Jim Bourg / Reuters The U.S. Capitol building on the day of a House of Representatives vote on the American Health Care Act, March 2017.

The Republican Health Care Debacle

How Not to Make Public Policy

In early May, the U.S. House of Representatives passed the American Health Care Act of 2017 (AHCA), which would undo significant parts of the Obama administration’s Affordable Care Act (ACA) and alter crucial aspects of Medicaid as it existed prior to the ACA. The proposed changes in federal policy—rolling back recent changes in insurance market regulations, sharply reducing federal subsidies for health care for lower- and middle-income Americans, and providing a large tax cut for upper-income Americans—would be dramatic. Even more striking is that these changes emerged from a legislative process that blatantly violated the norms of professional policymaking. Indeed, the development and passage of the AHCA is a case study in how not to make public policy.

The traditional process for developing and passing major legislation is straightforward although admittedly cumbersome: members of Congress and their staffs advance ideas for changing public policy; they describe the perceived advantages and disadvantages of those ideas; they receive feedback on the ideas from experts, interested parties, and the general public; they revise their ideas in response to that feedback; and, after many iterations, they vote on specific legislative language.

Following this process matters; it is critically important for effective governance in at least two ways. 

First, in a complex society, determining what changes in policies would be most effective cause the least collateral damage to other objectives is often a challenge, and the feedback provided by Congress’s own experts, outside analysts, and individuals and groups who would be directly affected by proposals is extremely valuable in making proposals better. This is not to say that analysts or interest groups should have veto power over legislation: analysts can be wrong in their assessments and interest groups are focused on specific constituencies, which is why we elect representatives to make policy decisions. But ignoring their perspectives can easily lead to policies that are ineffective and harmful. 

Second, members of Congress need to understand, in some detail, what they are voting for

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