“Nobody knew health care could be so complicated.”
-President Trump
Donald Trump and Paul Ryan may still be smarting from the loss of their healthcare repeal-and-replace legislation. The Speaker convinced the President that the better part of valor was discretion last Friday when Mr. Trump agreed to forego a floor vote on the bill in the House of Representatives. Best estimates are that it would have failed by half a dozen votes or more.
A number of reasons account for the failure of this particular legislation, and many of them could provide valuable lessons for the new president, if he were willing to accept them.
First and foremost is the fact that the bill was terrible. It was destined to deny health care to millions of currently insured or otherwise protected people and to raise insurance rates for many of the country’s poorest citizens. It would have provided major tax breaks for those at the top of the economic ladder at the expense of those at the bottom.
The bill was an ill-disguised effort by Speaker Ryan to reverse the newly accepted “right” to health care that is one of Barack Obama’s legacies. Say what you will about the former president as an agent of change, but one thing he succeeded in doing (through Obamacare) is to foster the view that in America health care is a right that all Americans are entitled to expect.
Ryan and his conservative colleagues hate that idea. They hate any and all “entitlements” that represent a program by the federal government to provide something to the people. The reason they hate things like Obamacare (and Medicare and Social Security and unemployment insurance and anything else that the government does to make life easier for the folks who pay taxes and struggle to make ends meet) is that those programs restrict the free market, which is where they believe all human destiny should be decided.
Simply stated, what Ryan would really like is for all Americans to find their own way regarding health care. He would like doctors and hospitals to be free to set their fees for services to those who could afford the charges. He would like insurance companies to be free to offer coverage to those the companies wanted to insure. He would like businesses to be free to provide health insurance to their employees in whatever manner those companies wished. And he would like the health care consumers in the country to be “free” to decide how they would provide for their health care needs in whatever way they chose.
Ryan and his colleagues hate Obamacare because it severely restricts, if it doesn’t eliminate, all of those “freedoms.” With their bill, they wanted to roll back the “entitlement” that Obamacare represents. And if you’re a conservative member of Congress, the bill should have had a lot of appeal, because it was an attempt to reverse the momentum towards a universal health care entitlement that Obamacare initiated. But Ryan’s bill ran up against staunch opposition from within his own party, and in that reality is the first lesson for Mr. Trump to learn.
The Republican Party, it turns out, is a badly splintered group that consists of conservatives (of the type Ryan represents) and ultra-conservatives (formerly known as the Tea Party, now calling themselves the Freedom Caucus). It was the Freedom Caucus (numbering around 35 representatives in the House), and not the Democrats, as Trump ridiculously claimed, who killed Repeal-and-Replace. Why? Because it didn’t go far enough; because it only cut back on Obamacare, rather than killing it entirely.
So, lesson number one for Mr. Trump is that you can’t expect to get legislation passed just because your party controls both houses of Congress. You need, instead, to gain the support of the Freedom Caucus and then try to hold onto those whose re-elections require less extreme policies and positions.
Lesson number two might be the harder one for Mr. Trump to accept, which is that to get legislation passed (even under the best of circumstances in this political environment), you have to do a lot more heavy lifting than he has, to this point, shown himself capable of doing. I’m talking about becoming immersed in the policies inherent in the legislation, in the nitty-gritty details of how the bill would actually work. Who is being asked to give up what to get what? What interest group has a stake in the bill’s impact that might not be apparent on its face, but that is critical to getting the support the bill will need? Why are certain organizations/factions/communities opposed to the bill in its current form? Can those entities be mollified, if not satisfied, without doing severe damage to the bill’s purpose?
These are questions that a president needs to be at least aware of if he is going to try to get the votes needed to get the bill passed. And it would help if the president cared enough about the bill to have a list of answers (options) for those questions.
Or course, to achieve that level of understanding/expertise about a bill, the president must be willing to endure some brain sweat; that is, he must do some homework, something Mr. Trump has shown no inclination to date to have any interest in doing. So there’s that lesson, which he’ll need to learn from this most recent debacle of an experience.
And then there’s lesson number three, which may be the hardest lesson of all for this very shallow, petty man who has flim-flammed his way to the highest office in the land. To get major legislation enacted, you have to have staying power. You have to be willing to take a punch and keep going, to have one version of a bill rejected and then be ready with another alternative, and, most of all, to be willing to fight the long fight, to stay with the battle, and to risk your political capital in the extreme to get it done.
That is what Barack Obama did to get the Affordable Care Act passed. And it did cost him. It cost him the loss of Congress in the 2010 elections, it cost his party the loss of many state legislatures in the years following, and it may have cost his party the chance to retake the Senate, if not hold on to the presidency, in 2016. But what Obama got, as has now been clearly established, is a change in the perception of the American people on his number one priority when he took office: health care as a right.
That was a goal worth fighting for, and Obama fought the good, long, hard fight to get it realized. And that’s Mr. Trump’s biggest lesson from his first major legislative defeat: You need the passion for something bigger than yourself.