The End of AHCA

March 24th, 2017

Writing two books about the Affordable Care Act has given me a sense of perspective. Day-to-day events concerning the law tend not to phase me, as I attempt to keep my eyes on the big picture. Today’s events, however, will ultimately be an entire chapter in my next book.

Rather than offering my commentary–I am still not quite sure what this means and where it leads–in this post, I will compile a number of the play-by-play accounts that were published hours after Speaker Ryan announced that there would be no vote.

From Tim Alberta in Politico:

Donald Trump had heard enough about policy and process. It was Thursday afternoon and members of the House Freedom Caucus were peppering the president with wonkish concerns about the American Health Care Act—the language that would leave Obamacare’s “essential health benefits” in place, the community rating provision that limited what insurers could charge certain patients, and whether the next two steps of Speaker Paul Ryan’s master plan were even feasible—when Trump decided to cut them off.

“Forget about the little shit,” Trump said, according to multiple sources in the room. “Let’s focus on the big picture here.”
The group of roughly 30 House conservatives, gathered around a mammoth, oval-shaped conference table in the Cabinet Room of the White House, exchanged disapproving looks. Trump wanted to emphasize the political ramifications of the bill’s defeat; specifically, he said, it would derail his first-term agenda and imperil his prospects for reelection in 2020. The lawmakers nodded and said they understood. And yet they were disturbed by his dismissiveness. For many of the members, the “little shit” meant the policy details that could make or break their support for the bill—and have far-reaching implications for their constituents and the country.

“We’re talking about one-fifth of our economy,” a member told me afterward. . . . .

The president had been working on many of them individually in recent days, typically with what members described as “colorful” phone calls, littered with exaggerations and foul language and hilariously off-topic anecdotes. In some cases, the pressure worked. Jim Bridenstine, a Freedom Caucus member and longtime problem for the Republican leadership, agreed to back the bill after conversations with Trump and other administration officials. (It wasn’t necessary to remind Bridenstine that he was a leading candidate to become NASA administrator, and would likely hurt his chances by voting against the president.) . . .

Then Trump made a mistake. After singling out Meadows and asking him to stand up in front of his colleagues, Trump joked that he might “come after” the Freedom Caucus boss if he didn’t vote yes, and then added, with a more serious tone: “I think Mark Meadows will get on board.”

It was a crucial misreading of Meadows, who has been determined to please both the White House and his conservatives colleagues on the Hill. Upon assuming the chairmanship of the Freedom Caucus earlier this year, Meadows was viewed suspiciously by some of his members who worried that the North Carolina congressman is too cozy with Trump and would hesitate to defy him. Meadows campaigned extensively with Trump last fall and struck up a relationship with White House chief strategist Steve Bannon, who communicates with him almost daily by text. Meadows knew the heath care fight would be viewed a test of his independence from Trump, and the moment the president called him out, he was boxed in.

“That was the biggest mistake the president could have made,” one Freedom Caucus member told me. “Mark desperately wanted to get to yes, and Trump made it impossible for him. If he flipped after that he would look incredibly weak.”

“Take one for the team” was a phrase repeatedly deployed; at one point, after Bannon used it, Joe Barton, a white-haired conservative from Texas, snapped back in response that Bannon was talking to them like children and he didn’t appreciate it. The room filled with uncomfortable silence; Bannon backed down and the meeting went on.

Through charm, force of personality and sheer intimidation, Trump did move some votes into the yes column. But GOP leaders were left wondering why he didn’t do more—why he didn’t send tweets, travel to congressional districts, put his famed dealmaking skills to work. The answer, to Republicans on both ends of Pennsylvania Avenue, is obvious: Because he lacked familiarity with the legislation itself, and thought it was Ryan’s job to sell the specifics.

“Trump is a business executive. When he tells his lieutenants to get something done, he’s used to it getting done,” one senior House GOP aide told me. “He’s really not used to getting involved himself.”

Of course, leadership officials also were eager to blame the Freedom Caucus, claiming the group simply has no interest in voting yes. But the fact is, after Thursday night’s impromptu conference meeting—in which Mulvaney delivered Trump’s ultimatum that he would move on from health care after Friday’s vote—the number of conservatives still opposed to the bill had dwindled significantly. There were 27 Freedom Caucus members voting no at the beginning of the week; by late Thursday, that number appeared to drop below 20. Jordan, worried that conservative opposition might be crumbling, spent Thursday night and Friday morning whipping his comrades to prevent further defections, members said.

Trump’s attempt to cajole the group into submission—tweeting Friday morning about the “irony” of its members opposing abortion but voting against a bill that removed Planned Parenthood funding—didn’t work, and probably backfired, just like his singling out of Meadows. I was told the members were slightly irritated but mostly laughed it off as “Trump being Trump,” and expressed surprise that he hadn’t tried to publicly pressure them ever sooner.

On the opposite end of the spectrum were Meadows, Jordan, Labrador and Michigan Rep. Justin Amash, arguably the four core members of the Freedom Caucus. Moments before I talked to Walker, I had intercepted the four of them walking toward the meeting room. They hadn’t heard the news; when I told them Ryan had pulled the bill, they exchanged glances and tried to suppress grins. Only Meadows looked upset; a southern gentleman and successful businessman, he wants to be liked by everyone, and the episode clearly took an emotional toll on him. He declined to provide a comment. So did Labrador and Amash. But Jordan, the godfather of the House conservatives—he arrived four year prior to the tea party wave of 2010—made clear that he wouldn’t go along with Trump’s decree that Republicans would abandon health care and move on to tax reform.

“We want to see Obamacare repealed,” Jordan told me. “That hasn’t changed.”

Ryan, for his part, told reporters in a somber press conference a short while later that he stood with Trump. Obamacare, that great white whale Republicans had long hunted—and hoped to harpoon on its seven-year anniversary Thursday—would remain “the law of the land” due to the GOP’s inability to function as a “governing body,” the speaker of the House announced. They had failed at fixing the health-care system; next they would try to overhaul the tax code.

The improbability of this sequence was not lost on anyone. Earlier, as Ryan’s motorcade was zipping toward the White House, I spoke with Kevin Brady, the Ways and Means chairman whose committee sits at the intersection of health care and taxes. I’ve known Brady, one of Congress’s truly decent people and a reliably cheerful spirit, for years; never had I seen him looking so despondent and defeated. Positing that health care was about to die, I asked Brady if re-writing the tax code would be any easier. “Tax reform is the hardest lift in a generation,” he told me, shaking his head. “So that would be a big challenge.”

“If you couldn’t get health care done,” I ask him, “how can you get tax reform done?”

Brady thought for a moment. “Every Republican is all-in on tax reform. We still have a lot of work. But it’s just a natural issue for us in a very positive way.”

But every Republican was all-in on repealing and replacing Obamacare, too, I told him. “Won’t the devil be in the details?”

Brady stared back at me. “It always is,” he said. “It always is.”

From WSJ:

And, on Friday, as Mr. Ryan hustled down Pennsylvania Avenue to deliver news that they didn’t have support to pass the repeal-and-replace bill, Mr. Trump insisted on a vote. A few hours later, he reversed himself and spared his Republican colleagues from taking a stand that likely would be used against them in the midterm elections.

Addressing reporters, a subdued Mr. Trump said that along the way he had “learned a lot” about loyalty, the legislative process and the “arcane rules” in Congress.

Still, New York’s Rep. Chris Collins, an early supporter of Mr. Trump during the campaign who has served as a liaison between the White House and Congress, said he had barely seriously considered that the bill might not pass.

“I don’t think many of us, myself included, even a week ago thought there was any chance that this would fail,” he said Friday. “And now it’s like, oh my God, this may fail, and if this fails, where do we go next, and how do we get there?”

The miscalculation by Mr. Ryan and Mr. Trump about the Freedom Caucus came to a head in the Oval Office on Thursday—on what was supposed to be the day the House voted on it, which also happened to be the seventh anniversary that President Barack Obama had signed the Affordable Care Act.

The White House had planned for Vice President Mike Pence to leave for Little Rock, Ark., to begin selling the bill in states that were home to wary GOP senators. Instead, Mr. Trump was still negotiating with Rep. Mark Meadows (R., N.C.), the head of the Freedom Caucus.

An increasingly frustrated Mr. Trump cut off the congressman in the Oval Office, according to a person briefed on the meeting. As Mr. Meadows made his case for a more comprehensive repeal of the insurance provisions, the president said, no, “this is my final offer.”

As the lawmakers were leaving, Mr. Meadow turned to Mr. Trump. “What about this…” he began. Mr. Trump rejected any further discussion, telling him he could take or leave his offer as it stands. “It’s always something else,” a person briefed on the conversation said. “Eventually [the White House] got tired of it.”

Mr. Mulvaney told the caucus Mr. Trump had made his final offer. The White House aides presented two letters, including one from the president, committing the administration to implementing some of the conservatives demand.

Still, the familiar arguments went round and round. Messrs. Ryan and Mulvaney told the lawmakers it was time to go around the room with each of them to say whether they would vote yes or no. Mr. Meadows stepped in to stop them, according to lawmakers who attended the meeting.

“I speak for them,” he told the speaker and the president’s aides, saying they wouldn’t have the votes. The vote, Mr. Mulvaney said, would go ahead anyway.

Around 10 p.m. Thursday, Messrs. Trump and Ryan connected, spending 45 minutes talking through what had happened and where that left them heading into the vote.

Mr. Trump, Mr. Pence and White House officials, including Kellyanne Conway, Mr. Bannon and Mr. Priebus continued to place calls Friday morning. Many of them were making intense arguments to Republican lawmakers. “March or die,” was the message, according to one person who participated in a phone call.

On Friday morning, after the Republican leadership’s last whip check, Mr. Ryan pulled Mr. Meadows into a room off the House floor. “You said you speak for the Freedom Caucus,” Mr. Ryan said to him. “Are you a yes or a no?” He was a no. Mr. Ryan left the room, according to people familiar with their talk.

Mr. Ryan traveled 2 miles from the Capitol to the White House during the lunch hour. Inside the West Wing, Mr. Ryan received a clear message back from Mr. Trump and his team: “Let’s vote,” said one official who was in the room during the meeting.

The vote would take place at 3:30 p.m., Mr. Spicer said Friday afternoon in a televised news briefing. Mr. Trump and his staff had “left everything on the field.”

From WaPo:

Shortly after House Speaker Paul D. Ryan (R-Wis.) unveiled the Republican health-care plan on March 6, President Trump sat in the Oval Office and queried his advisers: “Is this really a good bill?”

And over the next 18 days, until the bill collapsed in the House on Friday afternoon in a humiliating defeat — the sharpest rebuke yet of Trump’s young presidency and his negotiating skills — the question continued to nag at the president.

Even as he thrust himself and the trappings of his office into selling the health-care bill, Trump peppered his aides again and again with the same concern, usually after watching cable news reports chronicling the setbacks, according to two of his advisers: “Is this really a good bill?”

In the end, the answer was no — in part because the president himself seemed to doubt it.

“We were a little bit shy — very little, but it was still a little bit shy, so we pulled it,” Trump said Friday afternoon in an interview with The Washington Post.

He cajoled and charmed uncertain members, offering flattery and attention to some and admonishment and the vague threat of political retribution to others. He invited members to the White House for bowling sessions, gave others rides on Air Force One (complete with ­lasagna) and grinned for pictures in the Oval Office, where he reminded lawmakers of his margins of victory in their districts.

This account of Trump’s work on the health-care bill — based on interviews with roughly three dozen White House aides and advisers, members of Congress, and other key figures in the debate — revealed a president in a constant state of negotiation. He remarked to friends and aides that it did not feel much different from his real estate transactions.

“It’s the same thing,” he said Wednesday in the Oval Office. “Really, it is.”

Reflecting Friday on the failure, Trump said he thought he had cultivated a good relationship with the House Freedom Caucus — the band of hard-line conservatives who proudly oppose Ryan and other House leaders.

“I couldn’t get them,” Trump said in The Post interview. “They just wouldn’t do it. . . . I think they made a mistake, but that’s okay.”

Alluding to the long-running dramas on Capitol Hill, Trump added, “There are years of problems, great hatred and distrust, and, you know, I came into the middle of it.”

But that didn’t stop the president from trying. Just two days before the bill was withdrawn by House leadership, Trump sat inside the Oval Office at dusk as his aides offered yet another blunt warning in a week full of them: The measure was likely to fail. Too many Republicans were opposed.

Still in a suit jacket and striped red tie Wednesday evening, the president dialed Rep. Joe Barton, a wavering Republican from Texas, and placed the call on speakerphone. He put his finger to his lips to shush the clutch of advisers that always surrounds him. The president listened as the congressman ticked through his concerns, sipping from a glass of Diet Coke and jotting down notes with a thick, black Sharpie.

Never one to get caught up in policy details, Trump concentrated his pitch on the big picture: winning. Trump said he wanted a win for Barton, for Texas, for their party, for the country — and, of course, for himself.

When Barton told Trump that he could probably support the bill, with a few changes, the president smiled and winked at Vice President Pence, who stood hovering over the Resolute desk, and Health and Human Services Secretary Tom Price, who leaned forward to listen. As Trump wrapped up the call — “Talk soon,” he told Barton — Pence and Price silently punched their fists in the air. Barton was not an absolute yes but, for the moment, it was good enough.

Then the president was on to the next call.

On Thursday, Trump appeared embarrassingly out of the loop; as the congressional whip efforts faltered, Trump was busy at the White House, greeting commercial truckers and climbing into the cab of a 18-wheeler to honk the horn.

“It’s going to be a very close vote,” the president said, referring to what everyone else seemed to know had been delayed.

As the talks stalled later that night, Trump’s exasperation with the hemming and hawing of members escalated and he delivered an ultimatum: Go ahead with the vote no matter what on Friday, he said, all but daring fellow Republicans to vote against his first significant bill.

The president was finished negotiating, and his thinking was straight from “The Art of the Deal”: If the White House continued to postpone the vote, the holdouts would gain leverage and learn the dangerous lesson that they could challenge Trump and win. Lawmakers wanting to oppose the president would have to do so publicly, in a vote, and face the consequences.

Yet in the end, Trump acquiesced to the preferences of House leaders, who did not want their members voting on a controversial measure if the outcome were in doubt. Realizing the health-care plan did not have the support to pass, Trump and Ryan decided Friday afternoon to pull the bill — news Trump announced in a phone call with The Post, before Ryan even had time to personally brief GOP members.

“Just another day,” Trump said in the call. “Just another day in paradise, okay?”

Meadows said his mantra in negotiating with Trump had been, “If this was about personalities, we’d already be at ‘yes.’ He’s charming, and anyone who spends time with him knows that. But this is about policy, and we’re not going to make it about anything else.”

Trump also sought leverage by surprising members with cold calls. Rep. Dave Brat (R-Va.) was at home near Richmond one day last week, moving boxes into his car, when his cellphone rang.

“Someone came on with this very formal voice and said, ‘Please hold for the president of the United States,’ ” Brat recalled. But when Trump got on the line, the president could not have been less formal, Brat said. “He goes, ‘C’mon, Brat, what’s going on with this thing?’ ”

“I said, ‘I want you to be a success, but the price has to come down,’ ” Brat said. “But he puts on the hard sell. He’s selling. The salesman in sell mode. On that, he’s the best. Humor, heart, personality.”

Trump ended the call with a plea: “Dave, c’mon, we’re going to get it right.” But Brat was unmoved. “I get it,” he said he told the president, “but I couldn’t get behind it.”

From this surreal interview between the President and Robert Costa:

The Democrats, he said, were to blame.

“We couldn’t get one Democratic vote, and we were a little bit shy, very little, but it was still a little bit shy, so we pulled it,” Trump said.

Trump said he would not put the bill on the floor in the coming weeks. He is willing to wait and watch the current law continue and, in his view, encounter problems. And he believes that Democrats will eventually want to work with him on some kind of legislative fix to Obamacare, although he did not say when that would be.

“As you know, I’ve been saying for years that the best thing is to let Obamacare explode and then go make a deal with the Democrats and have one unified deal. And they will come to us; we won’t have to come to them,” he said. “After Obamacare explodes.”

“The beauty,” Trump continued, “is that they own Obamacare. So when it explodes, they come to us, and we make one beautiful deal for the people.”

Trump returned to the theme of blaming the Democrats.

“Hey, we could have done this,” he said. “But we couldn’t get one Democrat vote, not one. So that means they own Obamacare and when that explodes, they will come to us wanting to save whatever is left, and we’ll make a real deal.”

“Well,” Trump said, “we could do that, too. But we didn’t do that. It’s always possible, but we pulled it.”

Trump brought up the vote count. “We were close,” he said.

How close?

“I would say within anywhere from five to 12 votes,” Trump said — although widespread reports indicated that at least three dozen Republicans opposed the measure.

“You’re right,” Trump said. “I’m a team player, but I’ve also said the best thing politically is to let Obamacare explode.”

Trump said he made the decision to pull the bill after meeting Friday at the White House with House Speaker Paul D. Ryan (R-Wis.).

Was that a tense, tough conversation with Ryan, I asked?

“No, not tough,” Trump said. “It’s just life. We had great support among most Republicans but no Democratic votes. Zero. Not one.”

I mentioned to Trump that some of his allies were frustrated with Ryan. Did he share those frustrations, and would he be able to work with Ryan moving forward on plans to cut taxes and build an infrastructure package?

“I don’t blame Paul,” Trump said.

He then repeated the phrase: “I don’t blame Paul. He worked very hard on this.”

And again.

“I don’t blame Paul at all.”

As he waits for Democrats, I asked, what’s next on health care, if anything, policy-wise?

“Time will tell. Obamacare is in for some rough days. You understand that. It’s in for some rough, rough days,” Trump said.

“I’ll fix it as it explodes,” he said. “They’re going to come to ask for help. They’re going to have to. Here’s the good news: Health care is now totally the property of the Democrats.”

Speaking of premium increases, Trump said: “When people get a 200 percent increase next year or a 100 percent or 70 percent, that’s their fault.”

On this last point, Andy Slavitt sums it up well:

Trump’s threat could become “a self-fulfilling prophecy,” said Andy M. Slavitt, the acting administrator of the federal Centers for Medicare and Medicaid Services for the last two years of the Obama administration. “That’s like inheriting an overseas war, and deciding you let your own soldiers get killed because you didn’t elect to enter that war.”

Harvard University economics professor David Cutler, who helped advise the Obama White House on health care, challenged Trump’s argument that the ACA will always be associated with Democrats. “He owns it now,” Cutler said in an email, “because he could take many steps to stabilize things.”