The American Health Care Act, a.k.a. the House Republicans' plan to repeal and replace Obamacare, thudded to earth on Friday afternoon after Paul Ryan concluded that he lacked the votes to pass it and pulled the bill from the floor of the House. It's always big news when the ruling party fails to enact a major legislative initiative, and even more so just two months into a new presidency. Yet the ensuing media coverage, though extensive, nevertheless gives an incomplete—and perhaps even misleading—picture of how and why the AHCA imploded so quickly and spectacularly.
Most of the stories I've seen—especially on cable news—focus their attention on Donald Trump, portraying the bill's demise as primarily a failure of the president. This is hardly a surprise. Media coverage of American politics often revolves around the presidency while giving much less attention to other relevant institutions and actors, to the extent that citizens tend to overestimate the president's responsibility for outcomes and conditions.
Trump had also set himself up for a splash in the media dunk tank by spending the past year promising voters a health care plan that simultaneously expanded coverage and reduced costs, and by bragging that his unmatched skill at negotiation would easily overcome any remaining policy disagreements. Now that events have confirmed the widespread suspicion that both claims were pure fiction, journalists will not be shy about pinning the AHCA's failure on a president whom they already view as having a big problem telling the truth.
Over the past 24 hours, several inside accounts have been published that portray Trump as having blundered through meetings with congressional Republicans, exposing a lack of policy command and an empty desire to achieve an easy legislative "win" for its own sake rather than a demonstrated commitment to a particular set of substantive goals. Trump and his advisor Steve Bannon also apparently lectured and threatened Republican holdouts in ways that ultimately backfired in attracting support.
Those not inclined to solely blame Trump for the demise of repeal-and-replace—including the White House itself—have mostly aimed their shots at Ryan instead. Liberals who have rolled their eyes for years at Ryan's boy-genius reputation in Washington claim righteous vindication from this week's events, while some conservatives sympathetic to Trump have sought to shift responsibility to the speaker for drafting an unpopular and politically risky bill that could not make it through his own House.
While it's certainly true that both the president and the speaker made mistakes in handling the health care issue, it's inaccurate to portray the demise of the AHCA as primarily a consequence of individual failures of leadership or strategy. Replace Trump and Ryan with Marco Rubio and John Boehner, or Jeb Bush and Kevin McCarthy, and the results would almost certainly be more or less the same. The bill died so quickly, and was so far away from success when it did fail (remember, the House was by all accounts the easier lift of the two chambers), that the specific day-to-day behavior of the principal actors seems inadequate to account for the result.
The real obstacle to the passage of health care reform is the Republican Party itself, and any full reckoning with what just happened has to grapple with that fact. Nearly eight years of attacks on the ACA as a "government takeover" of health care, along with repeated promises to replace the hated Obamacare with an unspecified superior alternative, paid considerable electoral dividends but left the party committed to an unachievable policy goal. Republican leaders desperately sought to placate conservatives calling for a broad rollback of federal responsibilities and expenditures, but they simultaneously refused to acknowledge that satisfying these demands in practice would result in a reduction of coverage and a relaxation of popular regulations—which in turn would alienate swing voters and mobilize political opponents.
The national party has also become increasingly influenced, if not controlled outright, by unelected activists and news media personalities who gained considerable internal power during the Obama years by constantly criticizing Republican officeholders for insufficient ideological loyalty. This dynamic has, perhaps inevitably, resulted in the formation of a faction within the congressional GOP that plays to this constituency, even when doing so is counterproductive to legislative productivity or concrete policy achievement. From the Freedom Caucus in the House to the Ted Cruz-Mike Lee axis in the Senate, the existence of these self-appointed keepers of the purist conservative flame deprives the Republican leadership of a functional partisan majority on major legislation, and this obstacle has not been removed with the election of a Republican president.
Mainstream Republicans, Trump included, have viewed the entire health care policy domain most of all as a useful club with which to beat Democrats, while hard-line conservatives have likewise viewed it as a useful club with which to beat mainstream Republicans. The various partisan and electoral motives at play have often governed Republican behavior to politically successful ends, but few within the party have concentrated on the more difficult and less immediately rewarding task of first developing workable policy alternatives to the ACA and then investing substantial energy in building support for them among their colleagues.
Some critics have argued that the AHCA, a bill that was transparently pulled together in a matter of weeks with little expert input or elite support, ultimately failed because it was bad policy. Maybe so. But we should be wary of the ensuing implication that a "better" bill would have stood a stronger chance of passage in the House. It's fair to criticize Ryan for the legislation that he drafted and promoted, but he presumably believed its provisions would best reconcile the conflicting demands of swing-seat moderates and conservative purists. The revisions made in the final hours in a futile effort to attract greater support on the right suggest that opponents of the bill would not have been easy to satisfy even with a more thorough policy-making process.
Congressional Republicans' increasingly apparent challenges in reaching internal agreement on policy—which even Ryan was forced to publicly acknowledge yesterday—do not bode well for the rest of the party's legislative agenda, from tax reform to appropriations to the looming federal debt ceiling. Nor does the current chaotic state of the Trump administration, which will hardly be in the position to deliver much assistance to Ryan and Mitch McConnell in the exercise of their leadership responsibilities over the coming months.
Up to now, the news media and Washington community have treated Trump's shocking ascension within the GOP as a more-or-less random event—the hostile takeover of an otherwise sound party apparatus. But it's time to devote much more serious consideration to the question of whether its existing internal dysfunction left the contemporary Republican Party uniquely vulnerable to a Trump-led ambush. As any health care expert knows, an effective remedy for one's ills first requires a correct diagnosis.