Getty SOAPBOX Paul Ryan Failed Because His Bill Was a Dumpster Fire It was bad policy, not poor tactics or negotiating skills, that doomed the GOP’s efforts to repeal and replace Obamacare.

Harold Pollack teaches social service administration at the University of Chicago. A fellow of the Century Foundation, he’s a regular contributor to the Washington Post’s Wonkblog section and to healthinsurance.org.

The American Health Care Act died on Friday. Speaker of the House Paul Ryan has conceded defeat, declaring in words that must have been painful for him to utter—

“Obamacare is the law of the land”—as he yanked the bill from consideration. After all, Republicans had spent seven long years dreaming of this moment, only to find that when it came, they didn’t have the votes. No one can say whether Friday’s face-plant was the last word. Still, this was a defining political defeat for President Donald Trump and the Republican Party.

The most serious damage, though, was to Ryan and his allies. And like you, I’m reading all the insider accounts of what went wrong. By their nature, these stories focus on anecdotes about who said what and when. But make no mistake: This was a failure of policy and legislative strategy—things that were supposed to be Ryan’s special sauce—not of tactics. Even if President Trump were the master negotiator he claims to be, he probably couldn’t have saved it.


The House speaker is more identified with AHCA than anyone else, and had greater control than anyone else of its moving parts. It was his bill, his plan, his preferred timing. But he produced one of the worst pieces of major legislation in memory—and his reputation as a policy professional and legislative tactician may never recover. Given the opportunity to reshape critical pieces of America’s health care safety-net, Ryan might have led an effort to craft a conservative, but incremental bill consistent with President Trump’s economic populist rhetoric. He might have proposed more modest cuts on the most needy, smaller tax breaks for the wealthiest Americans, and tried harder to accommodate the needs of Republican governors, interest groups and citizens who rely on the Affordable Care Act in their daily lives.

He didn’t. Instead, he and his allies crafted a poorly constructed and radical bill that would sharply cut support to low-income Americans and those with serious health conditions, while enacting big tax cuts for the wealthy. The payout to the top 400 families alone was estimated to exceed total ACA subsidies in 20 states and the District of Columbia. All of this was wildly out of step with American voters—only 17 percent of whom supported this bill.

Every liberal and conservative think tank hated AHCA, albeit for different reasons. Medical provider groups hated it. The AARP hated it—even before the Congressional Budget Office estimated that 64-year-olds with $26,500 annual incomes would see their average net individual insurance premiums go from $1,700 to a $14,600. Republicans tried to patch this up. Too late. This 760 percent premium increase was politically immolating.

This was a baffling error. Everyone in health policy knew this assessment was coming. Did Speaker Ryan or the White House run these numbers? If not, did they understand their own legislation? If so, did they simply hope that no one would find out? Ryan’s spin of the CBO report—that it vindicated his argument that the AHCA would drive down costs—was laughable. The real takeaway was that 24 million fewer Americans would be insured, and those that remained would see their premiums increase as their coverage worsened.

What’s so baffling about Ryan’s failure is that he knows as well as anybody that social entitlements are devilishly hard to take away—because people like them. As the main features of ACA become embedded in American life, overturning it required legislative craftsmanship at the boundary between coalition politics and policy.

That’s the craftsmanship Nancy Pelosi provided in 2009 and 2010. She brought together—and kept together—a fractious Democratic House coalition that included coastal liberals wedded to the public option, Southern conservatives in vulnerable seats, committed pro-life and pro-choice members. She cajoled and coordinated major committees to provide common legislative language on a much more complex bill than the AHCA. When Democrats were rocked by Republican Scott Brown’s surprising Massachusetts Senate victory, liberal stalwarts such as Barney Frank were faltering, given Democrats’ loss of a filibuster-proof Senate majority. Pelosi mobilized livid House Democrats to sacrifice much of their valuable work and pass unchanged the more moderate Senate bill. These members put their trust in her to clean things up as she could through complex accompanying legislation and the reconciliation process.

By comparison, Speaker Ryan’s crafting of AHCA was a slapdash enterprise. Republican leaders threw in wild revisions up to the last moment in a vain effort to gain critical votes. Thursday morning brought word that the House Freedom Caucus demanded repeal of ACA’s Title I, the parts of the law that protect consumers from the harsh vicissitudes of the insurance markets. But even leading health-care experts were confused by the changes. As Timothy Jost noted at Health Affairs: “This comprehensive a repeal of the ACA would have far-ranging consequences for our health care system that can scarcely be described, much less understood, in the hours that remain before a vote.”

The more outlandish the process, the more I wondered whether the game plan was just for the House to pass something—anything—and then let the Senate do the real work. Several insiders told me that the real action would be a totally different Senate bill, and that whatever passed there would become the new law once the House assented.

As the conservative health-care analyst Philip Klein notes, the contrast with Obamacare couldn’t have been greater. Well before the Obama presidency, Democratic congressional leaders, interest groups and policy experts prepared the groundwork for the ACA, hammering out messy compromises, aligning House committees, working with presidential candidates Hillary Clinton, John Edwards and Barack Obama, all of whom proposed plans similar to what became the ACA. Then in 2009 and 2010, the House and Senate held dozens of hearings over the course of months, not days, and accepted more than 150 Republican amendments along the way. Learning the lessons of President Bill Clinton’s prior failed health reform effort, President Obama let Pelosi and her Senate counterpart Harry Reid take the lead, but he knew the intricacies of the legislation inside and out. Ryan and Trump threw in the towel after just 18 days.

So why did Republicans fail? In a word: insincerity. Republicans had seven years to do their own hard work, to coalesce around a credible conservative alternative to the ACA. They might have used this time to work with Republican governors, to explore which conservative policy ideas seem to stick, which aspects of ACA needed to be retained. They might have crafted a more moderate bill along the lines of the Cassidy-Collins bill, which would have given liberal states and Republican governors who adopted Medicaid expansion much greater leeway. Or they might have refined another conservative model, such as Avik Roy’s modifications to ACA exchanges, to turn ACA’s exchanges in a more conservative direction. They might have prepared the American public for whatever plan they chose.

They didn’t do any of this, perhaps because they believed they would never have to. Secure in the knowledge that they would face President Obama’s veto, Republicans rammed through a succession of extreme repeal-and-replace bills that resembled AHCA’s original draft. These bills excited the Republican base, but would have horrified most other Americans if they ever found sufficient reason to look. Then Congressional Republicans suffered what George W. Bush might call a “catastrophic success” with Donald Trump’s unexpected victory. They had nothing real to deliver.

Much has been made of Republicans’ hypocrisy in trying to ram the AHCA through Congress after complaining so vociferously about the legislative process that produced Obamacare. This hurt House Republicans less than the shoddy content of their actual bill, and the glaring mismatch between their political rhetoric and what their actual policy proposals were designed to do.

Nobody thinks Obamacare is perfect. Republicans from candidate Trump on down exploited real public dissatisfaction with the ACA. Millions of Americans are disappointed that the law didn’t do more to reduce burdensome insurance premiums, co-payments and deductibles. Senate Majority Leader McConnell was fairly typical, knocking the ACA for leaving 25 million people uninsured, and for leaving people in plans where the “deductibles are so high that it’s really not worth much to them.” President Trump was aided this election cycle by his apparent support for universal coverage. He vowed to replace the “failing,” “horrific” Obamacare with “something terrific.”

As Josh Barro, Ezra Klein, and Matt Yglesias impolitely note, Republicans had no plan or intention to address these complaints. President Trump has not honored his campaign promise. Republican proposals always provided smaller subsidies than ACA does, and would gut one of the key features that makes health insurance risk pools work: cross-subsidies from the young, healthy and prosperous to their older, sicker and poorer peers. Republican plans are designed around higher deductibles and narrower benefits, not to mention more limited Medicaid. The inevitable result is higher costs and more limited access for low-income people and near-retirees, and smaller financial subsidies for people with chronic health conditions. That was the clear intention, but Ryan refused to admit it.

There’s one more thing, too. Seven years ago, Democrats were proud of the ACA, even though they knew it wasn’t perfect and wouldn’t be popular—at least not at first. President Obama gave a beautiful speech rallying House Democrats before the main ACA vote, in which he said they had a rare chance to “vindicate all those best hopes that you had about yourself, about this country, where you have a chance to make good on those promises that you made in all those town meetings and all those constituency breakfasts and all that traveling through the district, all those people who you looked in the eye and you said, ‘You know what, you’re right, the system is not working for you and I’m going to make it a little bit better.’”

Many Democrats in that room lost their seats. I bet many still tell their grandchildren how they helped to insure 20 million people, about their pride in standing with President Obama. Despite all of ACA’s compromises and glitches, there was a largeness of purpose in that room, in that entire effort.

There was a conspicuous smallness to this AHCA effort, a puzzling shoddiness given the human and political stakes. Many in the GOP, above all President Trump, seemed strangely uninterested in the policy details. To the extent Republicans did have an animating passion, it was to puncture President Obama’s legacy—and to avoid looking foolish by failing to honor their “repeal and replace” rhetoric.

Only they had no viable replacement. For all their endless warnings about how Obama’s signature health law was hurting American families, driving up costs and putting us on the path toward socialism, it turns out they didn’t care enough to put in the work.