The American Health Care Act: An Autopsy

Autopsy, a noun: a postmortem examination to discover the cause of death or the extent of disease. After President Trump and Speaker Ryan declared the American Health Care Act dead, it is time to conduct an autopsy on it. The primary cause of death was bad floor management by congressional leaders. Contributing factors were: Speaker Paul Ryan’s preference for policy over legislative details; the process used to draft the AHCA; disengagement at the White House; President Trump’s lack of knowledge of both the subject matter; the Freedom Caucus’s intransigence; and former Speaker Boehner.

Bad Floor Management

A simple political axiom states: Never schedule a vote on legislation before you know you have the votes to pass it. Speaker Ryan and his leadership team violated that simple truth. Ryan and Trump said they were close. They never were. Congressional observers and staff knew the AHCA would fall between 25-30 votes. Trump “ordered” Ryan to hold an AHCA vote, but that was one day after Ryan postponed a vote – which meant Ryan didn’t have a majority of Republicans. Trump, or any President, has zero direct say in what happens at the other end of Pennsylvania Avenue. If you don’t believe that, reread the Constitution, specifically Article I, Section 5: “Each House may determine the Rules of its Proceedings . . .” Ryan, Majority Leader McCarthy, Whip Scalise, and Deputy Whip McHenry control the floor. They decide which legislation is voted on, when, in what order, whether amendments are allowed, and the debate time.

Ryan: A Policy Wonk, Not a Legislative Tactician

In order to understand why Ryan made what Minority Leader Pelosi called a “rookie error,” you first need to know that, while Ryan is a brilliant policy wonk, he is not a legislative tactician. The AHCA is an example of this lack of legislative finesse. Ryan apparently believed he could obtain the 20-some-odd votes needed through a deal with the Freedom Caucus. But, the compromises required to bring them on board would cause GOP moderates would jump off.

Ryan did not want to be Speaker, but took the position because he was the consensus choice. He would be happier in a lengthy discussion with Bill Clinton over methods to improve educational outcomes than in legislative strategy. After the 2012 presidential campaign, Ryan quietly toured anti-poverty programs. He wrote a more than 200-page policy manifesto based on those visits. Before last year’s elections, Ryan created a document called “A Better Way” that laid out his vision of solutions to America’s problems. As the Washington Post, noted, the AHCA “was sketched out” in Ryan’s agenda.

The drafting of the AHCA is an example of Ryan’s lack of legislative tactics. His policy staff largely drafted the bill behind closed doors, incorporating some language from bills introduced in the 114th Congress by Tom Price (then the Budget Committee chairman), and the chairman of the Ways and Means Committee. The Ryan draft was presented to the chairmen of the Energy & Commerce and the Ways and Means committees. That effectively cut Members out of the process. Members like to be involved in the process. When the legislation was shown to Members, they reviewed copies of the bill in an office guarded by armed U.S. Capitol Police. No staff were allowed into the room, and Members were not allowed to take copies with them. Lawmakers were furious at the process. One said Members have easier access to classified information.

Lack of Staff at HHS

While Ryan and his leadership team had a major role in the AHCA debacle, the White House also bears some of the blame. There is not a deputy secretary in place at the Department of Health and Human Services. Two people are in charge of legislative affairs at HHS, but neither has formally been nominated. For those outside the Beltway, the legislative affairs shops at federal agencies are responsible for getting the President’s agenda through Congress. Trump tried to enact a major overhaul of healthcare with Tom Price in charge of HHS and no one to help him. Price served in the House for 12 years. But he cannot run a major agency and guide major legislation through the process. No one could.

The administration’s point man on the AHCA was Reince Priebus. He was chosen because he is from Wisconsin and is a personally and politically close to Speaker Ryan. However, Priebus has never held elective office at any level. He cannot possibly understand bill drafting, process, and legislative coalition building. To use an analogy Trump would understand: It was like hiring someone with no drafting experience to be the architect for your first major skyscraper.

Trump Shares Blame

 Then there is the President himself. Members and lobbyists who spoke with Trump say it was obvious that he did not understand the intricacies of the AHCA and its possible effects on both the marketplace and voters. Trump ran on a mantra of repeal and replace. In order to achieve such a lofty goal, he had to propose legislation. The President allowed Ryan to take AHCA and run, with little input from the White House. Trump only became involved in the process of selling the bill when it already too late. He tried to get lawmakers to support the AHCA through pep talks and rides on Air Force One. That will never work when Member are faced with the choice of an airplane flight with the President or winning re-election. Guess which one politicians will take.

…And the Freedom Caucus 

As the President and numerous commentators have pointed out, the Freedom Caucus also played a role in the death of the AHCA, through its insistence that the bill be amended numerous times to meet their belief in a limited federal government. No one should doubt that tenet, just as no one should doubt the liberals want a more expansive federal government. This argument has been ongoing since before the Constitution was adopted. A major criticism of the Freedom Caucus has been that its members still act as if they are insurgents, rather than incumbents. The caucus has a tendency to oppose legislation, rather than to come up with solutions. A majority of the Freedom Caucus members opposed the AHCA. In an effort to get the votes need for passage, Ryan agreed to some of the caucus’ demands. In so doing, he lost moderates. In the end, the numbers were not there, and the AHCA was pulled. The Freedom Caucus succeeded in its efforts to kill a measure it saw as too expansive. Ironically, the end result was that a huge expansion of the federal government was left in place.

…And Former Speaker Boehner

Six years ago, the Freedom Caucus – which at the time largely was composed of members elected in 2010 – nearly shutdown the government when it refused to support a budget that included money for Planned Parenthood. That budget fight emboldened the Freedom Caucus. The fault for that lies squarely with John Boehner. Imagine what Sam Rayburn or Tom DeLay would have done if Members who had not been in office for a full year threatened them. Rayburn and DeLay would have put the lawmakers on little-known committees, never recognized them in the well, spiked any bill they sponsored or co-sponsored, taken their parking spots, and moved their offices to the fifth floor of the Cannon House Office Building – the House equivalent of Siberia. But Boehner caved. He agreed to allow a stand-alone measure to defund Planned Parenthood come to the floor. As a result, the caucus became emboldened.

Otto Von Bismarck supposedly said, “Laws are like sausages, it is better not to see them being made.” When it comes to the AHCA, Bismarck was wrong. It was like being at the abattoir watching the cow be slaughtered.

The author is a former congressional staffer. 


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