if the ACA were repealed. Check out California! You should explore the map. It is interesting.


The ACA looks like it was built on the concepts of the Triple Aim. It is a piece of legislation that is imperfectly aligned with the ideal that we are searching for:


Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness.


As imperfect as the ACA is, it has moved us toward the ideals of the Triple Aim. It was a giant, though incomplete, step toward universal coverage. There is much data to support that the ACA has improved the quality of care. Atul Gawande has published in the current New Yorker “Comments”, the best and most concise defense of the ACA that I have read. The ACA is most maligned because of the sense of federal control and regulation that it added to the lives of individuals and employers through its mandates, and because the cost of care for many individuals who did not qualify for assistance has risen even as the rate of the  annual increase in the total cost of care has diminished.


None of the accomplishments of the ACA are referenced in Speaker Ryan’s presentation. His focus on finance is legitimate and was shared by President Obama. His other criticisms are primarily distortions of the experience of the majority who have realized real improvements in their care. My fear, and the fear expressed by so many of the constituents that did show up at the town meetings, is that the gains we have made so far over many years will be thrown away while offering replacements that will damage lives and the economy. I believe that Ryan’s faux solutions will ultimately increase the cost of care, lower the number of people who have access to care, and diminish the quality of the care still available to those able to pay more.


When thinking about replacing the ACA after repealing it, fundamental questions are: where do we start and what objectives are we pursuing? The ACA made universal coverage and guaranteed access, and adequate benefits the highest priorities. Ryan does not mention universal coverage, guaranteed access or a protected benefit package. His paper speaks in terms of the grievances of those individuals who had care before the ACA. I am cynical and suspect his core objective is not universal coverage but rather a reduction in federal spending or other cloaked political objectives. The ACA did close the gap between the number of lives covered and true universal coverage. It is likely that true universal coverage is only possible with an “entitlement” realized through a single payer option similar to the plan that Bernie Sanders advocated.


It is my opinion that the real result of the election will be at least a ten, if not a twenty year, delay in the dream of universal coverage through a mandate or an entitlement. The only hedge would be President Trump’s promise to give everyone terrific care. He promises to present his healthcare plans to the nation in a speech tonight. If Trump’s promise is to be realized, I believe  believe it would require a federal investment that would give Ryan, Price, Pence and associates a huge problem with their aligned supporters. An article by David Frum in the Atlantic gives us an analysis of the likely relationship between Trump and the mainstream Republican members of congress.  The analysis suggests that if President Trump must choose between granting expensive programs to his populist base while enriching or incurring the wrath of the Republican majority in Congress, his best way forward is to sign off on the agenda of the members of the most demanding wing of the Republican party who want to see huge reductions in the federal budget that will undermine current support for healthcare, education and the other programs championed by liberals. We will see.


It is interesting to note that on February 7, CNN televised a healthcare debate between the two senators who were the “runners up” in the two Presidential primary marathons. You can watch the debate or read the transcript. If you listen closely to Senator Cruz, what you will hear is perfectly aligned with the position of Speaker Ryan. In response to one of the questions he talks about the “reason for action” behind “repeal and replace.” It is not universal coverage. It is about fulfilling campaign promises to the base.


Senator Cruz:…Now, nobody thinks we’re done once Obamacare is repealed. Once Obamacare is repealed, we need commonsense reform that increases competition, that empowers patients, that gives you more choices, that puts you in charge of your health care, rather than empowering government bureaucrats to get in the way. And these have been commonsense ideas, …This election is about honoring the promises we made to the people who elected us.


With Senator Cruz’s statement and Mr. Frum’s warnings about the relationship between Congress and the President in mind, let’s take a closer look at the document that Speaker Ryan presented to his colleagues. It’s not that long. Page one has several big points. One could call them a “reason for action.”


  • The law is only getting worse
  • Repeal is relief
  • A stable transition is the goal
  • We have a better way


Each item has more verbiage that may interest you. I find many of the assertions inaccurate. The discussion continues with “Key Obamacare Facts.” It is my opinion that many of the “facts” like the statement, “Obamacare is hurting more people than it is helping, forcing Americans to buy insurance they don’t like, don’t need, and cannot afford” are at a minimum debatable, if not just outright distortions of the truth. What is definitely true is the assertion that there are three different ways to undermine the ACA. In Speaker Ryan’s words:


  • Repeal and replace the Legislation: House Republicans will advance legislation in the weeks ahead to provide relief from Obamacare’s taxes and mandates–including eliminating the individual and employer mandate penalties–and move forward with patient-centered reforms.


  • Action from the Trump Administration: President Trump and HHS Secretary Price have an important role to play in providing relief from Obamacare’s burdensome regulations. Most recently, the administration issued a proposed rule to help protect taxpayers and stabilize the collapsing marketplaces.


  • Delivering Solutions through Regular Order: Both Energy & Commerce and Ways & Means have already begun to hold hearings examining reforms that will: a) Decrease costs and increase choices by promoting competition and innovation in the insurance market. b) Increase flexibility for employers to offer affordable, quality health care options to their employees. c) Allow individuals and families to purchase insurance across state lines.


Ryan’s policy statement is crafted to sound feasible while ignoring the underserved and the objective of universal coverage.  My greatest concerns are on page 7.


  • Modernize Medicaid
  • Utilize State Innovation Grants
  • Enhance Health Savings Accounts
  • Provide Portable, Monthly Tax Credits


Each of those objectives will undermine the resources for the underserved and take us further away from universal coverage and the objectives of the Triple Aim. Each of those objectives do speak to objectives that are espoused by many members of the middle class who feel threatened. They all translate into real benefits for people who already have coverage and think that they pay too much in taxes.


The remaining eight pages plus references are labeled “Policy.” I would label them as old ideas that are certain to translate into the cost of millions of people losing their coverage. Many of us believe that if millions lose their care with whatever replaces the ACA there will be a voter backlash in 2018. I hope that is true. For there to be accountability in 2018 there will need to be a continuing struggle against misinformation and self interest. Misinformation and self interest have been well managed by President Trump to get this far and the Republican Congressional Leadership has figured out that if they go along they have a very good chance to advance things that have been on their agenda since the era of Newt Gingrich’s “Contract With America” over twenty years ago.


Some hope exists, if a few Republican senators crossover and vote against the repeal. That possibility is enhanced if people study the issues now and speak out in ways that are effective. I can think of no better focus for action around which to bring voices together than the Triple Aim. Defending better care for everyone is the only durable way to be sure that you and your family will always have the care you need.  The most practical thing that caregivers and other healthcare professionals can do to defend their patients in these days is to work hard to reduce the total cost of care within the framework of an improved ACA.