Paul Ryan once famously said that he had dreamed about overhauling Medicaid since he was “drinking out of a keg.” But with the news that the House speaker will retire at the end of this year, it appears Ryan will leave Congress without achieving his lifelong ambition.

At least not directly. But if you look at the steps the Trump administration is taking to dramatically shrink Medicaid — the nation’s largest insurer, which covers more than 75 million Americans — it’s clear that Ryan’s dreams are alive and well. Through work requirements and other restrictions, President Donald Trump could eventually oversee the most significant rollback of Medicaid benefits in the program’s 50-year history.

And his subordinates are taking their cues directly from Ryan’s playbook.

Paul Ryan has long wanted to overhaul Medicaid — and he nearly did

Back in 2010, when Republicans were entirely out of power, Paul Ryan asserted himself as the conservative lawmaker with big ideas. He laid out his vision for America in his budget blueprints — and a staple of his budgets, even back then, was overhauling Medicaid.

He proposed fundamentally restructuring the program’s financing. The federal government currently has an open-ended commitment to Medicaid, paying a certain percentage of the costs (always more than half), with states picking up the rest. Ryan, citing concerns about the deficit and preaching state flexibility, proposed placing a federal spending cap on Medicaid, giving states a specific dollar amount (either a bulk sum or per person) while also relaxing some of the federal rules about whom and what states must cover.

In his 2012 budget, Ryan proposed adding a work requirement to Medicaid, citing President Bill Clinton’s 1990s welfare reform.

“The best welfare program is one that ends with a job and a stable, independent life for the individual,” Ryan wrote. “Now it is time to implement these same reforms across other areas of the social safety net, especially Medicaid.”

In 2017, with full Republican control of the federal government and Ryan in charge of the House, he got his chance to act on those plans. The Obamacare repeal bill that the House passed last year would have placed a federal spending cap on Medicaid and instituted a mandatory work requirement. He sold the bill as “the most fundamental entitlement reform in a generation.”

The Congressional Budget Office projected that the House’s American Health Care Act would have reduced Medicaid spending by $834 billion over 10 years, compared to current law, and Medicaid enrollment would have shrunk by 14 million people.

Yet from the Republican perspective, Ryan did his part. After a March hiccup, Ryan muscled the Obamacare repeal bill through the House in May. But the crusade died in the Senate, where Medicaid cuts were one of the most contentious issues that helped doom the plan in the upper chamber.

Ryan still held on to hopes of passing entitlement reform, including work requirements, after Obamacare repeal had died. But once again, his counterparts in the Senate let him down, signaling their unwillingness to take up such a divisive issue.

If Democrats can take back the House next year, as many observers now expect, it seems likely it will be years until Republicans can get another chance at overhauling Medicaid. In Congress, Ryan’s dreams might be dead.

But within the Trump administration, they are very much alive.

How Trump is carrying on Ryan’s Medicaid-gutting agenda

When Seema Verma, who oversees the Centers for Medicare and Medicaid Services, announced in January that the Trump administration would greenlight state plans to institute work requirements for Medicaid, she could have been reading directly out of Paul Ryan’s old budgets.

“This policy is about helping people achieve the American dream,” she told reporters. “People moving off of Medicaid is a good outcome because we hope that means they don’t need the program anymore.”

At least five of the most conservative states that nonetheless expanded Medicaid under Obamacare — Kentucky, Indiana, Arkansas, Arizona, and New Hampshire — have asked the Trump administration to let them establish work requirements and set other restrictions for many of their Medicaid recipients. Three of them have already been approved.

Much of Medicaid should be safe, or safer, from the Trump administration’s meddling. About 50 million of the program’s 75 million enrollees are children, elderly, disabled, or pregnant. Those populations are usually exempt from work requirements and these other restrictions, like time limits, and states are required to cover them under federal law.

But that still leaves about 25 million nondisabled, non-elderly adults who could potentially be subject to work requirements and other eligibility conditions, according to the Kaiser Family Foundation’s estimates. That figure is a starting point for understanding how much the Trump administration could pare back the Medicaid rolls.

The most vulnerable populations are likely to be the childless adults covered by Obamacare’s Medicaid expansion, which Ryan had tried to end as part of the House repeal bill.

Work requirements could become a tool by which states can partially roll back Medicaid expansion or implement a neutered version of it. The same could also be said of waiver provisions that would lock people out of Medicaid coverage for failing to pay a premium and that put a time limit on how long people can be eligible for Medicaid. Ryan’s home state, Wisconsin, is one of the states pursuing a Medicaid work requirement and such other restrictions, including drug testing for the program’s enrollees.

These policies are a remarkable reversal, Medicaid experts say, from the way waivers have been used in the past to expand health coverage.

“We’re just talking about ways to cut coverage,” Joan Alker, executive director of Georgetown University’s Center for Children and Families, told me earlier this year. “Under any previous administration, waivers have not been used to devise ways to cut coverage.”

And Trump officials don’t sound like they’re quite giving up the dream of Medicaid spending caps either. Just last month, Verma was still hinting that her agency would be looking for ways to implement that long-held conservative goal.

“Medicaid is supposed to be a joint partnership. But over time, costs kept going up. When that happened, the federal government started to regulate more,” she told reporters a few weeks ago. “If we can get to a place where we say to states: ‘Here’s your money, here are the outcomes we expect you to achieve’ and we have some parameters and guideposts around protections for beneficiaries, and if we can give states more flexibility, that’s what I’d like to get to.”

Paul Ryan couldn’t have said it better.