President Trump’s failure to push a repeal of Obamacare through the House on Friday was a major setback in his first real test as president. But was it a surprise? I say no. The “new” health care plan was flawed from the beginning. The GOP should have learned from the Democrats in that they used many experts including economists to develop the Obamacare plan.

Also, Nancy Pelosi and Mr. Schumer, what a bunch of ignorant children to celebrate failure when they could have contributed to a better health care system by recognizing the faults of the ACA and offering assistance to a better health care world.

It’s a good moment to take stock of lessons learned. Here are five:

1. This is a blow to Trump’s presidency, but let’s not get carried away.

The bill’s defeat is not a mortal wound to Trump. Disregard the Chicken Littles who describe the health care failure as the end-all of everything. Trump has only been president for two months. There is plenty of time for him and for Republicans to learn their lessons, regroup and recover.

But the admission of House Speaker Paul Ryan, R-Wis., that the United States will be “living with Obamacare for the foreseeable future” means that it’s unlikely Republicans will repeal the Affordable Care Act any time soon, if at all, during the next two years. They had a limited window of time to do this now, for complex procedural reasons, and because of Trump’s insistence that they do it quickly.

Now, Trump wants to move on to tax reform, which means that they can’t do health care reform this year. And it’s unlikely they’d want to touch such a controversial topic next year, when every member of the House is up for reelection.

As for Trump and Ryan’s relationship, which was rocky at best during the presidential election, Trump gave Ryan a vote of confidence. “I like Speaker Ryan. He worked very, very hard,” he said. A House Republican leadership aide added: “The president and speaker have a solid relationship. He knows Ryan worked his butt off to get these votes.”

2. Trump didn’t lead from the beginning, because he didn’t have a clue what he was doing, and it cost him.

“Nobody knew health care could be so complicated,” Trump famously said five weeks after his inauguration. The new president did not grasp the process of passing a health care bill, the politics or the policy.

Trump is notorious for scorning details. And so he provided no leadership on what the bill should look like at the front end of the process, leaving the entire venture to Ryan, who will also come in for plenty of criticism for drafting a bill that was widely criticized for its incoherence — even by some of the speaker’s close allies.

Vox’s Ezra Klein documented all the ways that Trump repeatedly made statements about what the health bill would do — promises that were completely at odds with what was actually in the legislation. And yet Trump continued to push ahead for a law that contradicted his very goals for health care reform.

Trump’s insistence on rushing ahead also complicated the process. Ryan and others in congressional leadership had preferred to focus on a process that dealt first with repeal, and then with replacement. Trump wasn’t the only impatient one. Many members of Congress wanted to do both at the same time, fearful of political blowback if they passed a bill that would kick millions off Medicaid — even if that would be delayed — without an answer for what would they would do instead.

But there’s no question that Trump pushed Congress to both repeal the ACA and replace it on a timeline that was wildly out of touch with reality. On Jan. 10, Trump told the New York Times that he expected Congress to pass a repeal bill “probably some time next week” and to replace it “very quickly or simultaneously, very shortly thereafter.”

Trump vastly underestimated the challenge involved in passing any major bill, much less one devoted to health care. Because of that, he created expectations that forced Republicans in Congress — who painstakingly built consensus last year around a replacement bill through Ryan’s “Better Way” plan — to try to rush a bill through Congress that quickly attracted opposition.

3. Ryan’s failure to win over conservatives was both inexplicable and unsurprising.

Ryan spent all of 2016 creating consensus about how to replace the ACA, in a widely praised process. Then he rushed the actual legislation through the House, without trying to win over conservative groups and lawmakers beforehand.

In one sense, Ryan had to hurry because Trump was announcing to the American people that repealing Obamacare would be done quickly, and because the process necessary for passing its replacement, known as budget reconciliation,  also meant Republicans had to be done with health care before they moved on to tax reform.

But the resistance of the conservative House Freedom Caucus and outside groups like Heritage Action hurt the rollout of the bill from the beginning, and it never recovered. Ryan and GOP leadership probably should have done more to try to win them over ahead of time, but on the other hand, there was never an expectation that they would be able to win them over no matter what they did.

“Given that Heritage Action was going to say, ‘Hell no,’ and the establishment press was going to run to them and cover them, you couldn’t get around that,” Grover Norquist, president of Americans for Tax Reform, told Yahoo News two weeks ago.

Ryan noted Friday that it is going to be a process for Republican hardliners to learn how to compromise. This is a group of people who have done little but oppose things for the last decade and been rewarded for it with fundraising dollars, notoriety and reelection.

4. Tax reform is not going to be any easier.

Trump, after the failure of the health measure, moved immediately to talking about tax reform. That, however, is an even more challenging topic for Congress to address, largely because there are so many interests arrayed against it.

The GOP tax reform bill in its current form raises revenue to offset the cost of tax cuts through a tax on imports. That proposal is opposed by big retailers like Walmart, and by the powerful Koch Brothers’ political organization. A large number of senators have signaled that they are opposed to the border trade adjustment tax.

But if the revenue stream were changed to closing tax loopholes for corporations and individuals, then opponents of the bill would really come out of the woodwork.

“Health care is like a 30-yard chip shot, compared to tax reform,” said Josh Holmes, a former chief of staff to Senate Majority Leader Mitch McConnell, R-Ky.

5. Trump, so far, is looking a lot like Jimmy Carter

Several journalists have noted a number of similarities between Trump and Carter, many of which have been on display during the battle over health care. But the comparison goes only so far.

Carter and Trump both ran as Washington outsiders, and against the political establishment. Carter in 1976 said the government was “disorganized, wasteful, has no purpose and its policies — when they exist — are incomprehensible or devised by special interest groups with little regard for the welfare of the average American citizen.”

And both men also entered the presidency with little use for Congress. “I alone can fix it,” Trump boasted during his acceptance speech at the Republican National Convention. Carter also assured then-Speaker Tip O’Neill that he would treat Congress as he had treated the Georgia Legislature, and that if they did not go along with his agenda, he would “go over the heads of the representatives by appealing directly to the voters.”

It’s still quite possible that Trump does this very same thing, using his celebrity and his social media bully pulpit to hammer members of Congress for voting against the health bill. He might also campaign in their districts and promote primary challengers.

But if this health fight has taught Trump anything, it is that the challenges of governance are tougher than he had expected, because Congress is a complicated and formidable institution.

Trump did do something in the last week or so that Carter avoided, seeking to win over lawmakers face to face, with both charm and threats. Carter preferred to explain and reason, and scorned the more personal approach to dealing with lawmakers.

PRINCIPLES FOR HEALTH CARE REFORM as suggested by ASPS

While the ACA resulted in a number of desirable reforms, including coverage of pre-existing conditions, removal of lifetime caps, and coverage of children to age 26, the American health care system remains beset by a number of serious problems. Health insurance costs continue to rise, and private insurers draw ever-more-narrow networks, threatening broad access to care. Health system consolidation has exploded, threatening the viability of private practice and increasing costs to patients, taxpayers, and insurers. Well-meaning efforts to use alternative payment methods to reward the value of care, rather than the volume, have resulted in systems ill-equipped to integrate, analyze and reward specialist services. These systems threaten the viability of independent medical practices across the country, while causing physicians to retire early or sell their practices to large corporations and hospitals

As the 115th Congress begins and a new administration takes power, policymakers are poised to again undertake health care reform. The following are key principles that the American Society of Plastic Surgeons believes must accompany such an effort.

MAKE PATIENT ACCESS TO CARE PRIORITY ONE

Patients should have timely access to high-quality medical care from the appropriate provider. To advance this goal, health care reform must –

o Maximize the availability of high-quality, affordable coverage.

o Prohibit denial or cancellation of coverage for pre-existing conditions.

o Prohibit denial or cancellation of policies when a patient becomes sick.

o Prohibit annual and lifetime caps.

o Maintain medical loss ratio provisions that require private insurers to spend an adequate percentage of their premium dollar on health care for their customers.

o Establish and enforce network adequacy and transparency rules. Insurance companies are creating extremely narrow networks that not only decrease patient choice but also affect patients’ access to health care.

 Payors should be required to design networks to have adequate number of active physicians in each specialty within a reasonable distance and availability to patients.

•   Patients may not understand which physicians are in their plan’s network, leading to unexpected expenses for patients when insurance will not pay after care is rendered. Payors should provide accurate and timely directories of the physicians, providers, and facilities within their network so that patients and physicians can make informed decisions about their healthcare.
•   It is very difficult for patients and even physicians to find out what the insurance will pay for certain procedures and visits. This affects patients’ ability to make informed decision about their health and finances. Payors should be required to provide accurate and timely fee schedules to patients and physicians so that patients can be informed about their out-of-pocket expenses.
•   Payors must provide patients with a clear description of coverage, not only after enrollment but also at the time of open enrollment, so that patients can choose an insurance plan that is right for their individual health needs.
•   Insurers should be required to offer an out-of-network option. This will ensure that patients have choices when their payor network does not have adequate number of physicians to meet patient needs. 
REBUILD THE PHYSICIAN/PATIENT RELATIONSHIP 
The ACA and subsequent legislation/regulation have moved the core of American health care delivery from a physician/patient-centric model to one where large-scale systems drive the patient experience. This has had a negative impact on physicians and patients by de-personalizing care and de-emphasizing the preferences of individual patients. To re-center this dynamic, health care reform should – 
o Help physicians spend more time working with and caring for patients, not on regulatory burdens and box-checking.

 There are a host of mandated federal reporting programs that in isolation are well- meaning and aimed at positive improvements. Taken together, though, they demand an overwhelming amount of a physician’s time.

Consequently, valuable time is allocated away from direct patient care, causing physicians to either see fewer patients or spend an inadequate amount of time with each patient. This dynamic is unacceptable. Federal programs focusing on quality, cost and health IT must be scaled back to a less burdensome level.

o Give patients more choices when selecting providers and potential care settings.

•   Support independent solo, small and medium-sized medical practices. Studies have shown that these practices are more cost-effective than larger systems in delivering care. In addition to reducing the administrative burden facing these practices, policymakers should provide direct financial and technical support to help them comply with remaining federal programs for quality, cost and health IT development. 
 Recognize and address the role that health system consolidation has had in undermining private practice. Individual, small, and medium group practices face intense pressure to sell to consolidated health systems, which reduces opportunities for patient choice and drives up costs.
•   Allow Medicare beneficiaries to privately contract with the physician of their choice without penalty for the physician, and reimburse beneficiaries for these services at the Medicare-allowable amount when they are a normally-covered benefit.

o Recognize the value of specialists in the care continuum and recast current delivery reform efforts to better incorporate specialty services.

 Improve systems that measure the quality and cost of care. Currently, these systems work backwards by beginning with measurement tools and forcing providers to use those mechanisms regardless of relevance.

New investments must be made in developing more relevant and useful quality measures and cost attribution methodologies that better capture high-value specialty care. Only when these are in place should specialists be required to integrate them into their clinical workflow.

FOCUS ON TARGETED COST CONTROL STRATEGIES, NOT BLUNT FORCE REDUCTIONS THAT DISPROPORTIONATELY IMPACT PHYSICIANS
The approach to reducing health care spending is critical, as missteps could result in serious, unintended negative impacts on patients. Efforts that focus disproportionately on one part of the system are unfair and short-sighted, Physician and other clinical services account only for 20% of U.S. health care spending. Disproportionate focus on physicians may undermine patient access to necessary care and does not have a commensurate impact on overall health care savings. To preserve patient access through equity in cost control, health reform should

o Evaluate, in a holistic manner, the actual costs of regulatory compliance and the aggregate impact of the many cuts to physician payments made across the federal policy landscape. These costs make it harder for physicians in small or solo practices to keep their doors open, and it acts as a disincentive to entering medicine for the brightest young minds.

o Repeal the Independent Payment Advisory Board. This unelected, unaccountable group of bureaucrats is mandated to, under certain Medicare spending scenarios, add to the already-substantial reductions in Medicare reimbursements facing physicians.

o Enact common sense medical liability reforms that do away with the current, high-exposure climate in which physicians practice defensive medicine and patients are subjected to unnecessary screenings, tests and hospital stays.

•   Routinely incorporate mediation as part of the complaint process
•   Employ expert boards to review the merits of medical liability cases
•   Cap non-economic damages.
•   Institute a reasonable statute of limitations on liability claims.
•   Implement standards requiring expert witnesses to have training in the medical field at subject in a lawsuit, be board certified in the specialty of the defendant, and spend at least 50% of their time practicing clinical medicine.
• o Seek to reduce the number of uninsured and underinsured patients, whose care is disproportionately underwritten by providers, taxpayers, and the privately insured.

All make sense right? Where do they go from here? I think the best strategy is to spend time looking at the principles that I just laid out and work with the Democrats in a bipartisan committee to improve the ACA. Forget the Freedom Caucus, they will never be happy. If they don’t, the ACA will be wallowing in debt, the youth of this nation will continue to see their premiums skyrocket or more and more will decide not to purchase health care insurance now that that IRS has decided not to pursue those who don’t have insurance. Are we making any progress in improving health care for all? I think not!

I want to continue what I was writing about before the campaign, what other successful health care systems look like and what a sustainable system in our country could look like. Yes, I know…dreamer!!