With interest growing among congressional Republicans and Democrats in modifying the Affordable Care Act to bolster the nation's health insurance markets, states are emerging as potential models for bipartisan cooperation.
The political battling over the 2010 healthcare law, widely known as Obamacare, may not be over, especially with President Trump continuing to undermine the law.
But Republicans and Democrats in a number of states have worked together on fixes and modifications in recent years, charting a more pragmatic path that has focused less on whether the federal law should be repealed and more on how it could be made to work better for patients.
"I don't think anyone here — Democrat or Republican — didn't believe that we needed to make sure our residents could get healthcare," said Lori Wing-Heier, Alaska's nonpartisan insurance commissioner, who worked with state legislators from both parties last year to help control insurance premiums.
Similar efforts to bolster insurance marketplaces created by the law have been undertaken in other states, including Minnesota, Iowa and Oklahoma.
Elected officials in red states such as Indiana and Arkansas have crafted bipartisan compromises to expand Medicaid coverage through the health law while incorporating conservative ideas for how the government safety net program should work.
"You have to compromise and put the people most in need first," said Indiana state Rep. Charlie Brown, a Democrat who supported conservative Medicaid expansions under two Republican governors, including Mike Pence, who is now vice president.
"Rarely does anyone get everything that they want," Brown said.
In Washington, the growing interest in bipartisan fixes to the healthcare law follows the collapse over the summer of the GOP repeal campaign amid widespread criticism that Republicans' legislation would have stripped insurance protections from tens of millions of Americans.
And although it's possible for congressional Republicans to revive the repeal push, that appears increasingly unlikely as GOP leaders turn to other legislative priorities, including must-pass legislation to fund the federal government and lift the government debt ceiling.
Starting this week, Senate Health Committee Chairman Lamar Alexander (R-Tenn.) and Sen. Patty Murray (D-Wash.), the committee's senior Democrat, are kicking off a new approach by convening a series bipartisan hearings to consider legislation to help stabilize insurance markets.
A more informal bipartisan group of House lawmakers calling itself the "Problem Solvers Caucus" has been discussing similar measures.
And last week, a bipartisan group of eight governors, led by Ohio Republican John Kasich and Colorado Democrat John Hickenlooper, sent congressional leaders a five-page letter calling for a set of specific steps to strengthen insurance markets, including helping insurers cover high-cost patients and assuring federal funding to lower deductibles and co-pays for low-income insurance customers.
"Lasting solutions will need support from both sides of the aisle," the governors wrote.
The obstacles to such solutions remain formidable, with many Republicans still committed to simply rolling back current law.
And even as members of Congress begin looking for ways to strengthen insurance markets, Trump, who has repeatedly threatened to let the law "implode," is taking steps that threaten to undermine that effort, including refusing to commit to long-term funding to lower poor customers' deductibles and co-pays.
Last week, the administration also announced a dramatic cut in federal efforts to help people enroll in health coverage, slashing planned advertising for the 2018 enrollment period by 90%.
But outside the Beltway, state elected officials have at times taken a more pragmatic approach to the health law, looking for ways to make it work better and adjusting it to help local residents.
Even GOP legislators who remain very critical of the law have agreed in some states to help their constituents struggling with rising costs.
"Government shouldn't destroy people's lives," said Minnesota state Rep. Greg Davids, a Republican and chairman of the state House tax committee. "Anything we can do to help people, we should do it."
Davids and other Republicans in the Minnesota Legislature helped put together a bill to provide additional financial aid to residents who use the state's insurance marketplace, where premiums have risen more than 50% in recent years.
Such local efforts have taken on added urgency in other states with high insurance costs.
In Alaska, which has some of the highest medical costs in the country, state leaders agreed to create a new government fund to backstop health insurers that have very high claims, a mechanism that helps control premiums for consumers.
A similar system is used in the Medicare Part D program to control premiums for prescription drug plans, and some in Congress are now talking about a national program to help control premiums on insurance marketplaces created by the healthcare law.
Few parts of the law have proven as politically charged as Medicaid expansion, which GOP officials have fought in many red states around the country.
To date, 19 states have refused federal aid made available by the law to expand coverage to low-income adults, a population not traditionally covered by the safety-net program. Many Republicans argue the program is too expensive.
But like insurance market stabilization, Medicaid expansion has spawned several notable compromises around the country.
In Arkansas, for example, a state with historically high rates of uninsured, GOP leaders in the state Legislature backed a push by the Democratic governor to expand Medicaid coverage.
But they did it using commercial health plans in a nod to market-based principles traditionally championed by Republicans.
"It was obvious to nearly all of us that it was important to expand coverage," said former state Senate President Michael Lamoureux, a Republican who worked with then-Gov. Mike Beebe, a Democrat, to craft the state's Medicaid expansion. "But it couldn't be done by simply expanding the government program."
As governor of Indiana, Pence championed a Medicaid expansion that requires poor patients to contribute to the cost of their medical care, a longtime Republican goal for the program.
Whether these models can be replicated remains unclear, but the Trump administration has expressed interest in letting states put more requirements on Medicaid patients, as Indiana does.
And though Democrats are wary, such changes to Medicaid may offer a path to expanding coverage in states that have historically denied such health protections.
Indiana state Rep. Ed Clere, a Republican who chaired a health committee in the Legislature and supported Indiana's Medicaid expansion, said compromises would be good for the law and the country.
"The fact is, Obamacare isn't all good or all bad," Clere said. "It's sweeping legislation that requires major ongoing work.… I hope someday there will be more appreciation for that."