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9 Strategic Mistakes President Trump and Republicans Made on Health Care

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Updated: | Originally published: ;

During the phone calls, which came to House Speaker Paul Ryan at all hours, President Trump had one question more than any other: When can you get Obamacare repealed? The details didn’t much matter for Trump. He wanted a victory.

It turned out that dismantling a law affecting one-sixth of the U.S. economy was a lot more popular as a slogan than as legislation, and that victory proved difficult to secure. Republicans’ made their first stab toward repeal on Friday, only to have the effort spiked at the hands of their own members. Democrats stood unified and the Republicans, who hold the majority, could not. Ultimately, Ryan pulled the bill from consideration just before members of the House were set to cast votes.

“We came really close today, but we came up short,” Ryan told reporters on Capitol Hill. “This is a disappointing day for us.”

At the White House, Trump estimated he was 10 or 15 votes short of the finish line. “We learned a lot about loyalty,” Trump said, seated in the Oval Office and clearly stung by the loss.

Trump, Ryan and their allies made a number of tactical errors as they tried to deliver on a promise made repeatedly over the course of several campaigns. Ryan called repealing Obamacare a promise that demanded to be made into action, but many in his caucus agreed with the principle but not the specifics and rejected the path forward. “We’re going to be living with Obamacare for the foreseeable future,” Ryan said, suggesting healthcare was off the table for the time being.

Here are some of the reasons the Obamacare gambit failed.

Donald Trump campaigned with big promises. As a candidate, Trump told his crowds that he would improve and expand care, bring down costs for treatment and drugs, and give Americans more choices. His pledges won him huge applauses and enough votes to earn the presidency. But it left fellow Republicans in something of a lurch.

For one, the centerpiece of the Republicans’ healthcare plan was to scrap the requirement that everyone buy insurance or pay a penalty. By removing that requirement, it would reduce the number of people buying coverage, which, in turn, would make prices continue their climb upward. The Congressional Budget Office, the nonpartisan referee of policy and money, estimated that some 24 million fewer people would have coverage under the plans the GOP considered.

At the same time, Trump’s promise to make care cheaper ran into stiff headwinds in the House. In a bid to win over conservative lawmakers, Trump agreed to scrap provisions of the bill that covered emergency room care, prescription drugs and mental health coverage. (In the end, the play wasn’t enough and alienated many moderates who hail from states plagued by the opioid crisis.) And the promise to bring drug prices down through government edict ran afoul of legislative rules. Eventually, costs would come down, according to the budget chiefs—because older Americans, who require more care, couldn’t afford to buy coverage in the first place.

Finally, Trump promised he would protect Medicaid, the health program for lower-income Americans. The CBO says the plan would spend $880 billion less over the next decade than if the law were untouched. The White House says that’s not a cut, but merely capping spending increases at 3.7 percent instead of the currently projected 4.4 percent growth rate.

Trump believed his record was predictive. At first, they said Trump wasn’t going to really run for President. Then, there were doubts if the thrice-married billionaire could carry a single state in a Republican primary. Then, he was going to be shut out of the race in South Carolina, Michigan, Florida and then, finally, Indiana. Opponents considered how to deny him the nomination at the party’s convention in Cleveland, then mulled dropping him from the ticket as scandal engulfed his campaign just before the second of three debates. Finally, Trump’s critics took solace the last weekend before Election in the polls that showed Democratic nominee Hillary Clinton leading Trump. Surely, he wasn’t going to win the White House. At every juncture, these naysayers were proved wrong.

Before Friday, the laws of political physics had yet to apply to Trump. Even after being shown, on video, to brag about sexually assaulting women, Trump still carried the majority of white female voters. So he counted on his luck continuing as he pushed his first major piece of legislation in the face of a hostile reality. Everyone on the TVs he watches so much had often been proved wrong, and he wanted another shot at making them look foolish. After all, it’s how he arrived at the White House and winning against all odds was all he knew in politics.

Trump famously is not a details person. The New York billionaire is accustomed to striking the broad outlines of agreements and leaving his lieutenants to hammer out the minutiae of his business dealings. In health care, an incredibly difficult policy morass where one errant breeze can result in billions of accounting changes, glossing over the details as not useful.

Health care professionals in Washington and around the country alike guffawed when Trump made an offhanded comment to Governors and health executives meeting with him at the White House. “It’s an unbelievably complex subject. Nobody knew health care could be so complicated,” Trump mused. Actually, many in the room were aware of the pitfalls and were there to urge Trump to more seriously consider what lay before him.

Even as the repeal plan appeared in peril, Trump turned to Twitter (of course) to cajole reluctant lawmakers from the conservative Freedom Caucus. He warned his 27 million online followers that if the Freedom Caucus didn’t support the plan, they would in allow Planned Parenthood to keep open its doors. The President didn’t seem to understand that the bill’s plan to defund the women’s health group—which in addition to abortion at some clinics funds services such as mammograms and contraception—would not survive the Senate. Separately, a Quinnipiac University poll found 62% of all Americans oppose cutting off federal dollars, which cannot fund abortions, from Planned Parenthood.

It’s tough to take away programs. Even those who despise Barack Obama and his health care plan have benefited from it. A Kaiser Family Foundation analysis found that at least 3 million people who live in consistently Republican-voting states receive health care subsidies to help them afford coverage. Adding in the swing states that Trump won, that number goes to 6 million people. Confronted with a Bloomberg analysis that the Republicans’ plan would disproportionately have a negative impact on countries that Trump carried, Trump seemed nonplussed. “I know,” he told Fox’s Tucker Carlson.

Many lawmakers were insistent that any repeal effort be coupled with a replacement plan to fill in the gaps. As written, it had some serious limits that Democrats were eager to highlight. In the end, the pressure mounted and enough Republicans realized that ditching programs that touch every constituent back home was bad politics. There is, after all, a reason Republicans have never dismantled FDR’s New Deal programs or LBJ’s Great Society efforts.

The outside groups did not buy in. It’s tough to oversell the powerful hive of outside conservative groups that have tremendous influence in the Republican Party. Breaks with party orthodoxy often result in primary challenges from deep-pocketed interest groups who seek to punish scofflaws. In ways, these fights become proxy battles over competing spheres of influence in the GOP, and millions from outside the states are not uncommon. The Establishment-minded U.S. Chamber of Commerce, for instance, backed a primary challenger in Kansas against a tea party firebrand who needled party leadership and had the backing of the network backed by billionaires Charles and David Koch.

This year, the nexus of outsiders stood ready. FreedomWorks, a libertarian group that organizes grassroots activists, staged a rally in opposition on Capitol Hill that drew favorites like Sens. Rand Paul of Kentucky and Ted Cruz of Texas—both of whom lobbied allies in the House to stop the bill as written. Heritage Action, the political arm of the respected Heritage Foundation, sent lawmakers a reminder that it was strongly opposed “an awful bill that will impact millions of Americans’ lives and is opposed by nearly every serious conservative health care analyst. This legislation is a policy, process and political disaster.” And the Koch network was ready with millions to give defectors political cover.

By contrast, Trump threatened lawmakers who didn’t sign on with re-election troubles of their own. Yet his outside political arm has yet to show its teeth. Its most memorable work so far has been a series of tweets and a commercial criticizing CNN’s Jim Acosta. Its leaders have been busy on Twitter, but it’s tough to match millions in campaign cash with 140-character bursts.

Trump trusted Ryan. The union of these two was always rocky. Trump is an outsider who has few unbendable political beliefs, while Ryan was a junior aide to Jack Kemp and student of his conservative ideology. Trump prides himself on being unpredictable whereas Ryan likes order and regimen. Trump vamps his way to victories while Ryan met with reporters armed with a PowerPoint about their strategy.

Ryan, who considered going to the University of Chicago to study economics, had hashed through details and legislative language with his trusted inner-circle at the Capitol. Asked about potential amendments and changes just after the New Year holiday, aides dismissed them. The plan Ryan had crafted was the plan. And the White House sent aides regularly to the Capitol for updates.

A fractured House had other ideas. Freedom Caucus members were champing for more severe changes that would fun afoul of Senate rules if not Senate votes. Ryan tried to explain that if his conference wanted to take an absolutist repeal, they would need the almost-impossible 60 votes in the Senate and not just the 51 they were seeking under the current legislative process. Fueled by outsiders and folks like Cruz, the deeply conservative members insisted on more concessions.

Trump then opened negotiations. Trump sees himself as a talented negotiator. He is credited with a New York Times best-seller titled The Art of the Deal. He sees everything as a give-and-take—contracts, legislation, politics, family life. There are always better terms to be had. Trump agreed to some of the Freedom Caucus demands, such as letting states decide what were deemed “essential services” in plans regulated by state insurance commissions. (Governors and state lawmakers, it should be noted, were none-too-eager to have the choice about whether to cover pre-natal care land in their laps.)

Freedom Caucus members were goaded on. Rand Paul bought his House colleagues copy of Trump’s Art of the Deal to highlight how Trump saw the world as a string of compromises in pursuit of a win. The Freedom Caucus had notched one victory. It was time for another. And another. And another. But they were not officially signing on as supporters, and ever shift rightward made it more difficult for lawmakers from swing districts or from moderate ideological backgrounds to acquiesce. Finally, Trump had reached his limit. He sent his budget chief, a former Freedom Caucus member, to the Hill to tell lawmakers that negotiations were over. He had done enough.

The Republicans forgot how to govern. After eight years with Obama in the White House, the GOP had forgotten how to pass legislation that the White House would sign. Ryan said he was aware of the problem during a 10-minute session with reporters where he accepted blame for the failure. He repeatedly said his caucus was used to functioning as “an opposition party” looking to move into a governing one. “We weren’t just quite there today. We will get there,” Ryan said.

Trump demanded a vote. His budget chief, Mick Mulvaney, and other top aides told Ryan that it was time to vote. The White House was done with the drama, at Trump’s insistence, and was ready to move on. His team issued an ultimatum late Thursday. (None of this took into account the headache the Senate would have carried with it for several more weeks of bill rewrites and negotiations.)

Trump wanted a conclusion. What started as a way for him to declare major victory became a crisis in search of an exit strategy. He met with Ryan midday Friday, during which time the House Speaker urged him to reconsider his insistence on having a recorded and messy vote. Trump listened and agreed. It was the most serious setback for his young Administration. Trump wanted out—and, given his proclivities, an enemy to blame for this embarrassment that ultimately left him weaker as he looks ahead to the next skirmish.

— With reporting by Sam Frizell and Zeke J. Miller in Washington.

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Write to Philip Elliott at philip.elliott@time.com