(photo illustration by The Washington Post)

Let the blame game begin.

Republicans’ failure to overhaul the U.S. health-care industry has ushered in a round of internal finger-pointing that threatens to deepen the very rifts that doomed the deal — and carve new ones that are likely to complicate the GOP’s ability to function in the Trump era.

Recriminations have been underway for weeks, but they intensified Saturday and cast a new spotlight on the breakdown that led Speaker Paul D. Ryan (R-Wis.) to pull the American Health Care Act from the House floor Friday afternoon, after it became clear to him and President Trump that they did not have enough Republican votes to pass it.

Some top Republicans interviewed Saturday singled out Ryan for blame, arguing that he did not sufficiently represent the views of conservative lawmakers or interest groups, who had pressed for a fuller repeal of the law. But some blamed Trump or his aides for not smoothing out the differences, a sentiment that has been stronger privately than in public. Still others found fault with various GOP factions and interest groups, on the right and in the middle, who opposed the bill.

All of this puts pressure on Trump, Ryan, the hard-right House Freedom Caucus and the moderate Republicans who voted against the bill to shore up their relationships and show the nation that they can achieve real successes together.

(Jenny Starrs/The Washington Post)

“Paul Ryan is a really smart policy guy, and we saw that on display,” Club for Growth President David McIntosh said in an interview Saturday. “But he lacks the legislative skills to put together a coalition to get the bill through.” The Club for Growth circulated a memo Saturday arguing that “conservatives saved Republicans from voting for their own version of Obamacare.”

Other Republicans argued that groups such as the Club for Growth and the hard-right House Freedom Caucus are at fault for stubbornly opposing the bill and continually demanding a more aggressive attack on the Affordable Care Act.

“Quite frankly, I think we had a group of people that are traditionally ‘no’ on everything. And they vote as a bloc. And so you’ve got to penetrate that bloc. And so we’ve got figure out how to do that,” said Rep. Mike Coffman (R-Colo.).

“I sometimes wonder with some of my colleagues, though, if they wrote the bill themselves, whether they could get to yes, you know?” said Rep. Bill Huizenga (R-Mich.). “Because it’s about protecting their brand or protecting their voting record or protecting their purity with an outside group.”

The bill also had its fair share of critics from the more moderate wing of the party — which has led some to conclude it’s not about Ryan or Trump but the hard-to-reconcile nature of the GOP right now.

“This is not a failure of leadership; it’s a failure of follow-ship,” said Rep. Tom Cole (R-Okla.), a frequent defender of both Ryan and Trump.

That still puts the burden on Ryan to figure out how to manage a new dynamic within his conference, with right and left flanks willing to buck him.

Which Republicans forced Trump to pull the health-care bill
‘We’re a no’

The discord started weeks ago but reached a critical point Thursday night, when the members of the Freedom Caucus sat in the Capitol before Ryan, White House chief strategist Stephen K. Bannon and budget director Mick Mulvaney, who had helped found the group of Republican hard-
liners two years ago.

With the bill — and the rest of Trump’s legislative agenda — hanging in the balance, Ryan polled the room: Would they support the bill after changes that would partially, but not entirely, meet their demands?

Rep. Mark Meadows (R-N.C.), the group’s chairman, spoke up: “I speak for the group. We’re a bloc. And we’re a no.”

The meeting sealed the fate of the AHCA, which would be pulled from House consideration less than 24 hours later, and brought to a head months of simmering frustrations between each of the parties — the Freedom Caucus, the House GOP leadership and the Trump administration.

Freedom Caucus members bristled at many of the talking points Ryan used as he blitzed conservative radio and television shows to project Republican unity on health care. One that particularly grated, according to several members of the group, was his repeated claim that Republicans had “run on” the health-care plan in 2016, because it was sketched out in Ryan’s “A Better Way” policy agenda.

While some caucus members participated in listening sessions about health care, the policy provisions that ultimately were included in the plan were written largely by Health and Human Services Secretary Tom Price, then the House Budget Committee chairman, as well as Ryan’s own policy staff and Ways and Means Committee Chairman Kevin Brady (R-Tex.). The plan included provisions that many hard-liners considered unacceptable — such as the inclusion of a refundable tax credit, something they saw as a new federal entitlement.

Michael A. Needham, the president of Heritage Action for America, a group that opposed the bill, said that a “blame game” is a distraction from the need to forge a better replacement.

“The problem with this bill wasn’t that it would be sound health policy if only it wiped away one set of benefit mandates,” said Needham. “It was that it was not designed from the ground up to circumvent Obamacare’s regulatory architecture. We would be very eager to be involved in crafting legislation that achieves that objective while navigating the relevant procedural hurdles.”

House leaders insisted that they were constrained by the special budget procedures they needed to follow to get the bill through the Senate without Democratic support. That prompted policy trade-offs that left some conservatives fuming. And the leaders faulted the Freedom Caucus hard-liners — and outside groups encouraging them — for ignoring that reality and constantly shifting their demands.

The sense that the bill was simply bad policy was shared by many of the centrist Republicans who opposed it — as well as the Democrats who united against it.

Second-string backing

Since the defeat, Trump and Ryan have declined to say anything indicating that they blame each other. That has not stopped some Republicans from musing that Trump’s less-than-full-throated support for Ryan and the bill along the way helped embolden critics to believe he was on their side.

While Trump supported the bill and sought to build support for it, he also sent confusing signals suggesting that he might be open to changes. It was Ryan who introduced it, championed the details and served as chief salesman. He also took most of the public heat from critics.

Still, Republicans have been less willing to criticize Trump publicly. One top Republican who spoke on the condition of anonymity to speak candidly likened the dynamic to a football game in which Ryan was the struggling starting quarterback, and fans were chanting for Trump to come off bench to relieve him. When Trump did engage, the Republican said, “Whatever good he did was amplified, because it makes a bad start look better.”

And like a second-string player, Trump took less grief for the eventual loss.

“I think he follows a pattern,” said Paul A. Gosar (R-Ariz.), a member of the Freedom Caucus. “He trusts the people that are around him, and I don’t know that the people around him and the people that he trusted actually did him service in this.”

A senior White House official said Saturday that the biggest lesson learned is that Trump and his aides must drive the process from the beginning. It was a mistake to come on board with the House plan rather than present Trump’s own initiative, this official said.

The official, who spoke on the condition of anonymity to speak candidly about White House strategy, said that when he is ready, Trump will offer his own plan on tax reform in a bid to have more control over the process.

“We’ve got to line up commitments earlier,” the official said. “Of course we’re going to look at these things.”

The White House also was caught off guard by the response of lawmakers who had repeatedly voted to repeal the Affordable Care Act. Trump aides never expected so many lawmakers in this category to decline to support this bill.

Some White House staffers and Trump advisers have pinned blame for the debacle on White House Chief of Staff Reince Priebus, who is close to Ryan and who encouraged Trump to embrace the House bill, according to several Trump associates, not all of whom say the criticism is fair.

For many Republicans, it was a problem of timing. They felt House GOP leaders rushed ahead in crafting the bill to repeal and replace the ACA, needlessly trying to hold a final vote on Thursday, the law’s seventh anniversary.

“Really, are we in the Hallmark card business?” asked Rep. Mark Amodei (R-Nev.) hours before the bill was officially pulled Friday. Amodei held both Ryan and Trump culpable for the mess.

Trump and some Republicans have sought to blame Democrats for not joining their effort — a claim Democrats say is outrageous. And they have embraced another potential path forward on health-care reform, predicting that the current laws will collapse under their own weight and that some Democrats finally will join their calls for repeal.

“ObamaCare will explode and we will all get together and piece together a great healthcare plan for THE PEOPLE. Do not worry!” Trump tweeted Saturday.

“I don’t think one party is going to be able to fix this by themselves,” said Sen. Lindsey O. Graham (R-S.C.) at a town hall meeting a few hours later. “So here’s what I think should happen next: I think the president should reach out to Democrats.”

But the Republican failure has only emboldened Democrats to defend the ACA.

“If they would denounce repeal . . . then we’ll work with them on improving it and making it better,” said Senate Minority Leader Charles E. Schumer (D-N.Y.). “They can’t continue to want to repeal.”

As they quickly filed out of a meeting Friday where GOP leaders officially announced the bill was doomed, many with dejected facial expressions, Republican House members said it was on them to work out their differences during this period of one-party control — and acknowledged it would not be easy.

“This is a learning experience. I want to learn from this experience. I hope my colleagues will learn from this experience,” said Rep. Garland “Andy” Barr (R-Ky.).

Juliet Eilperin contributed to this report.