(By Carolyn Long Engelhard, director of UVA’s Health Policy Program) These are difficult times for Paul Ryan, speaker of the U.S. House of Representatives, what with the ideological chaos that presumptive presidential nominee Donald Trump is bringing to the Republican Party, and the need to continue to rally the voters around repealing ObamaCare as a 2016 election referendum. Nevertheless, one Affordable Care Act replacement idea floated by the speaker is bad news: triaging people with serious and expensive medical conditions into state-based high-risk pools.