10 Lessons From the Republican Health-Care Debacle

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The hands of President Donald J. Trump while attending a meeting on health care in the Roosevelt Room of the White House. 

At the end of last week, the legislative Hindenburg that was the Republican plan to repeal and replace the Affordable Care Act met its end in a blazing inferno of failure and recrimination. This was the most momentous occurrence of the early period of the Donald Trump presidency, and it's full of lessons that will be good to keep in mind in the coming days. Here are ten of the most important ones.

1. Don't hire a businessman to do a politician's job. The rationale of Donald Trump's candidacy was a slightly exaggerated version of what we've heard from many businessman candidates before him: Politicians are failures, we need to run the country like a business, elect me and I'll bring my business savvy to Washington to get things done. This argument presumes that politics is an enterprise like no other, where experience is irrelevant and there's no body of knowledge that needs to be mastered.

Trump's unexpected success as a candidate probably convinced him that he didn't need to change anything when he got to be president, and he staffed his White House and administration with people who knew nearly as little about government as he does. In this instance, it came back to bite him. "Nobody knew that health care could be so complicated," he said in wonder, and the same could be said of the legislative process. It turns out that convincing 218 people with their own incentives and agendas to go along with you is nothing like getting somebody to pay you a license fee to put your name on a building they're constructing, but Trump apparently had no idea.

2. Donald Trump is not a very good negotiator. He may know how to work a real-estate deal, but he didn't understand anything about the nature of this particular negotiation or the people he was negotiating with. As the vote approached, Trump used a tactic he probably has before: threatening to walk away. He told House members that if this bill didn't pass, he'd leave the ACA in place and move on to other priorities. What he didn't understand is that the threat is very different when you make it to Congress than when you make it to a hotel developer. Trump could go find a different partner if he didn't like a real-estate deal he was negotiating, but there's only one Congress, and he has no choice but to work with them.

And he completely misunderstood the ultra-conservative House Freedom Caucus (HFC) that would doom the effort. At one point he called out HFC chair Mark Meadows and said to him and his colleagues, "I'm gonna come after you" if they didn't support the bill. What he didn't get was that these congressmen (and yes, they're all men) not only have big egos and don't respond well to being threatened, they define their identity by making principled yet seemingly impractical stands against powerful forces. That's who they are. Trump all but invited them to stand up to him, and they did.

3. Paul Ryan is not very good at being speaker of the House. Whether Ryan ever really wanted this job in the first place, he didn't spend his career preparing for it. He was mostly a policy entrepreneur, trying to spread a certain set of ideas through his party and then to the country as a whole. While Ryan's carefully crafted reputation as a brilliant policy wonk is not really deserved, one thing he's certainly not is a skilled legislator. As McKay Coppins wrote, "The former deals in theories and spreadsheets and white papers and Powerpoint presentations; the latter deals in real-life political power." When it came time to perform this critical legislative task, Ryan hastily slapped together a bill that nobody liked, then couldn't assemble the votes to pass it.

4. The Tea Party is still an opposition force. The Republican Party, particularly in the House, is dominated by people who arrived at their political identities during the Obama years. They aren't particularly concerned with the details of policy, since they're more interested in ending government programs than designing them. They have an opposition mindset, one that says that what's important is that you're fighting; it's the battle itself that gives your work meaning. And since they see Paul Ryan as an establishment stooge who isn't committed to the true and pure version of conservatism, they're more than happy to get into conflict with him and once again show how principled they are. This won't be the last time we'll see that dynamic play out on an important piece of legislation.

5. Major policy changes require time and work. Before passing the ACA, Democrats spent not just years but decades talking amongst themselves about what sort of health-care reform they wanted. Over time, a rough consensus emerged on the outlines of a plan, and even though every Democrat wasn't completely happy with it, most every Democrat could live with it, at least in the short-to-medium term.

Republicans never had that internal conversation, and as a result they never arrived at a policy solution everyone on their side could live with. There were a few provisions they all knew they were supposed to mention when the subject came up—health savings accounts, tort reform—but most of them didn't concern themselves much with the details. It was enough to say "Obamacare stinks, we need freedom" and leave it at that.

So conflicts emerged at the worst possible moment. Moderates (and senators who represent entire states) didn't want to destroy Medicaid or give people stingy tax credits, while arch-conservatives thought the bill wasn't cruel enough. If Republicans had spent years talking with each other about this conflict, then they might have worked through those differences and arrived at the kind of compromise that comes from people weighing options, understanding the political roadblocks that might impede their favorite policies, and making peace with accepting an imperfect plan. But they certainly couldn't do it in a matter of days.

6. Learn the lessons of the past. When Democrats set out to construct the ACA, they thought a lot about why Bill Clinton failed to achieve health-care reform in 1993. They decided that they had to leave the employer-based insurance system in place, because people fear change and to do otherwise would be too disruptive. They decided that instead of taking on powerful interests like insurers, they had to find a way to co-opt them. They labored to come up with a bill the CBO would score favorably. Those decisions meant compromise and made the bill less like a liberal's dream, but they also made it possible to pass it. This time, the Republicans seem to have learned nothing from what Democrats did right, and as a result they wound up with a bill that everyone hated and no plan for how to get it passed.

7. The substance of policy matters. In the end the biggest problem the Republican bill had was less that it wasn't strategically smart than the fact that it would do a lot of terrible things. Yes, the Republican spin was unpersuasive, but how do you spin the fact that 24 million people are going to lose their health coverage? Elected Democrats barely had to lift a finger to defeat this plan, because the truth of what it would do, once it became known, was so horrifying.

8. Grassroots mobilization works. When people started packing town hall meetings and inundating their representatives' offices with phone calls, some Republicans tried to dismiss the mobilization as nothing but a bunch of lefty rabble-rousers, probably paid by George Soros. But the truth is that nothing scares a member of Congress more than angry constituents, and they felt the pressure. As time went on they realized that while they might have something to fear from a disappointed base if they failed to come through on their promise to repeal the ACA, they had even more to fear if the bill were to pass.  

9. Don't get high on your own supply. Republicans had been saying "Obamacare is a disaster!" for so long, they convinced themselves not only that it was true, but that everyone agreed with them. Then they were shocked when ACA's popularity began rising as the threat of its benefits being taken away became real. Republicans assumed that because this vague abstract thing called "Obamacare" wasn't particularly popular at the outset, that the public would tolerate the incredibly disruptive and heartless things they wanted to do, so they never built support for the specific kinds of changes they had in mind.

10. The public has finally accepted that health care is a right, not a privilege. The Affordable Care Act may have been controversial from the start, but it has changed what Americans will and won't accept from their health care system. Republicans had to pretend they supported many of the law's core goals, like protecting those with pre-existing conditions and making sure everyone can get covered no matter their income, and when it came time to come up with their own plan, they were judged on whether it achieved those goals. From now on, no system that treats health care like something you can get only if you can afford it will be tolerated by the public.

That doesn't mean we're headed inevitably to a single-payer future. We'll probably have lots of people without insurance for some time to come. But the terms of this debate have changed, and the bar of what's acceptable has gotten a lot higher. In their failure, Donald Trump and Paul Ryan have made that clear.

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