President Trump laid out a grand vision to Congress Tuesday of the plans he has to Make America Great Again — healthcare reform, tax reform, immigration reform, the wall, a massive expansion of the military, reduction of the debt. More for less. Everything better. Everything safer. Everything great. Again.
But now comes the hard part. There is a vast expanse in Washington between promises and plans, and another expanse further to get to progress and achievement. That seemed to have finally dawned on Trump on Monday after he met with the National Governors Association at the White House and discussed healthcare reform.
“I have to tell you, it’s an unbelievably complex subject,” Trump said after the meeting. “Nobody knew that healthcare could be so complicated.”
Actually, everybody knew that healthcare could be so complicated. Everybody. The governors in that room surely knew. So does any member of Congress or staffer who was within 100 miles of the healthcare debates from 2008 to 2010. Hospitals, insurers, Medicare administrators, state health agencies, pharmaceutical companies and patients all know, too. Hillary Clinton found out the hard way in 1994. Is it possible that Trump is the only person in America coming to the realization that reforming healthcare could be so complicated?
To get a sense of just how complicated it’s going to be for Trump and Republicans in Congress to repeal, replace, repair and/or rebrand Obamacare, I spoke with House and Senate staffers who were at the center of the multiyear process to pass the Affordable Care Act under President Obama.
Purva Rawal, a senior health policy staffer for then-Sen. Byron Dorgan, worked for more than two years on the ACA. She has since written her own book about the entire process from start to finish. The book is complicated.
“When I saw Trump’s quote, my jaw dropped,” she said. “Healthcare accounts for 20 percent of our GDP. How do you change 20 percent of our GDP without it being hard and complex?”
Scott Mulhauser, who worked for Sen. Max Baucus during the negotiations, called Trump’s observation “a bigger jaw-dropper than the Oscars fiasco.”
Rawal described a years-long, intensely difficult series of meetings, negotiations and agreements that the Affordable Care Act required, but said the process began years earlier in 2006 in Massachusetts when the state reformed its healthcare system. “That was the proof of concept that you could do a health insurance exchange, that you could expand Medicaid, and that you could get a state’s uninsured rate down,” she said.
Healthcare then became a focal point of the 2008 Democratic primaries. Simultaneously, Democratic and Republican Senate staffs began meeting weekly on Capitol Hill to sift through the real-time healthcare system and sketch out concepts for improving it.
Even before the 2008 elections, a bipartisan group of senators began negotiating a first draft of a Senate bill and continued through 2009. The senators met together 29 times for 60 hours. Later, Obama held a healthcare roundtable at the White House. Another working group held a daylong series of panel discussions.
Once a framework was in place, then came the Congressional Budget Office. “The CBO piece of it was intensely complicated — we were on the phone with them several times a day, on Saturdays and Sundays, until 10 at night for months,” Rawal said. Two Senate committees and three House committees marked up pieces of the bill. One committee needed six weeks for its markup. Every amendment needed a CBO score.
As hard as the policy piece was, the politics were worse. Following the death of Sen. Ted Kennedy, Democrats accelerated their plans to pass their bill, even as the political climate went south in 2009. Democrats moved without skittish Republicans and pushed their own members to get on board. Death threats came for not only members of Congress, but their families, too. When then-House Speaker Nancy Pelosi walked across the Capitol Plaza to vote for the final bill, she and Rep. John Lewis marched arm-in-arm through a chorus of boos as they sang, “We shall overcome.”
Even with his signature law passed, or because it was passed, Obama lost momentum for immigration reform and climate-change legislation for the rest of his first term. Democrats lost 63 seats in the House and six seats in the Senate in the 2010 midterm elections. Healthcare reform, even with huge majorities and a Democratic White House, was complicated.
You know what else is complicated? Tax reform, immigration reform, and renegotiating trade deals, which Trump has promised to do, and funding the federal government past the current continuing resolution, raising the debt ceiling, and passing a budget, all of which he must do, soon.
Republicans may have unified control of government, but they have yet to speak with a unified voice on almost any matter of policy, especially healthcare. Most of the blame for that falls on Trump, who has made promises too big to keep and is making commitments on benefits, cost savings and reforms that will never add up. He changes course at a moment’s notice, keeps Republican leaders in the dark and is making an already difficult task for House Speaker Paul Ryan and Senate Leader Mitch McConnell almost impossible.
Big legislative packages are complex under the best of circumstances. But Trump’s grab bag of gigantic campaign promises is dangerously close to being declared dead on arrival with him at the wheel. The president may find out in the end that getting elected president, even against the odds, was easy. Being the president is complicated.
Roll Call columnist Patricia Murphy covers national politics for The Daily Beast.
©2017 CQ-Roll Call, Inc.