With Paul Ryan’s  launch of his “repeal and replace” bill , which he calls the American Health Care Act (AHCA) and I prefer to call “Ryancare,” he initiated a new phase of the healthcare debate. Finally, we are seeing the focused discussion of the complex issues of care, coverage, and cost that should have been a central part of the debate before the election. Talk show hosts and comedians are demonstrating a grasp for the complexity of the interplay of these issues that one wishes that the moderators of presidential debates might have shown. Organizations like the AARP, the AMA, the American Hospital Association, the American Nurses Association and other related organizations are weighing in now with their concerns about the AHCA and the damage it will do.


Within Congress there is a strange coalition of objectors. Members of the “Freedom Caucus” in the House and very conservative and libertarian senators object to the bill as “Obamacare Lite,” or a Republican expansion of entitlements. Democrats object because it will lead to many millions of recently covered insurance recipients losing coverage as it shifts significant monetary gains to upper income Americans. Despite objections, Ryan seems confident of quickly pushing his bill through the House and Mitch McConnell promises swift action in the senate. Ryan and McConnell had hoped to get the AHCA to President Trump for signing before the CBO could estimate its impact or comment on its funding, but now the CBO has announced that fourteen million people would lose coverage over the first year after passage with another ten million losing care by 2026. The likely outcome will be far less than the president’s expansive description of how wonderful the replacement plan would be after the repeal of the ACA.


I have downloaded the bill and given it a perusal. It is easy for you to do the same thing. It is not a big bill, but reading it is not a very satisfactory exercise. The download is 123 pages (25 lines to most pages with less than 10 words per line) and is probably less than 20,000 words. Its readability is reduced by endless legalese and references to sections of the ACA and other regulations. Curiously, there are several pages that seem written to prevent lottery winners of significant amounts of money from being on Medicaid. I saw no language about benefits or any evidence that improving healthcare was even a remote concern. The prohibitions against using federal funds for abortion were very easy to understand. The primary goal seems to be to reduce the federal responsibilities to states for Medicaid by setting limits on federal funding through block grants and reducing the number of people on the Medicaid rolls while being able to argue to their conservative base that the bill honors states’ rights and individual freedom of choice. Ryan has argued that if people are freed from the yoke of a mandate then many would chose not to be covered as an expression of their personal freedom.


The bill definitely does away with the mandate to buy insurance, but not really, because a patient must pay a 30% of premium surcharge as a backend surrogate mandate when or if they decide to buy insurance after being uninsured. That surcharge could potentially be more than the mandate penalty would have been. In a very informative piece in the New York Times entitled “Follow the Healthcare Money” David Leonhardt writes:

Many Americans over the age of 60 would have to pay more for health insurance under the Republican health care plan. Many low-income families would lose their insurance. Many disabled people, hepatitis patients and opioid addicts, among others, would no longer receive treatments that they do now.

Care to guess where the billions of dollars in savings from these cuts would go instead?

They would go largely to the richest 1 percent of households, those earning at least $700,000 a year, according to the Tax Policy Center. A disproportionate amount of the savings would go to the richest of the rich — those earning in the millions.


I apologize for the continuing cynicism that I attach to any pronouncements of the president or his Republican colleagues in Congress. Perhaps I hear deception, outright dishonesty, and deceit in their every attempt to communicate their plans to make America great. Since the bill is difficult to understand it is published with a FAQ sheet  (frequently asked questions) which you may want to read. If the “web of your beliefs”  or your personally evolved reality and biases has at its core a set of values that makes you a person who highly prizes self reliance, favors a small central government, hopes to see a reduction of entitlements, does not like to pay taxes, and believes that the free market and competition can solve all problems, then you will find the Q and A quite reassuring. If your reality is built on ideals of community, the belief in the ability of responsible government to improve the lives of people, have a desire to see a reduction in the social determinants of disease, and if you have concerns for the underserved and marginalized members of our society, then the Q and A will enrage you.


Below I offer some examples from the FAQ sheet and then give my answer after the “official answer”


What does your legislation do?


Our plan delivers relief from the taxes and mandates that have hurt job creators, increased premiums, and limited options for patients and health care providers.

It returns control of health care from Washington back to the states and restores the free market so Americans can access the quality, affordable health care options that are tailored to their needs.


As I have noted above, the bill definitely reduces taxes and ends the government mandate to consumers and employers. What it also does is to allow the insurance companies to introduce penalties up to 30% to those who attempt to buy insurance after a period when they are not covered. As the Commonwealth Fund has suggested it offers a way to substantially reduce the number of people who have access to Medicaid. By introducing grants to states rather than payment for the individuals on Medicaid, it will reduce the overall federal support individual states receive for Medicaid. The Boston Globe discussed how this will likely play out in Massachusetts.


Across the country you can expect to see as many as 10 million Medicaid recipients lose coverage and the benefits provided reduced for those who are still covered. Many believe that the number will be 20 million. David Blumenthal and Sarah Collins writing for the Commonwealth Fund say that 1 in 10 Americans or 30 million will lose coverage. I think Blumenthal’s and Collins’ projections are closer to what will happen. People who have not gotten subsidies through the ACA may get some money or benefit from expanded health savings accounts or their ability to buy cheaper insurance that covers less. The wealthy, big pharma, and medical device manufacturers will see their taxes go down.


How will this improve my health care?


What we’re proposing will decrease premiums and expand and enhance health care options so Americans can find a plan that’s right for them.

We also make sure Americans can save and spend their healthcare dollars the way they want and need—not the way Washington prescribes.


This answer makes me choke with disbelief. It is a perfect example of a statement that is essentially false but has small elements of fact that are expanded by a person of authority for a political advantage. The majority of Americans had pretty good coverage before the ACA but forget that their costs were going up annually by some multiple of the GDP and overall cost of living. The focus of the ACA for them was to bend the cost curve while offering a better product that could not be denied when they became ill or had a preexisting condition. For the minority of Americans who had no coverage the goal was to give them care through the expansion of Medicaid or allow them to buy insurance through the exchanges with financial support if their income was low. Ryan ignores and denies the progress that the ACA has made toward both goals. With the AHCA some employers and some individuals will have the option of buying coverage that is inferior to the standards established by the ACA. Insurers will be able to charge older Americans up to five times more than younger consumers. Many believe that the costs of care will take off again and the number of uninsured will rise dramatically. It is ironic that the Freedom Caucus is afraid that the government will still spend too much if the AHCA is passed.


Are you repealing patient protections, including for people with pre-existing conditions?


No. Americans should never be denied coverage or charged more because of a pre-existing condition.

We preserve vital patient protections, such as (1) prohibiting health insurers from denying coverage to patients based on pre-existing conditions, and (2) lifting lifetime caps on medical care.

And we allow dependents to continue staying on their parents’ plan until they are 26.

Some of this is true, but Ryan fails to completely reveal what will happen when a person has a “gap” in coverage or how the bill will finance the coverage of preexisting conditions minus the mandate and the taxes that will be repealed.

There are several more good examples of half truths and deceptions as you read through the FAQs. I will leave them to you to read after concluding this post with what I consider to be his most dishonest assertion.

Won’t millions of Americans lose their health insurance because of your plan?

No. We are working to give all Americans peace of mind about their health care. We will have a stable transition toward a system that empowers patients with more choices and lower costs.

During the transition, Americans will continue to have access to their existing health care options.

We even take steps to immediately provide more flexibility and choice for the people who purchase insurance through the individual marketplace. For example, individuals and families will be able to use their existing subsidy to purchase insurance—including the catastrophic coverage that’s currently prohibited—off of the exchanges.


I assume that he is hoping that his answer is true between now and the end of 2019 when the Medicaid expansion ends and the switch to a new funding mechanism is complete. According to numerous economists and healthcare experts, whose opinions he must be aware of, this statement is false. Do not forget that the AMA, the AHA, the ANA, and the AARP along with numerous others have protested that his plan will damage the lives of millions. That leaves me  with the conclusion that he is being dishonest with us or he is naive. I think that he is a focused politician who is willing to distort the truth to achieve an end that is consistent with his personal philosophy. Ironically, the Freedom Caucus and libertarians are more straightforward and truthful than Paul Ryan, Mitch McConnell, their colleagues, and the president. What makes this conclusion very likely is that Ryan, McConnell and the president did not want to wait until the Congressional Budget Office evaluated the economic impact of the legislation and now are denying its core findings.


I shake my head in disbelief when I think back on the debates and speeches during the run up to the election. During three debates between Clinton and Trump there was less than twenty minutes of superficial discussion of healthcare. The press may have failed to push the right questions. I remember all the discussions of walls, emails, Benghazi, marginal observance of social norms, and inferences about body parts, and virtually nothing about what voters might expect if the ACA were repealed without a better replacement.