Paul Ryan Proposes Risk Pools and Medicare Overhaul to Reform Healthcare | AMCP Nexus 2025

Former House Speaker Paul Ryan warned that the nation’s healthcare system is frayed and unsustainable without significant reform. As the keynote speaker at the Academy of Managed Care Pharmacy (AMCP) Nexus today, he painted a picture of a healthcare system under significant financial pressures.

But he also remained optimistic that reform and innovation that is guided by healthcare leaders and evidence can lead to a sustainable system. Ryan, who was in Congress from 1998 to 2019 and was speaker from 2015 to 2019, outlined his vision for a more patient-centered and sustainable healthcare system and advocating for state-based risk pools to cover the sickest Americans.

“Healthcare is the core of our social contract as a country,” Ryan said. “Our social contract is a healthy retirement security for all Americans and a safety net for the poor. Medicaid is a big part of the safety net. The challenge we have as a society is that we designed the social contract in the 20th century in a way that is proving fiscally unsustainable in the 21st century.”

He made his comments at the annual AMCP Nexus, which is being held at the Gaylord National Resort and Convention Center in National Harbor, Maryland, outside of Washington.

Healthcare, Ryan said, has become frayed for several reasons, including Baby Boomers retiring and fewer taxpayers following them into the workforce, which has created financial stress on Medicare. He noted that the worker-to-retiree ratio has shifted dramatically from 16-to-1 when Medicare began to just 2-to-1 today.

Impacting the ability of legislators to address these challenges is a populist movement brought about, in part, by social media. “The online life we live has changed the way we all interact with each other in our lives, and it has really changed the way politicians interact with constituents, and that has brought hyperpopulism to the conduct of government,” he said. “That’s unprecedented.”

With a Congress that is divided by populism, meaningful reform is unlikely, he said. This is why we are seeing reform by executive order, which is unlikely to provide long-term solutions because of legal challenges and the potential for future administrations to reverse those orders. “The best reform is for Congress to reassert its legislative power and write more specific laws that are very clear, and then you have an executive branch that's not reinterpreting or rewriting laws.”

Ryan proposed a comprehensive risk pool system as a solution to affordability challenges. He suggested that roughly 8% of the under-65 population with serious health conditions should be covered through federally financed, state-based risk pools. “If we, as a society, collectively pay for the sickest among us, we can make healthcare more affordable for everyone else,” he explained. This approach, he argued, would preserve access to high-cost therapies, such as gene and cell treatments, without bankrupting the system.

Medicare, Ryan said, will need to transition to a premium support system similar to the Federal Employee Health Benefits Program, with competition among plans and subsidies adjusted for health status and income. He also suggested retirement age adjustments tied to longevity tables, noting that improved health spans will enable people to work longer.

“There isn't enough money to tax; there isn't enough money to borrow to paper over this,” Ryan said.

He is optimistic that technology such as artificial intelligence can help to make the system more affordable. “Competition occurs, and things get better. Costs go down. The ability to build things gets cheaper. AI is going to supercharge that dynamic,” Ryan said.

Since Ryan has left Congress, he has started the American Idea Foundation, which promotes evidence-based policymaking in partnership with the University of Notre Dame. The foundation funds randomized control trials of programs addressing poverty and health disparities, seeking to scale those that deliver measurable results. “If we can agree on what works, we can bridge polarization,” he said. “Data and evidence can get us past partisan fights.”