Paul Ryan
Credit: Gage Skidmore/Flickr

Last week Tierney Sneed wondered whether the entire effort to repeal Obamacare was a trojan horse for gutting Medicaid.

The fights over how Republicans’ Obamacare repeal legislation changes or eliminates ACA-related provisions have made the loudest noise as the legislation has moved forward on Capitol Hill. But its biggest provision — both in terms of budgetary impact and long-term effect on the health care system — is its overhaul of Medicaid, a transformation that Republicans have sought long before the Affordable Care Act was passed in 2010.

Given the legislative limits GOP lawmakers face in fully repealing Obamacare and the struggles they’re having landing on a consensus ACA alternative, one could argue that the Obamacare repeal push is actually a trojan horse for the much more sweeping conversion of Medicaid…

Just to emphasize that point, Speaker Ryan told Rich Lowry that this is what he’s been dreaming about since they’d been drinking out of kegs.

Given that whip counts don’t look good for passage of the bill in its current form this Thursday, the Speaker is considering some changes.

House Speaker Paul Ryan said Sunday he’s seeking changes to the Republican health care bill to provide more assistance to people in their 50s and 60s.

“We believe we should have even more assistance — and that’s one of the things we’re looking at — for that person in their 50s and 60s because they experience higher health care costs,” the Wisconsin Republican told Chris Wallace on “Fox News Sunday.”

In other words, Ryan is considering the idea of making Obamacare Lite more like the original version by beefing up the tax credits for people in their 50’s and 60’s. Given the force with which groups like the AARP are fighting against this legislation, that makes political sense. But based on how far they go, it could seriously affect two things that Ryan actually loved about the CBO score: (1) deficit reduction and (2) the fact that by pushing the elderly out of coverage, premiums would be reduced.

CBO won’t have time to score these changes prior to the vote on Thursday. But conservatives from the House Freedom Caucus and the Republican Study Committee aren’t likely to approve because they already view these tax credits as a whole new entitlement program.

To appease those conservatives, Ryan seems willing to embrace a couple of other items, like implementing the changes to Medicaid sooner and allowing states to impose work requirements for able-bodied Medicaid recipients.

It’s important to note that, of the 24 million people CBO projected to lose coverage under the Republican plan, 14 million of them would do so because of changes to Medicaid. One of the reasons for the delay was to avoid having that happen prior to the 2018 midterm elections. On imposing work requirements, that is simply a nod to the conservative myth that Medicaid provides insurance to able-bodied Americans who use it to avoid getting a job.

Only 13 percent of adults covered by Medicaid’s expansion are able-bodied and not working, in school, or seeking work. Of that small group, three-quarters report they are not working in order to care for family members and the rest report other reasons, like being laid off.

Overall what Ryan seems to be signaling is that passing a bill that fulfills his dream of gutting Medicaid and provides the tax cuts he so desperately wants are the priorities.

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