In terms of political theatre, Donald Trump’s press conference on Thursday was the event of the week, or maybe the year. Strictly in policy terms, though, it was less important than the media briefing that Paul Ryan, the House Speaker, and other House Republican leaders held, also on Thursday, about their plans to abolish Obamacare and replace it with some version of what we might call Trumpcare, or maybe Trump/Ryancare.
There are still huge questions about what this new system will look like, and when it might be enacted. In a new seventeen-page paper, “Obamacare Repeal and Replace,” the G.O.P. lawmakers outlined proposals that are familiar from a plan that Ryan put out last year. They included expanded health savings accounts, financial aid for the establishment of high-risk pools at the state level, and the replacement of income-based subsidies to purchase individual insurance with universal tax credits.
But the paper also contained some huge gaps. It didn’t say how large the new tax credits would be, or how they and other elements of the reform would be paid for. To pay for its provisions, the 2010 Affordable Care Act levied more than a trillion dollars in tax increases over a decade. The Republican replacement will, in all likelihood, cover millions fewer people than Obamacare, but it will still have to be paid for. Ryan and his colleagues were largely silent on where the tax burden would fall.
For all this deliberate obfuscation, though, House Republicans are now being very clear about one thing: whatever legislation emerges after the Senate and the White House have weighed in, it will almost certainly roll back the Obama Administration’s expansion of Medicaid, the federal health-insurance program for poverty-stricken and low-income households. Under the outline released on Thursday, the current Medicaid system would be replaced by block grants to the states, and the extra federal money that went to Medicaid as part of the A.C.A. would gradually be removed. In effect, the Medicaid expansion would be slowly suffocated.