Photo by C-Span
It's fair to say that House speaker Paul Ryan's announcement yesterday that he would not seek re-election and would be retiring from politics for the foreseeable future was a surprise. It is rare for a politician to willingly relinquish such a role, especially when the move further jeopardizes the vitality of his party going into the midterm elections this fall.
As House Speaker, Ryan's exit means Republicans are losing one of the primary public faces of their party and one of its most vocal on the issue of healthcare, especially Medicaid reform.
"While there are a number of people who share his ideas, he was the most public leader. So it's not clear exactly who is going to take a high profile position on entitlement reform in the near future," said Christopher Kerns, executive director of research at Advisory Board.
It also calls into question to what degree that mission will be pursued as a whole. The drive for Medicaid reform saw perhaps its greatest push last year as Ryan spearheaded the campaign to get his American Health Care Act through Congress, a piece of legislation that the Congressional Budget Office said would swell the ranks of the uninsured to 19 percent from 10 percent over a decade, and would bring that number to 14 million in the first year. AHCA ultimately died in the Senate.
Kerns said given that experience last year, it's hard to tell how much appetite there will be to continue next year while, on the other hand, there could be a reinvigoration of efforts to reform Medicare and Medicaid depending on who takes the House next fall.
Most of Ryan's and the Republicans' recent successes with healthcare legislation were focused on incremental changes post ACA, the biggest being the repeal of the individual mandate, which in most surveys, Kerns said, was the most unpopular aspect of the law.
"It's gone now," he added. "So the question is will the parties decide to further their agendas or will they decide to stand back and just make changes at the margins?"
Ryan has never kept his long-standing desire to reform Medicare and Medicaid a secret. His widely reported comment to the National Review that he'd been dreaming of such reforms since 'you and I were drinking at a keg' was a vivid illustration. And while his Medicare reform strategy, as expressed in his A Better Way plan, were always going to be long-term, Medicaid reforms were designed to be a central part of the ACA repeal effort because a lot of the ACA hinged on Medicaid expansion, Kerns said. That failed effort illustrated how tenuous the healthcare debate has been for both parties.
"The truth is over the last decade, both parties have been burned badly by healthcare so it would be understandable if both sides wanted to declare victory for a while and make incremental changes," Kerns said.
Recently, though, aspects of Paul Ryan's healthcare agenda have gained traction. In addition to the repeal of the individual mandate, the advent of Medicaid work requirements, which at least three states have already moved to adopt, is notable. If they go through, that could be counted as another victory for Ryan's legacy.
Kerns did point out that those requirements will have a multifaceted effect. It could decrease the number of people on Medicaid, which could be a good or bad thing depending on the circumstances of the beneficiaries in question. The requirements could also hurt hospitals.
"From a healthcare perspective, for hospitals work requirements can be another hurdle for patients to get access to Medicaid and that presents collections challenges for hospitals in any environment," Kerns added. "It just makes it more difficult for hospitals to collect their reimbursements when it is harder for patients to access that insurance program."
Another pillar of Ryan's A Better Way plan that could see progress is around transparency of cost and quality. While the momentum may have started with the Obama administration, Kerns pointed out it is also a big priority of the current administration to give consumers better tools to evaluate the cost and quality of care they deliver.
"We are likely to see continued push around that," Kerns said. "The administration has been pushing for it, possibly new legislation and continued regulatory actions to make that happen."