In the fall of 1964, Wilbur Cohen, then assistant secretary of legislation at the U.S. Department of Health, Education and Welfare (now the U.S. Department of Health and Human Services), was summoned to the White House along with his peers from throughout the fledgling Johnson Administration. Lyndon Baines Johnson had just been elected president in his own right after succeeding the slain John F. Kennedy as president in November 1963. Johnson had won 61.1 percent of the popular vote and 486 electoral votes, and his party had large majorities in both houses of Congress.
According to Cohen’s oral history, Johnson told his staff: "'Now look, I’ve just been elected by the overwhelming majority. And I want to tell you that every day while I’m in office, I’m going to lose votes. I’m going to alienate somebody.' And then he took about 20 minutes and traced the history of other presidents . . . and he says, 'The President begins to lose power fast once he has been reelected . . . We’ve got to get this legislation [his Great Society Program, including Medicare] fast. You’ve got to get it during my honeymoon.'"
Johnson knew whereof he spoke. In addition to being Kennedy’s vice president, he had served in the House of Representatives, and then the Senate, where he was perhaps the most powerful and effective majority leader that body has ever seen. He understood Washington better than any president before or since.
In health care, history has driven Johnson’s point home. Time is a new president’s enemy when it comes to bold health care legislation. When Bill Clinton delayed in proposing his sweeping health reform package in 1992, his initiative collapsed in a legislative tangle. Learning from this, Barack Obama made the Affordable Care Act (ACA) his first priority and pushed hard for its quick approval. He succeeded, but just barely.
Johnson’s remarks carry huge potential significance for President Trump and his congressional allies if they are serious about replacing the ACA, not just repealing it. Unless Washington’s rules have changed completely, Republicans need to act fast to succeed. They can repeal the law quickly, but creating its replacement, as they are discovering, is every bit as complicated and fraught as the ACA's enactment. In fact, repeal and replace cannot be separated because the details of the repeal affect the shape and viability of replacement.
The entire endeavor is probably mislabeled. The Republicans call their effort “repeal and replace,” but history will call it “Republican health reform.”
Although Republicans have tried repeatedly to repeal the ACA, and were clear during the election about their intent to dramatically change it, they did not do the technical or political work necessary to break swiftly from the starting blocks in January. The more legislators seem to learn, the more they seem inclined to slow down. One potential strategy is to repeal the ACA and then “repair” it with incremental steps. But step-by-step legislating takes time, and time is the enemy. As Johnson would counsel, each incremental piece of legislation will cost some measure of support for the president and his party. This is a particular problem in the Senate, where Republicans need eight Democratic votes to overcome a possible filibuster of key replacement provisions. And those votes must be gathered repeatedly, for each new proposal.
What is more, as time passes, other legislative priorities will come barreling through to sideline the health care process: tax reform (with its huge health care implications), infrastructure, modifying NAFTA, regulatory relief, foreign crises and responses, and potentially, new staff embarrassments and scandals. All of these will be complicated and costly for the new president and the majority congressional party. Every day the president and his party will lose votes. Every day he and his congressional advocates will alienate somebody.
Of course, we may be in different times. We may have a new administration that will change all the rules that have governed the rhythms of Congress and the presidency in modern times. We may. But we may not.