AP Photo/Alex Brandon

The struggle to repeal the Affordable Care Act was the first real test of how Republicans would handle their total control of the House, Senate and White House — and how the health care world would respond. And though the top-line effort was a failure, this won't be the last big legislative test for Republicans, and the power dynamic in Washington shifted significantly during the health care debate.

So, who came out of the health care mess stronger, and who came out weaker? Looking beyond the "winners and losers" of this particular process, who positioned themselves well for the future, and who hurt themselves? Here's a quick breakdown:

Stronger

House leadership: Put simply, they passed a bill. This is more than the Senate can say. "In a sort of rare unified moment, the Republican caucus in the House was together and pushed something out in a partisan way," a former Senate GOP staffer told us. Speaker Paul Ryan and Chairmen Kevin Brady and Greg Walden deserve a lot of credit for this.

Mark Meadows: The House Freedom Caucus chairman's decision simply to try to help build a consensus was significant in its own right, given his reputation for throwing stones at GOP leaders from the sidelines. The fact that he was able to push the bill to the right and help deliver the votes to get it over the finish line gives him real clout within the GOP conference.

Ted Cruz: The ultra-conservative senator has earned notoriety for being a thorn in leadership's side, often taking an all-or-nothing approach. But he was at the negotiating table throughout the whole process, even initiating conversations with Lamar Alexander, chairman of the Health, Education, Labor and Pensions Committee. "I think he's better perceived today by his caucus than he was three months ago," said one of the former aides.

Susan Collins: Collins made her decision early and stuck to it, ultimately emerging as the repeal bills' harshest GOP critic. If she does want to run for governor, both the substance and firmness of her stance will likely help her. And if she wants to stay in the Senate, she'll remain a make-or-break vote with the power to extract major concessions from both parties.

Weaker

Dean Heller: Heller, who is considered the most vulnerable Republican senator up for re-election next year, was all over the place. At first he was against the Senate bill, then he was a maybe, then he voted against both the Senate replacement and its partial repeal bill but for the skinny repeal bill. "Heller is vulnerable to charges of being an opportunistic flip-flopper, one that even a Cirque performer would find impressive in his audacity," wrote Jon Ralston in the Nevada Independent.

John Cornyn: "John Cornyn is in deep, deep need of rehabilitation," another former Senate Republican staffer told us. "Everyone in health care knows nothing he said was right. He was consistently projecting what leadership wanted to happen, not what was actually happening. He was always wrong."

The Trump administration:

  • Slow-rolling failure on your first legislative priority is never a great way to start off an administration.
  • Trump himself didn't do much to help sell repeal, and calling the House bill "mean" made some Republicans both angry and wary of Trump's willingness to back them up.
  • Interior secretary Ryan Zinke's reported threats to Murkowski were counterproductive, as was the West Wing's desire to go ahead with politically difficult votes that were likely to fail.
  • HHS secretary Tom Price doesn't seem to have lost much clout on the Hill, but no one's sure yet how the defeat will affect his standing with Trump.

Insurers: Health care lobbyists had some particularly harsh reviews for the insurance industry's two biggest trade groups, America's Health Insurance Plans and the Blue Cross Blue Shield Association. The criticism: They were mostly pretty timid, angering Democrats who think the industry sat on the sidelines when everything was on the line; but when they decided to swing, they picked the moments that most frustrated GOP leaders.

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