Professor Paul Ryan's Health-Care Pitch: This Is the Bill

“It really comes down to a binary choice,” the speaker declared on Thursday, rejecting major changes sought by conservatives.

J. Scott Applewhite / AP

When most political leaders confront a moment of crisis, needing to salvage their careers or a prized piece of legislation, they deliver a speech.

Not Paul Ryan.

His healthcare bill faltering, the self-described “policy guy” now serving as speaker of the House turned to the one sales method he’s always excelled at: the PowerPoint presentation. So on Thursday, Ryan took off his jacket, rolled up his sleeves, clipped a microphone onto his tie and explained, slide by slide, why Congress should pass—and the public should support—the American Health Care Act as a replacement for Obamacare.

As he has before, the speaker described the current health law as “collapsing,” its mandates on individuals and businesses as “arrogant and paternalistic,” a system “riddled with regulations driving up the costs for American consumers.” He argued that the proposal before the House would make everything better—preserving the core protections that people like while freeing up choices and competition to drive down costs.

Ryan had a bigger audience that he usually has; excited by the visual shift from the speaker’s staid weekly press conferences, all three major cable news networks carried his presentation. But the group that Ryan really wanted to reach was much smaller: the Republican lawmakers—mostly conservatives—who are balking at the leadership’s bill and who will ultimately determine in the next few weeks whether it advances.

To those members, Ryan’s most important message came at the end, and it boiled down to just a couple of sentences that have nothing to do with health-care policy. “This is the closest we will ever get to repealing and replacing Obamacare,” Ryan said. “It really comes down to a binary choice.”

It’s now or never, and it’s this or nothing.

Over the last 48 hours, the question swirling over the White House and the Capitol was whether President Trump and the Republican leadership would accede to conservative requests to significantly rewrite the bill Ryan and his committee chairmen released on Monday. Everyone seemed to get a different answer. Conservative lawmakers and advocates left separate meetings with Vice President Mike Pence at the Capitol and Trump at the White House believing the administration was open to changes and negotiation. About an hour before Ryan spoke, the Republican Study Committee—the large bloc of conservatives in the House—endorsed two significant amendments that would freeze enrollment in Obamacare’s Medicaid expansion and institute work requirements for the program. Members of the smaller but more confrontational House Freedom Caucus want to axe the proposal’s refundable tax credits, which they call a new entitlement program.

Ryan, however, made clear that these ideas wouldn’t fly. Asked by a reporter whether his argument meant that the bill would have to pass without significant changes, he replied: “Correct.” The speaker explained that Republicans were limited by the Senate’s strict budget reconciliation rules requiring that any changes to current law involve taxes and spending, not policy changes. They need to use reconciliation to pass the bill with a simple majority and skirt a Democratic filibuster. Moreover, the speaker knows, but didn’t say, that if conservatives succeed in pushing the bill much further to the right, the leadership could lose the support of moderates, especially those who hold much greater sway in the Senate.

Ryan preached patience by saying the current bill is just one part of a three-step process. The Trump administration, he explained, will also reform health care using administrative powers granted in the Affordable Care Act. And then ultimately, Republicans will finish the job with legislation that is subject to the Senate filibuster, and thus, crucially, will require Democratic support.

Demonstrating the leadership’s commitment to the current bill, two House committees met through the night—more than 50 hours in total—and advanced the legislation without adopting a single substantive amendment. Trump has put on a full-court press at the White House, inviting leading conservative critics for a meeting Wednesday night, dining with Senator Ted Cruz in the evening, and lunching with more conservative House members on Thursday. Another group is going to the White House for a bowling night next week, and Trump reportedly is considering a visit to Kentucky, home of the Senate’s most vocal opponent of the House bill, Rand Paul.

Even as the president tries to woo conservatives with a personal touch, backers of the House leadership bill are running ads in the districts of Freedom Caucus members, urging them to “stand with President Trump.” Inside a House GOP meeting on Wednesday, the party whip, Representative Steve Scalise, made still a more aggressive push, telling members that to oppose the leadership’s bill would be to support Obamacare and side with Nancy Pelosi, the Democrat who passed it, The Hill reported.

Like Ryan, the White House tried to downplay opposition to the bill, which now includes major industry groups representing doctors, hospitals, insurers, and the 38 million members of the AARP. “Despite what you hear in the press, health care is coming along great. We are talking to many groups and it will end in a beautiful picture!” Trump tweeted. Later in the afternoon, press secretary Sean Spicer offered a Joe Namath-like guarantee: “This will land on the president’s desk,” he told reporters. “He will sign it.”

Shortly after he finished, the Freedom Caucus reiterated its call for the House to first pass a clean repeal of Obamacare along the lines of a bill former President Barack Obama vetoed in 2015. Republican Representative Justin Amash responded even more directly to Ryan. “‘Binary choice’ fallacy is a tool partisans on both sides use to quash policy debate and avoid difficult job of persuading and legislating,” he tweeted.

Ryan’s TedTalk presentation was both a laudably detailed, substantive argument in favor of his bill, and given the moment, an act of desperation. The facts and figures he deployed obscured the much harder sell he made at the end. And if the speaker was hoping for immediate results, he didn’t appear to get them.