House Speaker Paul Ryan thought he had found the “sweet spot” in the Republican health care plan – a bill that would appeal to both GOP conservatives and moderates.

But on Thursday, sweet turned sour. Despite intense coordination with the White House and the president’s personal involvement on the GOP bill to repeal and replace Obamacare, the speaker was forced to delay the bill for lack of Republican votes. A new vote is scheduled for Friday.

If Speaker Ryan is unable to forge a compromise that will bring him to victory, it will be a huge blow to the Republican agenda, to his speakership, and to President Trump.

Failure on such a high priority campaign promise would be “a very bad sign for Trump, Ryan, and the entire GOP agenda,” writes John Pitney, a congressional expert at Claremont McKenna College in Claremont, Calif., in an email. “Trump has said that his next big priority is tax reform, but he will find that this issue is just as complicated and contentious as health care reform.”

It’s unclear just how this will be resolved – or if it will be. Negotiations with the holdouts – mainly conservative members of the hard-line House Freedom Caucus, but also moderates – will continue.

“We’re going to get to the finish line,” Freedom Caucus leader Rep. Mark Meadows (R) of North Carolina, told reporters Thursday, saying negotiations are “making progress.” Still, he said, the caucus is trying to get another 30 to 40 “no” votes to “yes.” The speaker can afford to lose only 21 or 22 votes, depending on the number of people present.

But the factors that contributed to this embarrassing setback haven’t changed: ideological divisions within the GOP, a rushed and unwieldy process to tackle a complex issue, and a piece of legislation that’s not very popular.

Inability to bridge the divide in the House shows the bill “wasn’t conservative enough, and it was too conservative” at the same time, says G. William Hoagland, a health-policy expert and senior vice president of the Bipartisan Policy Center.

'Just so many questions'

“There’s just so many questions” about the bill, called the American Health Care Act, Rep. Walter Jones (R) of North Carolina told reporters on Wednesday. He planned to vote “no,” and said that emails and phone calls from his district totaled 800 in opposition to the bill, and only four in support. Voters oppose the GOP plan by a 3-to-1 margin, according to a Quinnipiac poll released Thursday.

The whole thing has been rushed, Congressman Jones complained, and said he’s particularly worried about tripling insurance premiums for older Americans who don’t yet qualify for Medicare. He has also received letters from the Paralyzed Veterans of America who have problems with the bill.

Republican House leadership beefed up financial assistance in their bill after moderate members – and some conservatives – were rattled by a nonpartisan Congressional Budget Office estimate that the GOP’s plan would leave 24 million people without coverage and significantly raise premiums on older Americans.

The report also estimated a cut of federal Medicaid dollars to the states by $880 billion, as the plan radically restructured this federal-state program for the poor.

To satisfy conservatives, the leadership allowed states greater flexibility to manage Medicaid, including the option to add work requirements for childless, able-bodied adults. But the changes were not enough, and hard-right Freedom Caucus members – supported by a few like-minded senators – are holding out for more.

They want assurances that premiums will come down and reportedly asked for documentation to that effect when they met with President Trump on Thursday morning. Some of them also want to kill all regulations in the Affordable Care Act – including protection from pre-existing conditions and keeping young adults on their parents’ plans, which Trump won’t back down on.

What the president apparently did offer was to strike the “essential benefits package” required of all health insurance plans, which says minimal coverage must include such things as mental health coverage, preventive care, and maternity care. That wasn’t enough for the caucus members, who say killing all the regulations will allow more competition and choice and bring down premium prices.

If the House leadership moves too far to the right, however, it jeopardizes support from House moderates, as well as passage in the more moderate Senate – already a very steep climb.

“There is a lot of concern” about the House bill, says Sen. Susan Collins (R) of Maine, a moderate who opposes the bill.

While she would welcome more flexibility in the types of plans that could be sold, “we have to remember that the essential benefits include substance-abuse and mental-health treatment that are critical to retain for my state and for many others given the opioid crisis,” she says.

The nonpartisan Congressional Budget Office scored the revised bill Thursday and says it would result in $150 billion less in savings, but still result in 24 million people losing health coverage.

Like several other Republican senators, Senator Collins believes the process needs to slow down.

Go-it-alone effort

Much of the debacle is due to the Republicans’ go-it-alone effort, observers say.

Two transformative presidents, Democrat Lyndon Johnson and Republican Ronald Reagan, were able to pass major bills by putting together bipartisan coalitions.

“That option is not available to Donald Trump,” explains Professor Pitney. “He has to pass it with Republican votes only, and his party is just so deeply divided.”

Republicans campaigned vigorously against President Obama’s Affordable Care Act in the last four elections, vilifying it and promising to pull it out “root and branch.” Democrats were not about to help them with this extraction, despite obvious problems with the law. They mounted a huge public campaign to defeat the GOP effort.

Republicans have “put themselves in a box canyon,” says longtime congressional observer Norman Ornstein, of the American Enterprise Institute, a center-right think tank.

The GOP’s do-it-yourself approach has forced the party to use an unwieldy budget process whose upside is that it only takes a majority vote in both houses to pass a bill – but whose downside is that the legislation has to relate strictly to the budget.

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It’s therefore not possible to completely repeal Obamacare and all of its stipulations using this budget process, called reconciliation, Republican leaders have explained. That’s a real problem for hard-liners who refer to the GOP bill as “Obamacare-lite.” Now they are trying to find a way around that to meet Freedom Caucus demands.

What Republicans are discovering is how difficult it is to take away a health benefit – even an imperfect one – and how complex health policy is, says Amy Black, a political science professor at Wheaton College in Illinois. “ ‘Repeal and replace’ is really catchy campaign rhetoric and works really well in that forum, but ‘repeal and replace’ is actually a very complicated path to take.”