Conservatives in Congress are not buying Paul Ryan's proposed ObamaCare revisions mainly because Ryan seems have accepted, as Trump implicitly did when he promised nearly universal coverage, the idea that health care services should be provided federally. In effect, Ryan's plan is unacceptable because it accepts the unacceptable: the replacement of individual responsibility for health care by collective responsibility and so drags the nationally socialized health care camel's nose further into the tent.

Last year, the same Paul Ryan said this about a full repeal bill vetoed by Obama:

Speaker Paul Ryan (R-Wis.) on Friday pledged that Congress would vote to override Obama's veto. The party lacks the two-thirds majority necessary to achieve that, however.

"It's no surprise that someone named Obama vetoed a bill repealing Obamacare. But we will hold a vote to override this veto, taking this process all the way to the end under the Constitution," Ryan said in a statement.

Ryan said the vote showed there is a "clear path" for Republicans to repeal the law.

"The idea that Obamacare is the law of the land for good is a myth. This law will collapse under its own weight, or it will be repealed," he said. "We have now shown that there is a clear path to repealing Obamacare without 60 votes in the Senate. So, next year, if we're sending this bill to a Republican president, it will get signed into law."

It's now "next year" so why not send Trump the same bill? Remember the "Romney killed my wife" ad from 2012? That's why: the story turned out to be a lie (the wife had health insurance, died in 2006, and Romney hadn't been involved with the company since before the layoffs) but the ad was devastatingly effective in hardening opposition to Romney among committed Democrats, including the media and the social circles the GOPe reacts to. It's rocks and hard places for Republicans elected on a promise to repeal Obamacare: they now control the House, the Senate, and the presidency but are desperately afraid to act because the media's emotional message will be uniformly negative and delivered by helpless minorities, weeping widows, and brave but uncomprehending children whose lives have been ruined by those terrible Republicans and the Nazi in the White House.

So what to do? how do we beat the unbeatable? Here's a four-step program that will work:

1) Send a full repeal bill -- 100% status quo ante as of some date like January 1st, 2018 - to the Senate and force the Democrats to block it.

At the same time, quietly pass the 2016 partial repeal (much of which is replicated in Ryan's current proposal) to the president for signature.

2) Have every GOP representative and senator use weeping widows and uncomprehending children to repeatedly expose VA abuses and failures (waiting lists, inadequate treatment, excessive paperwork, improper use of resources) in his or her district or state. The VA is much better than nationalized medicine in England or Canada, but is well on its way to developing many of the same problems -- and a concerted media campaign to show people what's going on will force Democrats in every district and every state to defend the indefensible while weakening their ability to deploy the same tactics against Republicans.

At the same time, develop and pass a VA privatization bill clearly distinguishing services for active duty personnel serving outside the United States (which would remain under DOD control) from services for personnel, dependents, and others in the United States -- with the latter served through ordinary employer group coverage. Ensure that members have cash incentives to minimize utilization and the power to direct DOD healthcare dollars to the providers of their choice.

3) Develop and pass a new health care act including hot button issues like tort reform, interstate access, and tax equalization through deductibility from income (but not through grants or credits) for private and employer plans, but largely focussed on the creation of a federally funded reinsurance program.

Under this program, the secretary of Health and Human Services would choose, every three years, at least two reinsurance carriers each represented in at least 40 states, to administer programs, open to all healthcare insurance providers operating in the country, designed to limit carrier exposure to catastrophic risks affecting their customers. Buy down limits, thresholds, and the carrier share of the cost, would be set in the initial legislation and amended (or automatically continued if not amended) by Congress prior to carrier selection every third year.

The point of this is that it uses limited federal funding to move health catastrophe insurance significantly down market and thus opens new markets to the industry without creating an entirely new set of perverse incentives driving costs up and performance down, without creating a new federal administrative bureaucracy, and without creating a highly visible public entitlement.

Note that this approach meets President Trump's commitment to making coverage available to almost everyone while supporting the conservative view that people should take responsibility for meeting their own needs.

4) Have Tom Price work with all fifty governors to develop a general framework for the administration and development of both Medicaid and Medicare in light of the other changes taking place in the federal role in health care funding. Divide this effort into two: in one of which every governor regardless of party (and every state representative or senator the governor involves) gets significant local air-time; and one in which state level experts get the work done.

Basically, it's obvious that Medicaid and Medicare have to evolve into a single program with Democrats trying to push toward nationalized healthcare, Republicans generally sitting with their thumbs in uncomfortable places, states rights advocates foaming, and no one either ready or willing to bell the cat -- so lets take a couple of years, hang it all out in public as elections 2018 fodder, and let the combination of VA privatization and partially federally funded reinsurance for carriers selling cheap catastrophic health insurance show people what the right answer might really be.