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WASHINGTON (AP) — The Senate debate over health care has made it painfully clear: behind their self-confident "repeal and replace" slogan, Republicans were never united around an alternative to the Affordable Care Act.
Rolling back a government program that's benefiting millions of people is hard enough, and maybe next to impossible. But Republicans compounded their own difficulties with factional divisions, a president who lacked a policy of his own, and a mission that became a Medicaid overhaul unacceptable to GOP governors.
Republican leaders say they remain confident they push through a bill. But they acknowledge they don't yet know how that will happen or what will be in it.
The turmoil could endanger other GOP priorities such as overhauling the tax system, not to mention basic government functions such as keeping agencies running or raising the federal borrowing limit.
Health care was supposed to be relatively easy, given that Republicans control the White House and Congress.
Hoping to score a quick victory on repealing and replacing the Obama-era health law, Republicans worked in private to hammer out their proposals. But that ignored the complexity of the health care industry; powerful interest groups including hospitals, doctors, and insurers were alienated.
The strategy foreclosed chances of co-opting any Democrats, some of whom share concerns about high premiums and shaky insurance markets.
As polls showed alarmingly low public support for their legislation, Republicans only dug in. President Donald Trump threatened retribution for lawmakers who broke ranks.
As a result, Republicans have managed to "make more popular a policy that wasn't very popular when we started trying to get rid of it," said Sen. John McCain, R-Ariz. The lack of bipartisanship on health care was an object lesson in McCain's impassioned floor speech upon returning to the Senate following a cancer diagnosis.
It was easy for Republicans to oppose former President Barack Obama's law when their party did not bear responsibility for governing. Now that they're in power, Republicans are divided in three broad groups.
Some would make revisions, cutting or replacing unpopular provisions and rebranding that as "repeal."
Others, fiscal conservatives, view the debate as the springboard for bigger curbs to government health insurance programs such as Medicaid and Medicare.
A third group questions government involvement with health care, arguing that a true market will only emerge when individuals bear more responsibility for costs.
The three strands are visible in proposals that Majority Leader Mitch McConnell, R-Ky., has tried to steer through the Senate. While Obama's law extended coverage to some 20 million people, nonpartisan analyses estimate the GOP proposals would make millions more uninsured.
Similar kinds of divisions could emerge on other issues, particularly if the health care debate leaves Republicans nursing grievances against one another.
During the 2016 presidential campaign, many Republicans hoped a consensus plan could be forged. But Trump never delved deeply into health care, basically issuing a series of talking points. At times, he sounded like a Democrat, promising "insurance for everybody."
"He is obviously working this from a political standpoint; what I don't see is him working it from a policy standpoint — fashioning that compromise for all Republicans," said Dan Mendelson, CEO of Avalere Health, a consulting firm. "There's no evidence of thought leadership."
Trump hinted that he would come out with his own plan, but that didn't happen. The congressional proposals that followed drove a wedge between Capitol Hill Republicans and GOP governors, chiefly over Medicaid.
Beyond repealing Obama's expansion of Medicaid, congressional Republicans proposed to limit overall federal financing for the federal-state program. Medicaid's 70 million low-income beneficiaries include many pregnant women and infants, severely disabled adults and people battling addiction, and many elderly nursing home residents.
The GOP legislation translated to hundreds of billions of dollars in cuts in projected federal payments to states.
"That joined a number of moderate Republicans to the interests of Democrats in not cutting or curtailing Medicaid in a dramatic way," said economist Gail Wilensky, a Republican. "I think what happened is there was a big overreach."
The National Association of Medicaid Directors, a nonpartisan group whose current members mainly represent Republican-led states, went on record opposing the Senate "repeal and replace" bill.
"Two-thirds of our members work for Republican governors," said Matt Salo, the group's executive director. "What we have here is Republican state executives saying there are fatal flaws."
Sen. John Thune, R-S.D., who ranks third in the leadership, said Republicans are not giving up.
"It has proven to be quite challenging to get 50 Republicans on board with one solution," he said. "We just haven't gotten there yet."
In his floor speech, McCain offered a possible way forward. He called it "regular order," the plodding work of legislating by committee.
"What have we to lose by trying to work together to find those solutions?" he asked. "We're not getting much done apart."
EDITOR'S NOTE — Ricardo Alonso-Zaldivar covers health care for The Associated Press.
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