At the National Review Institute’s Ideas Summit on Friday, House Speaker Paul Ryan had an interesting exchange with National Review editor Rich Lowry about the AHCA’s changes to Medicaid:

Lowry: You have been very clear for years—and we’ve seen compelling PowerPoint presentations—about how the entitlements and entitlements growing out of control is driving the country into a ditch on the debt. And we have a president of the United States who basically seems pledged not to touch entitlements. Where does that leave us?



Ryan: So, the health care entitlements are the big, big, big drivers of our debt. There are three. Obamacare, Medicaid, and Medicare. Two out of three are going through Congress right now. So, Medicaid—sending it back to the states, capping its growth rate. We’ve been dreaming of this since you and I were drinking out of a keg.

[Laughter]

Lowry: I was thinking about something else, he was thinking about reforming Medicaid.

Ryan: I was, I was! I’ve been thinking about this for a long time. We are on the cusp of doing something we’ve long believed in.

When Paul Ryan was doing keg stands with his Delta Tau Delta brothers, Medicaid provided insurance almost exclusively to poor families on welfare, pregnant women, and the low-income elderly and disabled on Supplemental Security Income. Today, in part due to Obamacare’s expansion of the program, Medicaid covers more than 73 million struggling Americans. Ryan’s AHCA gradually ends funding for the Medicaid expansion and allocates Medicaid funding to states based on the number of Medicaid beneficiaries rather than the actual cost of covering them as is currently the case. The Congressional Budget Office estimates that 14 million fewer Americans will be covered by the program by 2026 as a result. That number could balloon if the work requirements and block-granting currently being contemplated on the Hill make it into the final bill.

The prospect of so many being dropped from Medicaid and states footing a much larger share of Medicaid’s bills has spooked more moderate Republicans across the country—the majority of states where the federal government currently spends more than average on state Medicaid programs are deep red and 16 states with GOP governors took up the Medicaid expansion. It remains to be seen if the chance to fulfill Paul Ryan’s lifelong dream of denying the poor government insurance might tug at their heartstrings.