When Republicans took control of the House of Representatives a year ago *, they promised to “repeal and replace” the Affordable Care Act. They did vote to repeal it. What about replacing it? Yeah that part isn’t really happening. It’s a tricky position for Republicans, because, while the Affordable Care Act is not popular, neither is the old status quo. This places the party in a tricky position. They must act as though they have an alternative, yet this alternative remains perpetually in a hazy indeterminate future state.

At a recent town hall meeting, House Budget Committee chairman Paul Ryan was confronted by a 53-year-old man with end-stage renal failure, who pointedly told him that, under Ryan’s plan, he will die. This is probably true. The Affordable Care Act provides private health insurance for people like him who otherwise could not obtain private insurance. Ryan’s response was to reassure the man that he would be taken care of:

“You have a very unique health care condition. I’m very familiar with it,” Ryan says. “The federal government basically stepped up and said, let’s cover this disease because there’s no way private insurance can cover this. We learned a lot about end-stage renal disease, and that is this: There are some people in society who through no fault of their own — you’re a perfect example — get hit with an unpredictable extremely expensive illness.” Ryan explains that the solution is state-based “high-risk pools,” which would protect the 8 percent of the population that needs such subsidies and lower premiums for the other 92 percent. The audience applauds. And the man suffering from end-stage renal failure sits back down.



That’s from the Weekly Standard’s John McCormack, who uses the heartwarming tale to end his puff piece. (How puffy? In it, McCormack describes himself lobbying Ryan to enter the presidential race.) The man in question is probably already on Medicare, which covers people with end stage renal disease regardless of age. Ryan has promised to grandfather in all current Medicare beneficiaries, but everyone else with a high-risk pre-existing condition would be left extremely vulnerable.

Ryan explains that he supports the creation of high-risk pools, which is a special insurance system for people with expensive medical conditions. I should note that creating a system exclusively for people who are certain to ring up high medical costs is not really “insurance,” in the same sense that if you’re dialing up an insurer when you’re house is going up in flames, you’re really looking to buy a new house, not home insurance. Now, it is true that you could probably get insurers to cover a bunch of really sick people if the government threw enough money at them. But Ryan’s plan does not throw any money at them. Here, peruse the “Path to Prosperity,” the House GOP budget. There’s nothing in it for high-risk pools.

Contrary to the impression he left at the town hall, Ryan knows full well that his budget plan does nothing for the uninsured. Here he is, earlier in the summer, doing the thing where he pretends his imaginary alternative health-care plan is real:

Well, a budget resolution — because of the germaneness of reconciliation — you don’t put all those things in there, but there are a number of things I would do. Insurance reforms — not just inter-state shopping — but high-risk pools that are fully funded that subsidize those with pre-existing conditions. I really believe the tax exclusion is a huge source of health inflation, props up the third-party payment system and subsidizes the wrong people in society. If you’re in the top tax bracket, you get the biggest subsidy; if you’re in the lowest tax bracket, you get the smallest tax subsidy. It’s upside down. So I’ve always believed in refundable tax credits. But you can’t address all those things in a budget resolution. You need more than a budget resolution.



So his explanation is that he didn’t budget any money for high-risk pools because you can’t do that in a budget. This is obviously silly. A budget is precisely where you set aside money that you intend to spend. Ryan left no money to subsidize high-risk pools because he didn’t want to leave enough money for it. Meanwhile, the “Path to Prosperity” was a wide-ranging wish list of conservative desire. It repealed the Dodd–Frank financial reform. Does deregulating Wall Street that have any relevance to the budget? No.

Much as he wants to pretend otherwise, Ryan has a health-care plan. It’s to repeal the Affordable Care Act and let the uninsured fend for themselves.

*This post has been corrected. An earlier version stated that it has been two years since Republicans took control of the House, not one. It has also been updated and the headline changed to note that Medicare covers end-stage renal disease regardless of age.