House Speaker Paul Ryan, who has invested nearly all his political capital into repealing and replacing President Barack Obama's signature healthcare law, finds his fate suddenly tied this month to whether he can deliver on the Republican Party's promise to send a bill with GOP-centric health solutions to President Donald Trump's desk.
"You can't underscore how important this is to the speaker," said Matt Mackowiak, a Republican strategist who is president of the Potomac Strategy Group. "From a policy standpoint, it's becoming more closely identified as his rather than the president's."
Ryan's mission, however, will not be easy. His proposal has already faced setbacks from Democrats and Republicans alike.
Democrats remain staunchly opposed to repealing the Affordable Care Act, the healthcare law better known as Obamacare, while some Republicans, including members of the House Freedom Caucus and Sen. Rand Paul of Kentucky, don't think Ryan's legislation goes far enough to advocate free-market solutions.
The plan, as has been laid out, consists of three "phases," the first of which is an initial budget-reconciliation bill that requires 50 Senate votes if passed through the House. The GOP holds 52 Senate seats, making every vote critical.
But the political forecast seems only to be growing darker for Ryan.
On Monday, a report from the nonpartisan Congressional Budget Office estimated that the plan would cause roughly 24 million fewer Americans to be insured over the next decade.
And though Trump has backed the plan, the reliably pro-Trump website Breitbart News, whose former chairman Steve Bannon now has a top role in the White House, has established itself as the bill's top critic on the right.
This week, the far-right website released a tape of Ryan telling House Republicans in October that he would not defend Trump after years-old audio of Trump making lewd comments about women was released. The comments from Ryan had been reported on at length in October, but audio had never been published.
Another Trump ally, Chris Ruddy, the CEO of Newsmax, wrote online that Trump should focus on a proposal that expanded Medicaid and Medicare rather than on the House Republican bill, the American Health Care Act.
"I think the degree of difficulty in what they're trying to do is off the charts, given the constituencies, given the procedural challenges, and given the kind of state of play of the country politically," Mackowiak said.
Mackowiak added that it was a "big year" for Ryan and "a big part of why he was willing to be speaker."
"Look, Ryan didn't want to be speaker — he was very reluctant about doing this in the first place," Mackowiak said. "He was able because he had a lot of leverage, to structure the position in a way where he could do the things he wanted to do and have other members do the things he didn't want to do."
The bill is a part of the three planks to which Ryan has dedicated much of his political career: healthcare, tax reform, and entitlement reform. As Mackowiak put it, Ryan has been thinking about those items "seriously" for the better part of two decades.
"Now he has a chance, a real opportunity to have major achievements in those areas," Mackowiak said. "So I do think he has a lot riding on this. I also think if this were to go down one way or the other, it would imperil his ability to have achievements on the other issues he cares about."
Kurt Bardella, formerly a senior adviser and spokesman for the Republican-led House oversight committee, told Business Insider in an email he thought Ryan "has foolishly put himself in a lose-lose situation."
While Mackowiak said the criticisms of the bill were overblown, adding that all three phases needed to be in place before the legislation could be truly judged, Bardella said if "Trumpcare" passed at Ryan's push, the speaker would "have shilled for one of the worst pieces of legislation EVER at the expense of his majority."
"If it fails, Bannon-Breitbart are already laying the groundwork" for Ryan "to be the fall guy, and his position as speaker will come under attack," Bardella said.
Bardella continued: "Had Paul Ryan stood by his actual principles versus becoming one of Trump's lapdogs, he would have at least retained his own moral high ground and had a platform to lead the GOP for many years to come. Instead, the minute Trump became president, he, like so many in the GOP, rolled over and are on the wrong side of 24 million Americans who are about to lose their healthcare coverage."
Another top Republican strategist said he thought the biggest problem with the rollout so far had been the Ryan team's explaining of the legislative process, saying he was "frustrated" by the debate because it had been mostly discounted that the bill will in all likelihood face some major changes in the Senate if it arrives there.
"So the House and Speaker Ryan in turn are taking way more arrows than they need be right now," the strategist said, adding that it was only "the first step of many."
"They need to start explaining that better to people," the person said. "It's not a final bill."
If Republican leaders don't explain that aspect better, the strategist said, House Republicans — and chiefly Ryan — will "get saddled with every negative outcome." But even as Breitbart slams Ryan with persistence, the strategist said he didn't see a political threat to the speaker.
"There were some stumbles out of the gate," the person said. "The speaker has done a pretty admirable job pulling it together and making the best case. He's out there alone right now, but he can handle it."
And, for the GOP, it's not just Ryan who has a lot on the line.
"All Republicans have a lot riding on this," Mackowiak said. "Whether they realize that or not."
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