Speaker of the House Paul Ryan has a problem.

His ObamaCare replacement bill, the American Health Care Act, is up for a vote in the House on Thursday and it's an unqualified disaster. In order to give the very richest people in the country a big fat tax cut, the bill would slash the ObamaCare subsidies, especially to old people, who tend to get sick more often and thus use more care than everyone else. In fact, the Congressional Budget Office found that the AHCA would increase premiums for some near-poor 64-year-olds by over 750 percent — from $1,700 to $14,600.

Worse yet, old people vote. So Ryan proposed a patch over the weekend: some kind of additional tax credits for older, low-income people.

As a policy, we can't know what it will do until we see the actual mechanism. But Ryan, in an attempt to mask the incomprehensible brutality of his health-care ideas, is inadvertently revealing why government is involved in health care in the first place.

Health insurance is fundamentally different than most other types of insurance. Bracketing some complexity, home insurance works by charging you premiums that are equal to your expected future claims, plus some profit for the insurer. Of course, given accidents or good luck, it doesn't always work out like that, but averaged over a large insurance pool, the statistics shake out in the end. Each person is paying more or less for themselves.

We could have health insurance like that, but it would mean that access to lifesaving care would be rationed by price. Some people have medical conditions which cost far, far more to treat than they could ever possibly afford. In such a world, if you couldn't afford the premium increase from a diagnosis of diabetes or cancer, you'd simply die.

We as a society have correctly decided such a situation would be monstrous. That belief is what's behind the basic premise of ObamaCare: that the government should ensure that everyone has insurance — and despite the government's many flaws and failure to achieve this goal, a majority of people agree. But what this conviction means in practice is that there must be systematic transfers from the healthy to the sick. That is the foundation of all health insurance systems, from Medicare to private plans, which could not possibly exist without extensive government regulations and subsidies.

But transfers of any kind are anathema to Paul Ryan. One of the few highlights of the early Trump presidency is seeing Ryan unmasked as the vicious Ayn Randroid he is and always has been. He's reasonably fluent in the faux-intelligent, sesquipedalian rhythms of Beltwayese, and can simulate a very earnest and sincere affect. He has parleyed that plus the fervent desire among center-left and centrist journalists for a credible conservative policy mind into one glowing profile after another. No less than Ezra Klein fell for his routine back in 2010.

Today, by contrast, it's beyond obvious that what offends Ryan about ObamaCare is this basic transfer function. He harped on it extensively during his slideshow presentation of the AHCA. (Randian ethics has a word for people who can't afford their heart medication: "moochers.") So when the CBO found that the AHCA would increase the uninsured population by 14 million in a single year and 24 million over a decade, here's how Ryan responded:

In reality, not only does the CBO predict an increase in premiums over the short term, it foresees a slight decrease over the long term only because the AHCA locks most elderly people out of the insurance market altogether. Who you gonna believe, me or your lying eyes? And as Brian Beutler explains, that's not the half of Ryan's deception on this bill.

But given Americans' belief that poor people shouldn't die, the only way to sell a bill as poisonous as the AHCA is simply to put on your best wonk game face and talk out of both sides of your mouth at the same time.

It's just when the brutality becomes too much to deny, Ryan has to write up some tiny patch so he can pretend he's not doing all he can to take coverage from millions, without question killing many of them, so that the obscenely rich can have even more.