Paul Ryan was forced to respond to a Republican voter who would've died without Obamacare

If you take away a person’s health care without offering an adequate replacement, or exclude them from affordable coverage because they are already sick, or create a situation in which their local hospital closes due to a lack of funding, they can die.

These are the stakes of the process that Senate Republicans set into motion when they voted to begin repealing the Affordable Care Act without a plan in place to match its current levels of coverage.

A brief but important exchange from House Speaker Paul Ryan’s CNN Town Hall, which aired Thursday night, made this clear in blunt terms:

It might have made for good television that this man, who would have died without the insurance he was able to get under President Obama’s signature healthcare law, campaigned for Ronald Reagan and changed his mind on the insurance exchanges after he personally benefited from them.

But it’s also irrelevant to the basic fact that he would have died. He would have died under the system that made it nearly impossible for sick people to get the insurance that could help them get treatment.

And while the current system has holes big enough to let thousands of low-income people fall through, it has expanded coverage to 20 million people and transformed what’s considered basic care in this country—for women, for people with substance abuse issues, for people with pre-existing conditions.

Ryan seemed taken aback that this man would say his party pushed for repeal without a viable option in place, but he shouldn’t be. Even his fellow Republicans acknowledge there is no plan for once the dog catches the car.

Rep. Tom MacArthur, a Republican from New Jersey, said this week that he opposed the budget resolution passed by the Senate because there is no replacement being discussed in concrete terms.

“We’re loading a gun here,” MacArthur said, as reported by the Associated Press. “I want to know where it’s pointed before we start the process.”

But it wouldn’t be accurate to say there are no Republican alternatives on the table. It’s just that they largely mirror failed approaches to coverage that existed before the new health care law went into effect.

Ryan, as he explained later in the town hall, wants to return to running the kind of high-risk pools that around 35 states had previously used to cluster together sick people, effectively isolating them from the market. That kept costs low for some healthier people, but could mean catastrophe for, say, a cancer patient who needed coverage.

These pools often had waiting lists, premiums that were sometimes 250% the cost of average premiums, and could come with unmeetable deductibles. They were insurance in name, not practice.

Republicans in the House have claimed they could reform high-risk pools to avoid these problems, but it’s difficult to see how, at a moment when Ryan wants to block grant Medicaid and cut overall funding for government programs, states would have the resources necessary to help manage the costs of these high-risk pools without denying people care.

The math just doesn’t work. And people can die when they need insurance but the math doesn’t work in their favor.

That’s what happens when you let the market sort it out and profit incentives dictate how people access health care. And that’s the system Ryan wants.