Poor Paul Ryan. He has basically spent his entire adult life working for one goal, which is to reshape the American welfare state along conservative lines. For awhile, it looked like the goal was closer than ever — Republicans had both houses of Congress and most state houses, all it needed was the White House, and the Democrats were running their most unpopular candidate in a generation. And he, after unexpectedly landing in the House speaker's office, was going to be at the heart of it all.
And then Trump happened. That big, bloated, orange meteor that crashed right into the GOP and threatens to suffocate all non-aquatic life.
Well, Ryan is still sticking to his plan. He's going to spend 2016 putting together an agenda regardless of what the GOP nominee does, so that Ryan's priorities will be on the agenda. And it's good constitutional sense as well: After all, in the Founders' original vision, Congress, not the president, is supposed to drive policy.
And this plan matters even more now that Trump is the nominee. Conservatives who don't like Trump and still support him live with themselves, they've told me, because they believe it's a chance to finally rebalance the country's constitutional makeup — the country is supposed to be run from Congress. All you need is for Trump to sign the bills Congress sends.
I think this theory is completely implausible for many reasons, as Ryan probably believes, too, but it only highlights that the House GOP needs to have a good, robust agenda. Ryan calls it "A Better Way," since everything in Washington must have a marketing-speak name.
My friend Avik Roy of Forbes and formerly of the Manhattan Institute takes a deep dive into the plan, and I agree with his bottom line: "No proposal is perfect (...) but, all in all, we would have a far better health care system with the Ryan plan than we do today."
The plan would change both the health care system and health care entitlements, since you can't reform one without the other.
On entitlements, the plan is by now familiar Republican stuff. It reforms Medicare by allowing younger people to use Medicare money to buy a private plan, and reforms Medicaid by offering a block grant and adding a work requirement.
It's worth noting how things have changed. Very recently, Medicare reform wasn't familiar Republican stuff, and it was far from being the semi-official plank of the Republican Party. It was Paul Ryan's policy entrepreneurship that got us here.
When it comes to employer-based coverage, the plan wouldn't do much beyond expanding health savings accounts and weakening ObamaCare's so-called Cadillac Tax, which is a cap on the employer tax exemption for health insurance. Honestly, this is weak sauce, and doesn't do much to alter the biggest, and one of the most dysfunctional, parts of the U.S. health care system.
And finally, the Ryan plan gets rid of ObamaCare and replaces it with...something! This is new! Specifically, a refundable tax credit to buy health insurance.
This is good policy, but it's also a key point in an important policy debate on the right. Too many Republicans object to making sure the uninsured have access to health care coverage as a matter of principle. I still remember when Bobby Jindal thought it was a smart move to put out an ObamaCare replacement plan that gave the uninsured the middle finger, essentially, and then attacked all the candidates who sought to cover as many people as ObamaCare as socialist sellouts. Glad that's over.
The simple fact of the matter is that any ObamaCare replacement which covers less people is a political loser. But this isn't the only reason why conservatives should support Ryan's approach or the kind of approach supported by the likes of the American Enterprise Institute's James Capretta, who has long promoted a tax credit as a way to get universal coverage with conservative principles.
The point is that given its fantastic wealth, the United States government should make sure everyone has health care coverage for the same reason that it makes sure everyone in the United States knows how to read and count. Not because it's "welfare," but because it's something that expands economic and social opportunity. The U.S. health care system is a bloated, government-dominated monster, which is the main thing that makes it so expensive and inefficient. Reforming it along conservative lines would be an economic and technological boon, it would make tens of millions of people better off, and it would make it cheap enough to provide everyone with the sort of social insurance that would ensure no one is at the mercy of a budget-busting emergency.
Wanting to cover everyone, as long as it is done responsibly and intelligently, is not something that conservatives should be ashamed of. To the contrary.