Ryan ready to alter repeal plan, but in which direction?

Speaker Paul Ryan acknowledged today that his health-care proposal must change to pass the House, and said he is prepared to change it. As the Washington Post points out, this seems like a departure from Ryan’s earlier position that his proposal presented lawmakers with a “binary choice” and could not be altered significantly.

According to the Post, Ryan did not say what changes to his plan are under consideration. Nor is it clear how the legislation can be changed in ways that will garner majority support in the House.

The problem, of course, is that Ryan’s proposal faces Republican opposition from the left and from the right. Changes that appease one faction will further alienate the other. If the changes are significant enough to make inroads with one faction, they may well be significant enough to enable the other faction to pick up new defectors.

For example, conservatives are unhappy that alterations to the Medicaid expansion don’t kick in until the end of 2019. They would like to push that date forward to early 2018.

But moderate members are troubled by the Ryan bill’s approach to Medicaid, and certainly don’t want the starting date pushed forward. Rep. Charlie Dent, co-chairman of the centrist Tuesday Group calls this move “a nonstarter” that “would be enormously and hugely problematic for many of our members.”

Might the moderates accept conservative changes on the theory that the bill won’t make it through the Senate? Possibly, but I don’t think Ryan should count on this.

To ensure a good reception from moderate hold-outs, a revised plan presumably would have to be more generous with tax credits and/or Medicaid. It would probably need to produce a different CBO estimate than the one that forecasts 24 million people losing their health insurance by 2026. But conservatives are likely to balk at the kind of changes that would cause the CBO to lower that number significantly.

Can Speaker Ryan thread the needle with a plan that commands 218 Republican votes? I don’t know. I do know it will be quite difficult.

It would be great if Ryan would pull his plan and make a fresh start, but I don’t suppose that’s going to happen.