The Fate of Republicans’ Health Bill Might Rest With This Unelected Official

CBO Says GOP Health Plan Leaves Millions More Uninsured

The fate of U.S. President Donald Trump’s health-care overhaul could rest with a government employee little-known even around Washington, D.C. The Senate’s parliamentarian, Elizabeth MacDonough, will determine which provisions of a Republican replacement plan are allowed by Senate rules. This puts an obscure, nonpartisan office in the middle of the highly partisan debate over whether and how to replace Obamacare, the health-insurance system put in place under former President Barack Obama.

1. What does the parliamentarian do?

She and her handful of assistants, from seats on the Senate dais, provide advice to the Senate’s gavel-wielding presiding officer (usually a senator from the majority party) on interpreting Senate rules. Rarely is the parliamentarian’s work front-page news.

2. Why is the parliamentarian so important right now?

Simple math. Republicans hold 52 of the 100 seats in the Senate. Without help from Democrats, they can’t meet the 60-vote threshold needed to pass major legislation. But in a process known as "reconciliation," some budgetary matters that come before the Senate can be passed with a simple majority of 51 votes. Who decides which bills require only 51 votes? The parliamentarian does.

3. Will replacing Obamacare require 60 votes?

That’s the big question facing MacDonough. She will rule whether the American Health Care Act-- the Obamacare alternative passed by House Republicans -- meets the standards to be exempted from the 60-vote requirement. If she rules that it doesn’t, the House might have to reconsider its bill, or the Senate might have to strip provisions from it. Even if Senate Republicans go ahead with plans to rewrite the bill from scratch, MacDonough will be called upon to make a similar decision.

4. How will this work?

Democrats and Republicans will make their respective cases to MacDonough -- initially behind the scenes and eventually on the floor -- that key pieces of the House bill violate or comply with the rules for reconciliation. Democrats have already indicated they will challenge some provisions, including the so-called MacArthur Amendment, which allows states to waive certain insurance regulations and protections for people with pre-existing conditions. Democrats may also challenge whether the Republican bill cuts $1 billion each from the deficit from areas overseen by the health and finance committees, as required by the budget resolution passed in January. In all this, MacDonough will be guided by a May 24 analysis from the Congressional Budget Office, which said the House bill would cut the deficit by $119 billion over a decade and increase the number of uninsured by 23 million.

5. When will she rule?

Final rulings likely won’t come before the Memorial Day recess.

6. Does the Senate have to listen to the parliamentarian?

No. Her rulings are advisory, and the presiding officer -- a role officially assigned to the vice president, who carries it out during major votes -- can choose to follow or ignore them. Democrats would be powerless to overturn such a ruling. But the parliamentarian is very rarely overruled, and Republican leaders have said they don’t plan to do so this time.

7. What happens in the event of a standoff?

Ask Robert Dove, one of MacDonough’s predecessors. He was dismissed in 2001 by Trent Lott, the leader of the Senate Republican majority, who was unhappy with his rulings on tax and budget matters. MacDonough, however, isn’t seen as a partisan official but more of a referee of Senate rules, and lawmakers in both parties have praised her integrity.

8. How did MacDonough become parliamentarian?

She was appointed in 2012 by Harry Reid, a Democrat who was then Senate majority leader. The first woman to hold the top position, she had worked in the parliamentarian’s office since 1999. Before that she was a trial attorney at the Department of Justice.

The Reference Shelf

(Corrects fifth paragraph to say uninsured instead of insured.)
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