Conservative policy wonks got a small taste of just how hard the task would be earlier this year, when several groups of lawmakers—including Ryan—tried to figure out what they’d do if the Supreme Court axed the health care law’s premium subsidies in most of the country.
“I think we have ideas based on this experience, and our ideas we’ll continue to work on and flesh out so that we’ll be ready with a new president to do this,” a GOP health care aide, who was involved with crafting King v. Burwell response plans, told National Journal.
They ultimately didn’t need such a plan, but the process was a stark reminder that fiddling with one piece of Obamacare, especially something as critical as its subsidies, has broader ripple effects throughout insurance markets nationwide.
“I think everyone kind of knew there would need to be time, I think it was just surprising how long it would take if you change just little aspects of it,” the GOP aide said.
Ryan avoided the spotlight while Congress battled over what it could do should the Supreme Court strike down premium subsidies on federal exchanges, letting the Senate introduce solution legislation and limiting his public input to an op-ed he wrote with other House committee chairmen.
Meanwhile, most plans put forward extended Obamacare premium subsidies for some amount of time while taking a partisan jab at the law—for example, repealing the individual mandate.
But out of the public eye, Ryan was also looking for a way to keep millions of people from potentially losing their health insurance should the court side against the law in King v. Burwell. And working on legislation cushioning the impact of a King win taught the GOP that even the standard six-month-or-so lead time contained in some replacement plans would probably not be long enough.
The Affordable Care Act is a complicated law, and most of its pieces are intertwined. Restoring its subsidies while repealing the individual mandate, for example, might have seemed like a political compromise, but it wouldn’t have done much to prevent real-life disruption and premium spikes for millions of consumers.
Weakening its employer mandate is also politically attractive—until you realize that it would probably increase the cost of the premium subsidies. And all of that potential for disruption would be magnified in a comprehensive overhaul.
“There would be huge transition issues that would have to be worked out with any repeal-and-replace plan,” said Larry Levitt, a senior vice president at the Kaiser Family Foundation, after former Gov. Jeb Bush released his health-reform plans last week. He said Bush isn’t alone in his lack of a well-developed transition plan; he hasn’t seen anyone put one forth.
If there isn’t one, “It would make the cancelled-plans controversy from the fall of 2013 look like small potatoes,” he said.