The Most Important Person in the Healthcare Debate

No, not President Donald Trump. Not even Health and Human Services Secretary Tom Price.

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It isn’t Speaker of the House Paul Ryan and it isn’t Senate Majority leader Mitch McConnell.  

Who could they be?

You’re probably not familiar with her because she likes to stay out of the spotlight, but she has a lot of power and influence in Washington. The most important person in the healthcare debate, right now, is Elizabeth MacDonough. 

MacDonough’s role is Parliamentarian to the United States Senate. Simply put, she is an attorney who advises the Senate on official matters. MacDonough has a huge task ahead—advising the Senate on how they can proceed with the American Health Care Act (AHCA), which aims to repeal and replace much of the Affordable Care Act (ACA).

Normally, 60 votes are needed to pass a bill in the Senate. However, if it’s a bill that only impacts federal spending (referred to as a budget reconciliation bill), only 51 votes are needed. Republicans currently hold 52 seats in the Senate, Democrats and Republicans don’t seem to agree on anything, so Republicans are using the budget reconciliation process to try and oust key parts of the ACA. This means the ACA can’t be repealed in its entirety, but the financially-driven components of the law can be overturned. 

Here’s where MacDonough’s role becomes so important. She instructs the Senate on what provisions can (or can’t) be included in a budget reconciliation bill, and there are some things in the AHCA (at least in its current form) that walk a fine line.

For example:

If passed, the AHCA would let insurance companies charge older people a premium five times higher than that of a younger person.  It would also give states the ability to determine which benefits are essential and must be included in health insurance plans.

Are these budget-related items? Or are these insurance rules? Republicans will tell you these types of things impact premiums, which tie back to subsidies, and therefore effect federal spending. Democrats will tell you that’s a far stretch and these types of things are insurance rules which require 60 votes to pass in the Senate.

But it doesn’t matter what Republicans or Democrats think.  It matters what MacDonough thinks.

After hearing arguments from both sides of the political aisle, MacDonough will provide the Senate with guidance on provisions that are budget-neutral and advise what must be removed or changed under the current version of the AHCA.