American Idea Foundation

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Paul Ryan on the Future of Health Care & how Congress can make quality care more affordable

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By: AIF Staff

Janesville, WI: Last week, American Idea Foundation President Paul Ryan discussed the future of health care on Health 2049, a podcast hosted by Bisi Williams and Jason Helgerson. The podcast features thought leaders sharing their recommendations, perspectives, and views on what health care might look like in the year 2049.

 In a wide-ranging conversation, Ryan discussed his experiences trying to advance health care reforms during two decades in Congress. He also detailed his preferences for reforming the social safety net and for moving to a more patient-centered health care system that promotes universal access to quality, affordable care and focuses on innovation, competition, and choice.

Paul Ryan, Former Speaker of the House and Founder of the American Idea Foundation

To listen to Speaker Ryan’s entire interview on Health 2049, click here. Excerpts of Ryan’s responses, edited lightly for clarity, follows.

Breaking the policy gridlock by putting ‘ideological sabers aside’:

“We spend two times what anybody else spends per person on health care in the world, but we don’t have a system twice as good as anybody else. It’s nothing close, so I think we can get to that. I think we spend enough money. I think it’s the way we spend our money that needs to be changed and I think we need to have a system that accommodates and encourages competition and choice.

“This also means we have to put the ideological sabers aside. From my side, let’s accept universality. Let’s accept that the government is going to be involved. On the left, let’s accept the private sector is going to be involved as well. This cannot be a government granted right where the government decides, controls and rationalizes healthcare.

“I think both sides of ideological extremes need to be pushed to the side. And I think there’s a center, I’d like to say center-right, but a center-based system that can be had.”

Developing an initial interest in health care policy:  

“I was primarily a fiscal policy guy concerned about debt, deficits, and the dollar as the world’s reserve currency. When you dig into those issues, it basically takes you to the entitlement programs and when you dig into that, it takes you to health care. So, I walked into the health care issue a little later, about two terms into my tenure in Congress because it became very clear to me that this was the biggest fiscal challenge of our country. And I was representing Southern Wisconsin where this was a big concern, a big issue for my constituents, so it became really clear to me that I needed to learn more about health care.

“I spent a number of years just trying to learn about health care from providers, from consumers, from economists, and then I spent a lot of time with the Committees, with the Joint Committee on Taxation, with the Congressional Budget Office, the think tanks, and in the Budget Committee. I was Chairman of Budget and Chairman of Ways and Means, which are the primary health care committees, so I spent a great deal of my time on this issue….

“I produced a number of different bills: Some passed, many didn’t. I had, with Senator Tom Coburn, the conservative alternative to the Affordable Care Act in 2010 and then I built budgets around health care proposals. I’m currently working on something right now with Jim Capretta at the American Enterprise Institute, to be released later in 2022, so I still spend time on the issue.”

What health care might look like in 2049:

“I hope that we have a fully-funded system that does not have trillions of unfunded liabilities and that is not saddling the next generation with insurmountable debt. I hope this system is characterized as one where everyone has healthcare coverage and you have a system where the health inflation rate is nothing like what it is now and it’s closer to the actual nominal inflation rate, which, frankly, is kind of high right now.

“it’s a system known for and driven by innovation, choice and competition, where markets work. It’s a system where markets are designed in such a way to protect those with pre-existing conditions, and that the preferences and fiscal policy are aimed towards helping the sick and the poor, but that everyone has access to a system where they are guaranteed coverage. It is also a system where those with tough health conditions don’t go bankrupt if they get sick. I believe that this is absolutely achievable.”

Two paths for the future of American health care:  

“I think we currently have a system right now that is a fiscal train wreck and we are piling on top of the system unfunded liabilities, which will make for a very, very difficult moment fiscally, right around 2049 actually.

“I look at 2049 and I see either a fiscal train wreck where we lose the dollar’s status as a reserve currency and we have to do immediate budget surgery to the budget where we have to cut benefits back in real time for real beneficiaries, and people who are dependent on these programs and who organize their lives around these promises that have been made by government.

“Or, and this is the glass half-full side of things, things that I think and hope will happen, which is we have a system that doesn’t have a fiscal train wreck, that doesn’t bankrupt the country or our entitlement programs, that is market-based, and that takes taxpayer dollars and puts them where they ought to be, which is toward the sick and the poor.

“As I mentioned, I hope we have a system where you have legitimate health insurance competition and innovation. A system where the American system of innovation is alive and well and we come up with new drugs and new therapies to make our lives healthier, happier, longer. I believe that that’s eminently achievable.

Advancing Patient-Centered reforms to improve health care:

“I have a few white whales in my career that I wanted to slay, that I could never get, one of which is the tax preference for health insurance. The tax exclusion is upside down. We give the biggest tax benefit to the highest income earner and the lowest tax benefit to the lowest income earner. By excluding health care benefits from your job from taxation, the higher the tax rate you have, the bigger the subsidy you get. That is completely wrong. It is the biggest tax expenditure in the tax code. I tried to cap it when I was Speaker and I couldn’t even get the votes for that among Republicans. And the Democrats tried it with the Cadillac Tax, which is very controversial on their side as well and keeps getting pushed around, but so I think Obama was going at it the wrong way with the right idea with the Cadillac Tax. 

“What I wanted to do is repeal that tax exclusion. I wanted to convert it to a fixed, refundable tax credit so that more of the money goes to low-income individuals and families, less to upper-income individuals. We should throw a deduction on top for those people and allow people to take that refundable tax credit to buy health insurance….

“And when you roll into retirement, I’m a big believer in a premium-support model for Medicare. They should be set on a bid-based pricing system so that market bids are what set the rates. Even the Congressional Budget Office, under Doug Elmendorf, built a model that showed it’s the smartest way to reform Medicare. I think this would put Medicare on a much better footing. It reduces the unfunded liability and if we go to a premium-support model with Medicare — with more for the poor, more for the sick, less for the healthy and the wealthy within the Medicare system, where you have a number of plans to choose from, to a premium support model, much like the federal employee health benefit plan, I think you can mitigate or avoid a debt crisis.

“The fee-for-service system, which is more than half debt-financed, is tumbling toward a debt crisis in about the year 2049 and, frankly, if you would convert our system to a premium support system, with the kind of system for the under 65 population that brings in choice and innovation, it would hopefully have a mitigating effect on inflation. Then, I think you’ll have a system for under 65 and for over 65 that works quite well.”

Preserving the Social Contract in a bipartisan way:

“It’s going to be ugly for a while, politically speaking, but I think the math is going to get us. I think the realization that these programs are running into fiscal reality, which jeopardizes their own viability, will spur action.

“The social contract is an important concept. It’s very important…. I see the social contract as extremely important — a viable safety net for the poor, health and retirement security for those who are in old age, and then all the other things we talked about in between.

“For that to be sustained in this century and on, it will have to change. These were designed in the 20th century with 20th century economics, and 20th century debt demographics, all of that is changing for the reasons we just discussed and I think Congress will get there because they will have no choice but to get there. And the bond markets will make them do it.

“I think the only real viable way in the mid-term, not this year, this session, or even probably the next session of Congress, is a commission. I hate it. Like I said, I was on Bowles-Simpson, I served on some of these commissions, but I’m not a big fan of them because I think it’s Congress ducking its responsibility, but Congress is just too broken to take all of this on on their own.

“My buddy, Senator Mitt Romney has a bill with a commission where I think he has an equal number of Democrats and an equal number of Republicans to take on these entitlements and to have a forced up or down vote, like the base closing commission…. I believe the rightly-formed commission in the right Congress with the right President can put before Congress a solution to this problem that can buy us decades and really chip away at this problem and pass Congress in the medium term. I think that’s probably the best and easiest most viable path forward to solve this problem.”

On “Hardly Working” podcast, Ryan discusses why evidence-based policymaking is essential to fight poverty effectively

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By: AIF Staff

Washington, DC – Earlier this week, American Idea Foundation President Paul Ryan was a featured guest on theHardly Working podcast. The podcast, hosted by Brent Orrell and produced by the American Enterprise Institute (where Ryan is a visiting fellow), focuses on the future of workforce development and on how policymakers can help individuals meet the diverse needs of the 21st century economy.

During the podcast interview, Speaker Ryan and Orrell discussed using evidence-based solutions to break through partisan gridlock, the amazing accomplishments of the Nurse-Family Partnership program, and other ways to successfully fight poverty.

Listen to the entire interview here or by clicking the icon below. Highlights of the conversation, edited slightly for clarity, follow.

The genesis & aims of the American Idea Foundation:

“After I retired as Speaker of the House, I wanted to focus on some of the things I really cared about which are poverty and strategies to improve our fight against poverty. I wanted to help go after poverty’s root causes and help break the cycle of poverty. There are different kinds of poverty, but I wanted to focus on intergenerational poverty and it’s just a perfect segue to what we are talking about which is the last law I wrote in Congress. It’s this thing called the Evidence Act.

“It’s a bill that I did with Senator Patty Murray. We founded this [Evidence-Based Policymaking] Commission and we got the idea from Jim Sullivan at Notre Dame, economists at their Laboratory for Economic Opportunities, and Raj Chetty, an economist at Harvard…. We put Ron Haskins from the Brookings Institution in charge of it because I wanted to make sure this was not seen as some Republican thing, but rather just a good thing. The Commission gave us its results, we took them and put them in a bill and got it through Congress….

“Now, academic researchers can look at the data and see what works and what doesn’t and then get the government to actually measure the results of programs, the effectiveness of programs, and whether something works or not.  [It helps] get the muscle memory built in the minds not just of the bureaucracy, but of policymakers and of philanthropy to focus on evidence-based policymaking, so that we can bypass the ideological loggerheads….

“So, my foundation is basically focused on what I would call center-right ideas for fighting poverty and restoring civil society and reproducing upper mobility that we aspire to as Americans. It’s called the American Idea Foundation and I’d say the “American Idea,” or at least what we think of, is that the condition of your birth should not determine the outcome of your life.

“America is the only country founded on natural rights. It’s a beautiful thing. We are the only country that’s founded on an idea and it’s the job of Americans to pass this on to every generation.

“My foundation is trying to do that by making sure that we’re [using] evidence as a policy-making barometer and as a tool in government and out of government. Then [we’re trying to support] those things that connect the private sector, the public sector, and the philanthropic sector to get capital into poor communities, to get the private sector into poor communities.”

An evidence-based success story: The Nurse-Family Partnership program

“I’ve been to the Nurse-Family Partnership programs in Kenosha and Racine and I was just down in rural South Carolina last month touring [their program]…. The Nurse-Family Partnership is where a nurse partners with an expectant mom and they become very close. They become friends and the nurse effectively acts like a mother or a mentor – that’s probably a better word, a mentor to the expectant mother to help her figure out what you have to do to have a healthy pregnancy. The nurse says these are the vitamins, this the diet, these are the things you don’t do, these are the things you do, and here’s how you get prepared. No one else would tell [these mothers] this and then after they’ve had the baby, they help them for [two] years… with all those other things in infancy and it has huge impacts on a child’s development.

“The program has been subjected to randomized controlled trials (RCTs) and we’ve been running evidence and analytics on this program for years. I first got involved with it in the George W. Bush Administration which grew the program. President Obama was enamored with it and they expanded it and then President Trump saw it and he reauthorized it. So, it grew under Bush, Obama, and Trump, three very different Presidents.

“It’s a program that just has really good evidence that proved [its concept]. It’s teaching women who are having babies…. how to be good moms and how to raise those kids and how to do so at a really critical stage of development from pre-birth to three years old.

“It’s extremely successful. Those nurses and those moms become extremely close, and they help these moms really ratchet themselves up the ladder of life, up the escalator of upward mobility, and get them on a really good path, putting their life together so the mother is better off. And if she’s going to be better off, we all know and it’s really clear that her child is going to be better off.

“This is an example of a government program and of civil society working to actually alter people’s trajectory and change society for the better…. For moms who’ve never had a baby and who didn’t know how to raise a baby, there is a good program that actually works. And if we prove that it works, then let’s fund it and let’s take the money from the programs that have been proven not to work and use that so we don’t actually net increase spending.”

Focusing on outcomes, not dollars spent, to better fight poverty:

“For lack of a better phrase, the War on Poverty got gripped by an ideology and because of that ideology, we started to measure success by throwing money at problems. We measured success by inputs like money or creating new programs.

“In many ways, they created this notion of “just let the government do it” if we’re trying to fight poverty and trying to get people out of poverty. [It was a notion of] don’t worry, pay your taxes, the government has got this figured out. [The government] will create programs to deal with this, as if that is a perfectly decent substitute for communities, for mediating institutions, for people helping fix problems person to person or community to community. They decided big is better. [They decided] the federal government is more efficient and they can just design programs and therefore materialistically [the government] can solve this problem.

“It blew up in our faces. It created a lot of dependency and it backfired. Materially taking people out of poverty, from a technical perspective by throwing money at the problem – sure, you can do that — but have we really created a society enriched with upward mobility, with people living the best versions of their lives and becoming the best versions of themselves? Did these policies do that? No.

“I think what is missing is the sense of community, the sense of solidarity, the mediating institutions that civil society provides. We displaced people participating in helping the lives of one another…. You can’t just substitute [government] for the private sector and for economic growth, wage growth, competition for labor, innovation, opportunity, social capital and all that comes with it.

“I think we went down this path in the War on Poverty of just getting rid of the secret sauce that makes all this stuff work and substituting all of it for more programs, more money, more dependency and [we’ve seen] predictable results.”

Strengthening civil society in an era of digitization and polarization:

“We are in real trouble right now because of digitization. I think we are living more artificial lives on our electronic devices and it is actually bringing atrophy to these mediating institutions — our churches, our civic organizations, the place and space where we live our lives, the space between our government and ourselves.

“And there’s also capital. Obviously, you have to have investment. You have to have organizations that promote civil society and all these things that help people realize their humanity and that work with one another to do that….

“The best thing I can come up with is we have to revitalize those institutions and revitalize civil society. We have to revitalize those non-government organizations and, since we’re becoming less religious as well, it is these non-government organizations that connect us and give us a sense of value and pride in helping other people. They give us this common good sense of community. If you’re raising kids — and I’ve got two that still have to get through high school, you’re really involved in this stuff but once you’re done with that, everybody leaves and that’s what’s sort of happening in society today.

“I wish I could say there’s a government program or a bill with the capacity to fix this but there really isn’t a way other than to have a good, healthy, growing economy so people have discretionary income, so they have more hours at home, working on these parts of their community.”

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Ryan talks with Franciscan University students about the intersection of faith, community, & public service

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By: AIF Staff

Janesville, WI – This Fall, former Speaker of the House and current President of the American Idea Foundation Paul Ryan spoke with students and leaders of Franciscan University of Steubenville about how faith has influenced his life and his approach to public service.

In a virtual discussion led by Fr. Dave Pivonka (TOR), the President of Franciscan University of Steubenville, Speaker Ryan shared his thoughts on how religious principles can shape policymakers’ outlooks, how tax and spending policies will impact the poor, and how religious values like subsidiarity and solidarity continue to drive his efforts today. Further, Ryan touched on the ongoing work of the American Idea Foundation to link community leaders with legislators and identify evidence-based policies and programs capable of lifting Americans out of poverty.

Excerpts of Speaker Ryan’s conversation with Franciscan University of Steubenville’s President, Father Dave Pivonka (TOR) follow. Video of the virtual discussion is accessible here.

On the intersection between public life and Catholic social teaching

“We have a Compendium (of the Social Doctrine of the Church) that’s pretty handy. If you look at my Compendium, it has got lots of dog ears in it. The quick of it is…. you have prudential judgment and you exercise that prudential judgment within your principles but you’ve got to know where those parameters lay…

“The debate over the Child Tax Credit right now is a perfect example of this debate. The current majority in the House, the Democrats, are trying to move this reconciliation bill. It’s a bill that I really have a big problem with.

“We won’t get into all of it, but they want to massively expand the Child Tax Credit. This, in and of itself, sounds great. It sounds wonderful because we want to help and as a Catholic, you think: “Yes, I want more assistance to families having children because we want more of that.” Yet they’re designing this in such a way that is contrary to all of the evidence – and we have compiled a lot of evidence through Catholic Charities…

“We know that a work requirement with aid and having a person help support an individual and family through a case management system is the best way to help a person get out of poverty. What this new reconciliation proposal says is we are going to sever the ties between families and work and between families and case managers, a person who is helping them navigate through poverty, and just send them a check in the mail from the IRS.

“[Under the reconciliation bill,] we are now estranging our families from the existing assistance of our safety net, which involves a human being helping individuals get out of poverty and includes incentives that have proven to work extremely well. Work is a way out of poverty… and this is especially true for parents who want to set examples for their kids and put themselves on a pathway out of poverty. This new reconciliation proposal is basically saying that the IRS will put money on your debit card or send you a check in the mail. It is cash assistance untethered to anything else.”

Addressing the long-term debt will avert a debt crisis & help the poor

“The last president made it really clear to me that he did not want to engage in fiscal discipline. He did not want to engage in it at all, at least in his first term…. There was no appetite for it because a lot of the things that you need to do are not necessarily popular, but they’re necessary. It’s not a partisan thing. It’s just a math and economics thing…

“I passed a budget about eight years running to balance the budget to pay off the debt and there are just some necessary ways of doing that. You can’t just cut defense and balance the budget, for example.

“And my point is, overspending means the government is making promises to the public that it can’t keep. When the money runs out — meaning when we lose our reserve currency status and our interest rates go up, which would happen eventually because of our profligate spending, then the social safety net itself collapses and goes bankrupt. The social chaos that would occur when the social contract of health and retirement security and safety net for the poor becomes uncomfortable, that would be a real crisis.

“And so, the prudential thing to do is know that [a debt crisis] is coming because it is and know that you cannot keep borrowing like we are, because we can’t. We know that if you put in really important reforms now that we can maintain these programs’ missions, and do them in such a way that can reduce the debt load so that you can keep the promises [of these programs] going in the future.

“It’s a smart thing to do but it involves structural changes to these programs which disrupts the status quo. Those who like the status quo don’t like that, but a stitch in time saves nine. If you put important, programmatic reforms in place now that do not affect those in or near retirement, I would argue that you would make the safety net even better, but it would work differently, and you can avoid a debt crisis.”

Ongoing efforts to protect religious liberty:

“I fought when I was Speaker with then-President Obama on this. I talked to him about this for hours and unfortunately, we never got a good resolution but it got to the point where I invited the Little Sisters of the Poor to the State of the Union address to sit in my box and use them as my best lobbyists to try to advocate for a change.

“We got the regulatory change by the time we got onto this issue with President Trump. We had religious liberty protections. Secretary Alex Azar at HHS was extremely helpful in this as well. The problem with doing this on a regulatory basis through Executive Orders is the order only lasts as long as the President lasts. That’s the problem.

“In the House, we passed legislation to protect religious liberty when I was there but you need 60 votes in the Senate. This is something that can be filibustered and it always will be. We’ve never had the votes to get these protections into law. We had the votes out of the House but we could never get out of the Senate.

“There are two things going forward: Continue to press the Biden Administration to keep these regulations that Trump put in place. I mean, President Biden is a Catholic. I would like to think that I know him well… and I would like to think there’s a more willing audience than say in the Obama administration. So, I think that’s priority one. Priority two, particularly for students in places like Franciscan University, is to educate their lawmakers.

Overcoming ideological impasses with evidence to better assist the poor:

“I think the social safety net has to be redesigned and rebuilt in the 21st century so that it’s sustainable and so it’s working based on outcomes. I think this current reconciliation bill is going to roll back about 30 years of progress.

“What I mean when I say that is this. We’ve learned a lot through data and evidence about what works and what doesn’t work since LBJ declared the War on Poverty. It was extremely well-intended, but it was a 60-year “war” with over $60 trillion spent. We’re spending about a trillion dollars annually on 100 different programs just through the federal government and only 1% of those programs are measured based on evidence and outcomes.

“Currently, success is basically measured on effort and inputs. How much money are we spending, how many programs are we creating, how many people are in these programs? We should be measuring it based on are we getting people out of poverty? Is it working? What is the outcome? And invariably, when you dig into this issue, you will find evidence is a really important component and there are a lot of people in government that want to forget that.

“You find that incentives matter, that work works, that local control and human interaction are really, really important ingredients….

“We have a new law that I wrote called the Evidence Act, which releases all this federal government data so that academic institutions — and Notre Dame does a lot of this and you can do this too through your Economics Department – can study this data and find out what actually works.

“We can leapfrog what I would argue is an ideological stalemate and just go to data and evidence and invariably the principles that we believe in – which is the full spectrum of Catholic social teaching in my judgment – will be validated by this evidence. And so, I’d rather go have a data and evidence debate than continue to face an ideological impasse.

“I think there’s a real future for fixing the safety net and fixing how we service the poor. I think we have breakout moments ahead of us so long as we don’t lapse back into what are some really bad policy decisions…. But going from ideology, where we just have impasses on, to data and evidence, which by the way, we have learned really buttresses our principles, is a good idea. And there’s a moral high ground to be had and to maintain and I think we should go get it.”

Strengthen civil society to combat moral relativism, polarization, and digitization:

“We have a fire burning across the country in terms of moral relativism and its off-shoots, like identity politics, polarization, and the rest. It’s really challenging. The best answer I have is two things:

“Number one, we have got to do everything we can to revitalize civil society, which are those mediating institutions between ourselves and our government. It’s the space where we live our lives, where we can drink and breathe life into institutions, like churches and civic groups, and where we understand right and wrong and moral absolutes.

“Number two, people of faith have got to get out into the community. They have to get out and rebuild these institutions. I am a big supporter of home-schooling, particularly with COVID-19 and all the rest, but what you have are the very people in our communities that we need to be out in the communities, winning arguments, being on school boards, and going to the PTA, they are just walling themselves off and forming pods with their other like-minded people.  It’s totally understandable…. but it’s really important that people of faith engage in the broader community.”

Founded after World War II, Franciscan University of Steubenville’s initial student body consisted mostly of returning veterans. Since then, the Catholic university has since grown to over 3,000 students, many of whom are seeking to deepen their understanding of theology and religion. The discussion featuring Speaker Ryan was part of the American Idea Foundation’s ongoing efforts to introduce the concept of evidence-based policymaking to different audiences.

Since leaving Congress in 2019, Speaker Ryan has prioritized speaking with college students and younger Americans about becoming active members of civil society, giving back in ways that improve their communities, and engaging in political debates with evidence and facts, rather than partisan sound bites.

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