Forced to navigate House Republican politics, the lobbying pressure from the insurance industry, and the obscure rules of the budgeting process, Ryan has produced a bill that nobody would ever propose as a sane solution to the problems with Obamacare. Its only chance is speed. If Ryan can rush and muscle it through the House and Mitch McConnell can do the same in the Senate, it might end up on Trump’s desk. But the more scrutiny this House bill is subjected to, the more likely it is to share the fate of most efforts at health-care reform and die somewhere on its journey to the Senate, and perhaps long before then. If his health-care-reform effort fails, Ryan himself may not survive as the House leader. Meadows and his colleagues catapulted Ryan to the Speakership, and they still have the power to bring him down.