Trump alone is not to blame for this. Trump didn't care about the details -- he only wanted a "win" -- and thus embraced Paul Ryan's plan. It is Ryanism, which includes repeal-and-replace as part of the broader goal of shredding the safety net, that helped create this disaster. Ryan was supposed to craft a policy that would prove ideologically satisfactory to congressional Republicans and could also be sold through shrewd rhetorical subterfuge as a fulfillment of Trump's promise of better health care for everybody at lower costs. The CBO blew all that up by unmasking its truly regressive nature and, in the process, the big policy lie at the core of Trump's repeal-and-replace promise. The details ended up mattering.