Trump, Ryan should learn from AHCA fiasco

By George LeMieux

Monday, April 3, 2017 | 2 a.m.

More than a week has passed since House Speaker Paul Ryan pulled from consideration the Republican replacement for Obamacare. As the fog of war lifts from this debacle, we can gain some clarity on what went wrong, why and the prospects for health care reform going forward.

Here are some of the key lessons:

• Not a details guy.

In seeking to win over recalcitrant conservatives, President Donald Trump reportedly dismissed questions over details of the legislation in a White House meeting, saying, “Forget about the little s--t. Let’s focus on the big picture here.” This failure to discuss, and perhaps understand, the policy points underlying the proposed Obamacare replacement resulted in only two or three of about three dozen Freedom Caucus members supporting the legislation.

Presidents do not need to be down in the weeds to be successful (witness Ronald Reagan), but if they are not into the details they need people around them to help negotiate and win supporters on key points. The president and the House speaker could have put these three dozen lawmakers together in a room at the White House with key administration staff to work through the issues and win votes. They could have done the same with recalcitrant moderates of both parties. In fact, the two groups could have been pitted against each other. There was some progress made with conservatives on providing Medicaid block grants to states and adding a Medicaid work requirement, but not enough to garner the votes for passage.

• The party of “No.’’

Although the vote was not taken, reports from insiders is that the bill was approximately 10 votes short of the required majority to pass the House. If Trump could have moved one-third of the Freedom Caucus, or pulled in a few Republican moderates or middle-of-the road Democrats, he would have had enough to send the bill to the Senate. In the aftermath of the legislation’s failure, Ryan lamented, “We were a 10-year opposition party, where being against things was easy to do. Now, in three months’ time, we tried to go to a governing party where we actually had to get 216 people to agree with each other on how we do things.”

If Republicans are going to be successful, they must learn how to govern. A recent column in Forbes by Avik Roy correctly points out that Ryan, and for his part Trump, failed to make the case to House conservatives why Obamacare should be replaced. While “repeal and replace” was a catchy, consultant-created campaign line, conservatives never supported the costly expansion of health care and were not keen to replace it with a similar, albeit somewhat less costly, Republican version. Most politicians are motivated by two things: principle and fear. Ryan and Trump offered no principled reason for conservatives to support the replacement.

• A strategic mistake.

Perhaps the biggest mistake lies at Ryan’s feet. By structuring the repeal and replace vote together, Republican members of Congress had the choice to vote “no,” keep the status quo and complain that the replacement was not to their liking. Ryan should have split the repeal and the replace votes. The first vote should have been structured to repeal the Affordable Care Act effective Jan, 1, 2018. That vote would have put all 237 Republican House members on the line. Each of them campaigned on repealing Obamacare, especially the Freedom Caucus members. That bill would have passed, and then the replacement legislation could have been offered. The dynamics would have shifted from a “no” vote keeping the status quo, to Obamacare disappearing in nine months. That would have made the alternative proposed by Ryan and Trump more attractive and may have garnered enough votes to at least send it to the Senate. Worst case, if the replacement vote failed, Congress would have been forced by year-end to find a replacement.

• This is where the fear comes in.

Approximately 23 million Americans would lose health coverage if Obamacare was repealed. Members of Congress, the vast majority of whom want to be re-elected, would have thought seriously about finding a replacement. The House could still pursue this strategy.

If pressed, I believe Congress would pass a replacement by year-end.

Governing is hard, and starting off an administration with a big loss is not a good sign. Republicans say tax reform is next, and the House Ways and Means Committee is working on a large reform package. Comprehensive tax reform, which we have not had since 1986, may be more challenging than health care reform. Republican leadership would be wise to create a principled case for reform, negotiate with outlying members to secure votes and create a deadline for passage, such as the August recess. If they do, they may fare better on their second priority than they did on their first.

George LeMieux served as a Republican U.S. senator, governor’s chief of staff and deputy attorney general. He is a correspondent for The Tampa Bay Times.