The decision leaves President Barack Obama’s chief domestic achievement in place and raises questions about the GOP’s ability to advance other high-stakes priorities, including tax reform and infrastructure spending. Ryan (R-Wis.) remains without a signature accomplishment as speaker, and the defeat undermines Trump’s image as a skilled dealmaker willing to strike compromises to push his agenda forward.
In an interview with The Washington Post, Trump deflected any responsibility for the setback and instead blamed Democrats. “We couldn’t get one Democratic vote,” he said.
“I don’t blame Paul,” Trump added, referring to Ryan.
Trump said he would not ask Republican leaders to reintroduce the legislation in the coming weeks, and congressional leaders made clear that the bill — known as the American Health Care Act — was dead.
Shortly after the decision, Ryan told reporters his party “came really close today, but we came up short.” He added: “We’re going to be living with Obamacare for the foreseeable future.”
“It’s done, DOA,” said Energy and Commerce Committee Chairman Greg Walden (R-Ore.), who drafted much of the legislation. “This bill is dead.”
Instead, Republican leaders said, they would wait for the Affordable Care Act to encounter fatal problems, believing that Democrats will then want to work with them to make changes.
“As you know, I’ve been saying for years that the best thing is to let Obamacare explode and then go make a deal with the Democrats and have one unified deal,” Trump said. “And they will come to us, we won’t have to come to them.”
It remains far from certain that Republicans, in control of the White House and both houses of Congress, will be able to credibly foist responsibility for the nation’s health-care woes onto Democrats. What is certain is that Republicans continue to have difficulty turning their campaign promises into legislative action.
For seven years, GOP candidates have pledged to repeal the Affordable Care Act, which expanded Medicaid and created subsidized, state-based exchanges to expand health insurance coverage to 20 million Americans, decrying the taxes and government mandates it enacted.
“Since 2010, every Republican, with the exception of probably a handful, has campaigned from dogcatcher on up that they would do everything they could to repeal and replace Obamacare,” White House press secretary Sean Spicer said Friday. “To get in and say you’re going to do something else would not be fair to the American people.”
But in that time, the party never coalesced around a consensus alternative to the law, and the scramble to develop one after Trump’s election revealed some of the reasons: Republicans were loath to repeal popular ACA provisions such as a requirement that insurers cover those with preexisting conditions and dependents up to age 26 but wanted to repeal the taxes and the individual mandate to have insurance that helped make those provisions possible.
The policy difficulties were amplified by an ideological cleavage within the House GOP. Conservative hard-liners chafed that the Ryan-drafted bill left too much of the ACA in place and enshrined a federal role in health insurance markets, while moderates feared that cuts to tax subsidies and Medicaid would leave their constituents uncovered and their states with gaping budget gaps.
The drama on Capitol Hill unfolded amid new evidence that public opinion was running against the bill: A Quinnipiac University poll released Thursday found that U.S. voters disapproved of the legislation 56 percent to 17 percent, with 26 percent undecided.
Signs of trouble across the Republican spectrum were evident by midday Friday, as lawmakers streamed onto the House floor for a procedural vote.
In one stunning defection, House Appropriations Committee Chairman Rodney Frelinghuysen (R-N.J.) announced midday that the bill was “unacceptable” and that changes made late Thursday to placate conservatives “raise serious coverage and cost issues.”
He was joined by rank-and-file members such as Rep. David Joyce (R-Ohio), a low-key appropriator, and Rep. Barbara Comstock (R-Va.), a longtime Ryan ally who represents a competitive Northern Virginia congressional district.
But the White House and House leaders both saw the key bloc as the House Freedom Caucus, a group of roughly three dozen hard-line conservatives who made numerous demands of the bill since January — including a flat repeal of the ACA, a major reworking of the GOP bill’s tax incentives and new Medicaid restrictions.
Most of those demands were rejected, primarily due to the political reality of holding a Republican majority together in support of the bill.
The Freedom Caucus chairman, Rep. Mark Meadows (R-N.C.), became a central player in the negotiations, however, and the group kept an open line to the White House — particularly with chief strategist Stephen K. Bannon and Office of Management and Budget Director Mick Mulvaney, who had been one of its founding members. The group made a final demand this week: The bill had to eliminate a set of ACA insurance mandates that, it argued, were a key factor in driving up premiums.
In a Thursday morning White House meeting, Trump made what would be his final offer: The bill would gives states the option to eliminate some of the mandates, 10 “essential health benefits,” but would leave others in place.
That afternoon, the Freedom Caucus met to reject the deal. Hours later, Mulvaney came to a closed-door House GOP conference meeting to deliver a final ultimatum, saying Trump was ready to move on if the bill failed Friday. Afterward, members lined up at microphones to deliver emotional pleas for party unity. Some were veiled critiques of the Freedom Caucus; others were less veiled.
During the midday procedural vote Friday, Ryan asked Meadows if his group had changed its stance. It had not, Meadows told him — meaning as many as 20 hard-liners would oppose the bill. Twenty-two Republican no votes would sink the bill, and more than a dozen other members had announced their opposition by Friday afternoon.
Ryan left shortly after for the White House to tell Trump the bill would fail.
Meadows declined to answer questions after the bill was pulled on Friday. But several Freedom Caucus members said they would not be cowed by Ryan or even Trump — a figure most of them had enthusiastically supported.
“You know what? I came here to do health care right,” said Rep. Paul A. Gosar (R-Ariz.), who was one of six Republicans who voted against the procedural measure.
“A no vote means we save Donald Trump from a Democratic majority in 2019,” said Rep. Louie Gohmert (R-Tex.), one of Trump’s most ardent congressional supporters.
The defeat has left the remainder of the Republican governing agenda in Congress in tatters. A proposed corporate tax overhaul favored by Trump and Ryan depended, in part, on the health-care legislation proceeding — creating both political momentum and fiscal space for dramatic action.
Before the bill was pulled Friday, Rep. Bradley Byrne (R-Ala.) called it the “first big vote in the presidency of Donald Trump,” one that would be “a statement, not just about him and the administration but about the Republican Party and where we’re headed.”
“So much about political power is about perception. And if the perception is that you can’t get your first big initiative done, then that hurts the perceptions down the road about your ability to get other big things done,” Byrne said.
Trump had personally lobbied 120 lawmakers, either in person or on the phone, Spicer told reporters on Friday. The president, he said, had “left everything on the field.”
The White House did not think that defeat would slow other parts of Trump’s agenda, including tax reform and changes to immigration, Spicer added.
Vice President Pence, White House Chief of Staff Reince Priebus and Health and Human Services Secretary Tom Price also engaged in last-ditch attempts to win over members Friday — including a midday huddle with Freedom Caucus members at the Capitol Hill Club, a GOP social hall next door to the headquarters of the Republican National Committee.
The heart of the argument made by GOP leaders was that keeping the Affordable Care Act would be a worse outcome than passing a potentially flawed replacement. That worked with some Republicans, but not all.
Rep. Joe Barton (R-Tex.), a Freedom Caucus member who said he would have voted for the bill, rejected the idea that the hard-liners were to blame.
“I thought we were constructive,” he said. “Because of the sensitivity of the issue, some of the normal compromise mechanism didn’t quite get us there. That doesn’t mean they won’t get us there sometime in this Congress.”
At the Capitol, a deflated Ryan said he would confer with fellow Republicans in the coming days about how to proceed, but he made clear health care would no longer be a central agenda item.
“Moving from an opposition party to a governing party comes with growing pains,” Ryan told reporters. “We’re feeling those growing pains today.”
“Doing big things is hard,” he added.
Trump said he had no problem waiting for Democrats to seek cooperation with Republicans on health care: “I never said I was going to repeal and replace in the first 61 days.”
In fact, Trump said repeatedly as a candidate and before his inauguration that he would work to repeal the ACA on his first day in office.
Democrats, completely sidelined as Republicans quarreled among themselves, quickly disputed Trump’s accusations.
“The blame falls with President Trump and with the Republicans,” Senate Minority Leader Charles E. Schumer (D-N.Y.) said in a statement.
“So much for the art of the deal,” he added.
Kelsey Snell, Sean Sullivan, David Nakamura, David Weigel, John Wagner and Paul Kane contributed to this report.