“The way I see it, if we don’t like the direction the country is going in, and we don’t, then we have an obligation, a duty to offer an alternative.”
It was with these words that House Speaker Paul Ryan introduced A Better Way, the long-awaited Republican replacement for the Affordable Care Act, on June 22. Acknowledging the criticism that he and other House Republicans have faced over the past six years for their lack of alternative healthcare proposals, Ryan went on to assert that A Better Way represented a “real plan, in black and white” in a brief introductory speech during the plan’s grand unveiling at the American Enterprise Institute in Washington, DC. But while the twenty-thousand-word plan offers the most in-depth outline of a Republican healthcare proposal to date, Ryan’s “better way” leaves much to be desired, reading more like a set of conservative ideals than a serious piece of healthcare legislation.
Broken up into five sections or “principles,” A Better Way contains many familiar ideas. From promoting “Health Savings Accounts” (tax-advantaged accounts dedicated to medical expenses), to allowing insurers to sell across state boundaries, to putting states back in charge of regulating healthcare plans sold in their jurisdiction, much of the plan’s substance is made up of proposals that have been circulating in conservative congressional chambers for years.
In fact, the final section of the plan, titled “Protect and Preserve Medicare,” is entirely based upon the “Premium Support” model, an alternative Medicare system that Ryan has proposed, in various forms, since 2011. This model calls for the creation of a Medicare exchange, where the traditional fee-for-service option would be available, but would compete with private plans; for consumers who selected a private option, Medicare would make a “premium support payment . . . directly to the [private] plan or the fee-for service program.” However, A Better Way provides little information on how these “premium support” payments would be determined; while the plan promises that “payment[s] would be adjusted” based on health and income, there are no specifics given on what the flat rate would be and how those adjustments would be made. This lack of detail is especially glaring given Ryan’s history with the “premium support” model: when he first presented it in his 2011 budget proposal, it prompted a report from the Congressional Budget Office that concluded that “Medicare beneficiaries participating in the new premium support program would bear a much larger share of their healthcare costs than they would under the current program.” This conclusion was based largely on how the payments were set up, so A Better Way’s lack of specificity in this area raises serious questions about its potential impact.
This lack of detail extends far beyond the plan’s final section. A Better Way also promises major medical liability reform, but without a single suggestion for it beyond “caps on noneconomic damage awards.” Moreover, as mentioned before, the plan simultaneously claims that states “should be empowered to make the right tradeoffs between consumer protections and individual choice” and that consumers should “no longer be limited to coverage options available only in their state.” This dual promise faces a major constitutional challenge: under Article 1, Section 8, Clause 3 of the Constitution (also known as the Commerce Clause), the federal government is in charge of regulating all commerce “among the several states.” If this clause is interpreted broadly, A Better Way’s proposal to destroy state lines in health insurance would transform the market into interstate commerce, meaning its regulation would be entirely controlled by the federal government rather than by the states themselves. While the Commerce Clause has been interpreted in a variety of ways over the years, and has been read conservatively in the Supreme Court’s most recent rulings, the plan’s failure to address this potential outcome calls its feasibility into question.
However, all of this pales in comparison to the greatest detail missing from A Better Way: the cost. While the proposal claims in its conclusion that “unlike Obamacare, under this plan, total federal spending would decline significantly,” it does not offer a single number to back up that statement. The plan’s failure to provide any cost analysis becomes even more egregious when one considers that, according to a 2015 study by Congressional Budget Office, “including the budgetary effects of macroeconomic feedback, repealing the ACA would increase federal budget deficits by $137 billion over the 2016–2025 period.” In order to fulfill its closing promise, A Better Way would have to save 137 billion dollars annually—a tall order for a plan without a single number.
A Better Way has been praised by many as a shining example of serious conservative legislation; and to a certain extent, that praise is well deserved. In a partisan political climate defined less by issues than by emotion, Ryan and his colleagues have put forth a collection of serious ideas about how to reform American healthcare. However, Ryan cannot call this proposal a “real plan.” A Better Way lacks detail and specificity, and healthcare is an area where detail and specificity make all the difference. While it represents a major step towards healthcare reform, Ryan’s “better way” still leaves much to be desired.
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