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April 12, 2018

The king of entitlement reform will retire from Congress—without major Medicare, Medicaid overhauls

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    House Speaker Paul Ryan (R-Wis.) on Wednesday announced he will not seek re-election in November, raising questions about whether Congress will achieve his long-sought goal to overhaul federal entitlement programs, such as Medicare and Medicaid.

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    Ryan, who plans to finish the current term, has served in Congress for nearly 20 years, during which time he has chaired both the House Budget Committee and the House Ways and Means Committee. He assumed the role of House speaker after former Rep. John Boehner (R-Ohio) unexpectedly retired in 2015.

    Ryan during a press conference expressed a desire to spend more time with his family. "I have accomplished much of what I came here to do, and my kids aren't getting any younger," Ryan said. "What I realized is if I serve for one more term, my kids will only have known me as a weekend dad."

    Ryan's legacy on health care

    Ryan touted as key accomplishments the recently enacted tax reform law, which as of 2020 will eliminate the Affordable Care Act's penalty for being uninsured, and increased military spending included in the fiscal year 2018 omnibus spending bill that President Trump signed into law last month.

    But the Congressional Budget Office (CBO) on Monday projected that the tax reform bill and increased spending will raise the federal deficit to more than $1 trillion by 2020—an outcome that is at odds with Ryan's past comments decrying funding spending levels. According to Modern Healthcare, Ryan dodged a question about the nation's debt level rising during his tenure, and instead touted his record on entitlement reform.

    "Entitlement reform is the one other great thing I spent my career working on. ... I'm extremely proud of the fact that the House passed the biggest entitlement reform bill ever considered in the House of Representatives," Ryan said, referring to the House-passed bill to repeal and replace the Affordable Care Act.

    Yet the future of federal entitlement reform, and of broader health care reform efforts, remains uncertain as the GOP loses its biggest champion of those initiatives, the Wall Street Journal reports. Ryan dating back to 2008 has pushed for proposals that would largely privatize Medicare, limit the amount of federal Medicaid dollars states receive, and ease rules on eligibility and coverage requirements.

    But none of those efforts have made it across the finish line in part because there is strong opposition—even among some Republicans—to proposals that would scale back eligibility for programs like Medicare and Medicaid. Robert Laszewski, president of Health Policy and Strategy Associates, said, "The fundamental problem for Ryan's entitlement reform ideas is that he couldn't get a majority of his own party to touch the Medicare entitlements."

    Ryan came close last year, when the House passed a health reform bill that CBO estimated would have reduced federal Medicaid spending by $834 billion and Medicaid enrollment by about 14 million by 2026. But lawmakers from both sides of the aisle raised concerns about constituents losing coverage, and the bill ultimately failed in the Senate.

    Ryan said, "Do I regret the fact that the Senate did not pass this? Yes, but I feel from all budgets I've passed ... normalizing entitlement reform, pushing the cause of entitlement reform and the House passing entitlement reform—I'm very proud of that fact but of course more work needs to be done."

    What comes next for Ryan and entitlement reform?

    Following Ryan's announcement, President Trump, as well as some lawmakers and industry experts, praised Ryan's work, but some said significant entitlement reforms are unlikely in the near future.

    President Trump in a tweet Wednesday said Ryan "will leave a legacy of achievement that nobody can question."

    House Minority Leader Nancy Pelosi (D-Calif.) in a statement said, "The Speaker has been an avid advocate for his point of view and for the people of his district," adding, "Despite our differences, I commend his steadfast commitment to our country."

    Rep. Mark Meadows (R-N.C.), chair of the conservative House Freedom Caucus, said, "[Ryan's] been the only one who has truly been the torchbearer and the person out there raising the issue on entitlement reform." He added that lawmakers in this congressional sessions are trying to move ahead with "small entitlement reforms."

    Laszewski said of Ryan's work on entitlement reform, "He really doesn't have a peer—much less a successor—in that regard."

    For his part, Ryan suggested he plans to keep "fighting for" entitlement reform, saying, "that's where the work needs to be done."

    Even without help from Congress, Vox notes that some of Ryan's proposed changes to Medicaid coverage rules are likely to continue in the Trump administration. The administration has already approved three state Medicaid waiver requests to implement work requirements, and on Tuesday Trump signed an executive order requiring federal agencies, including HHS, to find more ways to legally tie work requirements to federal safety-net programs.

    But those and other GOP health care reforms are likely to face opposition. Ethan Rome, co-director of Health Care for America Now, said of Ryan's departure, "It does mean no more Paul Ryan budgets." But he added Republicans are likely to keep pushing for more conservative health care changes "and we're going to continue to fight it."

    Looking ahead to midterms

    Some lawmakers and observers also suggested Ryan's retirement could signal that Republicans may face big losses in November's midterm elections. According to Axios, Republicans this year have seen a record number of retirements from committee chairs, and 39 of the 58 House seats being vacated this year are currently held by Republicans.

    But Ryan dismissed those concerns, saying, "If we do our job, as we are, we are going to be fine as a majority."

    If Republicans are able to hold on to the majority, several media sources have speculated that House Majority Leader Kevin McCarthy (Calif.) and House Majority Whip Steve Scalise (La.) could be candidates for House speaker.

    Meadows said he expects those discussions will start soon. "I think everybody will start jockeying for position immediately." He added, "They won't wait for nine months" (Gay Stolberg/Kaplan, New York Times, 4/11; Scott, Vox, 4/11; Bartash, MarketWatch, 4/11; Matthews, Vox, 4/11; Taylor, NBC Connecticut, 4/11; King, Washington Examiner, 4/11; Brufke et al., The Hill, 4/11; Kane et al., "PowerPost," Washington Post, 4/11; Sykes, Axios, 4/11; Luthi, Modern Healthcare, 4/11; Radnofsky/Timiraos, Wall Street Journal, 4/12; Frieden, MedPage Today, 4/11).

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