The House GOP effort to repeal and replace Obamacare appeared in deep trouble Tuesday, underscoring the limits of a party that has traditionally put a priority on cutting taxes and government spending over digging into the details of safeguarding Americans' healthcare.
Many Republicans in Congress remain in outright revolt over the bill, warning it does not have enough votes to pass the House or Senate against stiff Democratic resistance.
A few moderate Republicans emerged from a Senate lunch Tuesday optimistic that House leaders would amend the legislation to meet their concerns. They want to preserve coverage for the millions of Americans who are projected to be left without insurance.
But conservatives were pulling the bill in the opposite direction, demanding deeper, faster cuts.
Meanwhile, GOP defections continued, including Florida Rep. Ileana Ros-Lehtinen, who said the current bill would be too detrimental to her elderly constituents.
"Is there anyone left in the country who actually likes it?" asked Senate Minority Leader Charles E. Schumer (D-N.Y.), reading the lists of doctors, hospital organizations and others who have registered opposition.
The tribulations now facing Republicans are not hard to understand: The party never set out to revamp the nation's healthcare system. That was always a Democratic pursuit.
Republicans simply wanted to repeal Obamacare, which they saw as a costly government intrusion.
Only after they took the White House and it became apparent that millions of Americans would lose their health coverage under a straightforward repeal did Republicans begin to take seriously the "replace" part of their campaign promise.
But while Democrats have been churning out healthcare proposals since Franklin D. Roosevelt, Republicans have become increasingly fixed on the Reagan-era goal of reducing the size of government. Most Democrats see healthcare as a fundamental right or entitlement; few Republicans do.
That has left Republicans without a deep bench of healthcare policy experts in Congress, despite a cadre of doctors-turned-lawmakers.
One architect of the latest GOP effort is Tom Price, the former congressman and orthopedic surgeon who is now the Health and Human Services secretary. But to many, his experience in reforming government healthcare programs pales in comparison to the late Sen. Edward M. Kennedy, the liberal lion who for decades set strategy for Democratic reform efforts, including Obamacare.
Lawrence Jacobs, director of the Center for the Study of Politics and Governance at the Hubert H. Humphrey School at the University of Minnesota, said the Republicans' struggles are not surprising given the difficulties of healthcare reform and the party's resistance to taxes and government spending.
"We've generally seen Republicans steer away from health reform if it involves raising taxes," he said. "Republicans are allergic to the coverage issue because it requires them at some point to have revenue either for tax credits or spending."
That resistance has been apparent in the GOP effort to reform Obamacare, where the party's small-government ideals have sometimes clashed with the task of protecting government benefits for the poor.
For example, its plan ends a key money source by repealing a 0.9% tax imposed under Obamacare on those earning more than $200,000 a year.
And rather than focus solely on fixing Obamacare's problems, the House plan also seeks to achieve a long-standing Republican goal: capping expenses for the entire Medicaid program, far beyond those covered under Obamacare
Jacobs noted that even Democrats, with all their experience and commitment, rarely succeeded in advancing sweeping legislation.
"Passing national health reform is one of the hardest things to do in America," Jacobs said. "There is a reason liberals and progressives failed for over half a century."
As the House plan appeared on life support, Republican leaders, backed by the White House, fanned out Tuesday with a full-throated defense ahead of a planned House vote next week.
Price and Vice President Mike Pence met behind closed doors with Senate Republicans at their weekly lunch, joined by the chairmen of the House committees who drafted the GOP bill. House Speaker Paul D. Ryan (R-Wis.) spoke by phone later in the day with President Trump.
Leaders balked at a report from the nonpartisan Congressional Budget Office that 24 million more Americans would be left uninsured under the GOP plan – wiping out the health coverage gains under the Affordable Care Act, also known as Obamacare.
Republicans contend that their plan would ultimately lower costs and give Americans more choices, and they complained that deductibles were so high under Obamacare policies that it put access to healthcare out of reach.
"Democrats were concerned about coverage. They're patting themselves on the back for giving you coverage, but you still couldn't afford to go to the doctor," Mick Mulvaney, the administration's Office of Management and Budget director, said on CNN. "That's what we are trying to fix."
The CBO report, however, predicted that while insurance premiums would eventually come down, deductibles under the GOP plan would be higher for many consumers.
Even as some moderate Republicans bolted after the CBO report, pressure mounted from conservative lawmakers and outside groups for a complete repeal of the Affordable Care Act. They want to reduce coverage requirements and more quickly end Obamacare's expansion of Medicaid for low-income Americans in some states.
"We're making real good progress with the White House and leadership, and I'm optimistic we'll see some good results in less than a week," said Rep. Mark Meadows (R-N.C.), the chairman of the conservative House Freedom Caucus, which is set for a meeting at the White House this week.
Republicans weren't always at odds with a government role in expanding the nation's healthcare system. Some voted for President Lyndon B. Johnson's push to create the Medicare program for seniors.
President Nixon once considered an even more expansive healthcare system, and President George W. Bush launched a new entitlement, the Medicare prescription drug Part D program, which continues today.
But President Reagan famously campaigned against Medicare, deriding it as socialism. And some conservative groups abandoned Bush over the new prescription drug benefit.
Sen. Bill Cassidy (R-La.), a physician who is a leader in his party on health policy, is working to amend the House bill to ensure that millions of Americans — particularly older, low-income adults — don't lose coverage.
He rejected the premise that Republicans are not as versed in health policy as their Democratic colleagues and noted that not every lawmaker can be an expert on every issue.
"Republicans did Medicare Part D, which is pretty significant, and they certainly collaborated with CHIP," he said, referring to the Children's Health Insurance Program.
"My golly, if I've been living healthcare for 30 years I'd hope I'd know a little bit," he added, referring to his work as a doctor. "Someone else knows far more about real estate."
The challenge now for Republicans is trying to remain the party of small government while also becoming the party that preserves a healthcare entitlement program that a growing number of Americans say they want to keep.