How disastrous for Trump is healthcare collapse?

Anthony Zurcher
North America reporter
@awzurcheron Twitter

media captionTrump's battles with Obamacare - in his own words

How bad was Friday's defeat of the American Health Care Act in the House of Representatives? Bad. Very bad.

After a tumultuous week, it's worth stepping back for a bit of perspective.

For the first time in 11 years, Republicans control the presidency and both chambers of the Congress.

There are 44 more Republicans than Democrats in the House of Representatives.

Republicans have been vociferously calling for repeal of President Barack Obama's healthcare reforms for seven years.

The American Health Care Act was the first major piece of legislation pushed by the White House and the Republican-controlled Congress, a key political test early in the president's term, when he should be at the height of his power and party cohesion at its strongest.

In spite of all of this, Mr Trump, House Speaker Paul Ryan and the Republicans running Washington could not get the job done. The president tried to lay the blame at the feet of the Democratic House minority. Nobody will buy that.

For Republicans Friday wasn't just bad. It was a disaster. Here are five reasons why.

A busted dealmaker

media captionPresident Trump 'open' to healthcare deal with Democrats

Donald Trump staked his reputation as a dealmaker - as a "closer" in the words of press secretary Sean Spicer - on getting the healthcare bill through the House of Representatives.

The president sang the bill's praises on Twitter, in press events and at campaign-style rallies.

On Friday Spicer told reporters the president had gone through "extraordinary feats" to try to get the bill approved.

"Has he pulled out every stop, has he called every member, has he tweaked every tweak, has he done every single thing he can possibly and used every minute of every day that's possible to get this thing through, then the answer is yes," Spicer said.

The reality, whether or not the president tried his absolute best, is that the bill went down in flames. Not only that, but all the threats and promises he made in the process were proven to be hollow.

He guaranteed a vote on Thursday that didn't happen. Then guaranteed a vote on Friday, and that didn't happen either. He warned his party of the dire consequences of a failure to act, and they ignored him.

Just over two months into his presidency, and Mr Trump's poll numbers are sagging, his agenda is on the ropes and his power is greatly diminished.

A powerless speaker

media captionPaul Ryan: "I won't sugar coat this. This is disappointing"

If it was a bad day for the president, it was a terrible day for Speaker of the House Paul Ryan, whose inability to control his congressional cohort was exposed for all to see.

As he stood before the cameras explaining the defeat, he looked and sounded like the coach of a team that had just lost a big game it had been favoured to win.

"We came really close," he said, "but we came up short."

The speaker of the House has considerable power to wield over individual members. He sets the rules of debate. He controls choice committee assignments, determines key legislative priorities and can direct party funds to his supporters.

All of that wasn't enough to prevent wholesale desertion on this bill from the left and right flanks of his party.

The conservative House Freedom Caucus may only be 29 members strong, but it proved it could go toe-to-toe with Mr Ryan and prevail, even squeezing a number of major concessions in the last few frenetic days.

Now that they have a taste of victory, they will be an even more potent thorn in Mr Ryan's side in future legislative battles.

An agenda derailed

image copyrightEPA

The New York Times recently reported that the president has been grousing privately that he never should have agreed to take on healthcare reform as his first legislative priority.

Although he mentioned the topic repeatedly on the campaign trail, it always felt like a throw-away line offered to the Republican base - a bit of conservative gospel that party stalwarts expected to be repeated.

Policies like trade, infrastructure spending, tax reform and that "big, beautiful" wall on the US-Mexico border were always nearer and dearer to the Mr Trump's heart.

Those agenda items, however, are now at risk, as healthcare reform sinks beneath the waves. Tax cuts, for instance, are made considerably more complicated as long as the tax aspects of Obamacare remain on the books.

Wall Street investors are already expressing their growing pessimism over any serious tax-policy efforts, with stock prices sagging as the prospect of Republican healthcare reform's success dimmed, for instance.

There will still likely be members of Congress who want to keep plugging away on Obamacare repeal, seeing as how they campaigned on it for the past seven years. It will be difficult to agree on where to go next, and not everyone will be keen to listen to a president who botched his first big legislative test.

Healthcare in flux

"I don't know what else to say other than Obamacare is the law of the land," Mr Ryan said in his afternoon press conference conceding defeat. "We're going to be living with Obamacare for the foreseeable future."

Mr Obama's healthcare reform may remain in place, but its future is still murky. Although Congress has failed in its attempt to dismantle the law, the Trump administration can still do a great deal to undermine it through executive action - in fact, it already has.

image copyrightGetty Images

The mandate that all Americans purchase health insurance isn't being enforced. Efforts to encourage enrolment through the healthcare marketplaces are being curtailed. More states will be given leeway to alter and adjust how they implement their components of the law. All of this could significantly affect how Obamacare looks and operates across the US.

Mr Trump has repeatedly said that it was the wiser political move for Republicans to let the Obamacare systems collapse on their own and then blame the resulting chaos on the Democrats. While the political wisdom of this strategy is uncertain, the fact remains that Mr Trump and his administration could go a long way toward causing the works to "implode and then explode", in the president's words.

The law as it's currently constituted does have some self-correcting measures to prevent total collapse, however. If insurance rates increase, the size of the government price supports will grow accordingly. The basic regulations - such as "essential coverage" guarantees and price controls - will remain.

The bottom line is Obamacare lives to see another day - and, perhaps, another Democratic rise to power, when it can be more fully revived.

An angry base

For seven years Republicans have been promising that they will tear up the Obamacare "root and branch", in the words of Senate Majority Leader Mitch McConnell. Success, they've said, is just an election away.

In 2010 Republicans won control of the House of Representatives. In 2014 they won control of the Senate. In 2016 they won the presidency. At last, Republican grass-roots activists were told, victory was in their grasp.

Only victory, at least for now, has slipped through conservative fingers once again.

image copyrightGetty Images

At some point, the Republican base may start to wonder whether Obamacare is ever going to go away. And at some point if it doesn't, they may start to wonder why.

It's worth remembering that the reason the effort to pass the American Health Care Act failed was because the Republican Party itself was torn asunder on what to do about healthcare. Moderates feared that the proposed legislation would leave too many of their constituents without healthcare. Conservatives, on the other hand, thought the repeal efforts didn't go far enough.

Those problems aren't going to disappear anytime soon. While in the minority, it's been easy for Republican politicians to promise their voters "action" and "change". Now that they're in power, it has proven difficult to translate those words into policy.

When the next election rolls around, the Republican Party may face a Democratic Party that has been stirred into action and a Republican base disillusioned by their party's failure to perform. That, needless to say, is a recipe for electoral disaster.