After chasing the Obamacare car for years, Republican dogs finally caught it and have no idea what to do next.  Seven years of anticipation and endless promises of “repeal and replace” have been replaced with “remain and recriminate.”  So, they did nothing, instead sitting on their haunches and barking at the moon. Obamacare remains the law of the land and blame is flying back and forth faster than Trump’s tweets.

When lost, it’s helpful to look backwards and retrace your steps. How did we get here?

Obamacare passed on a strictly party line vote. As an aside, I’ll offer a rare compliment to Nancy Pelosi and Harry Reid. As despicable as they might be, as leaders of the Democratic Party they were brilliant. They took advantage of a political opportunity. Controlling Congress and the White House was their best and only chance to fundamentally transform healthcare.

Their bill was ready to go and supported by all Democrats. No disperate factions as we see on the Republican side. No “Socialism Caucus” holding out for single-payer. No Tuesday (or Wednesday or Thursday) group pushing for more moderate reforms. Harry and Nancy herded their cats, all supporting their party and president, taking political advantage of their once-in-a-generation opportunity.

Ironically the Democrats were Reagan disciples when it came to Obamacare. They didn’t get all that they wanted in Obamacare, such as universal coverage or single payer, but they heeded Reagan's wisdom, “I have always figured that a half a loaf is better than none, and I know that in the democratic process you’re not going to always get everything you want.”

Not so for Paul and Mitch. Why not? They have been chasing the repeal and replace car for years, passing legislation which at least went to the White House, even if it was ultimately vetoed. After all those years, why didn’t they have a bill ready to go, built on consensus among the various Republican congressional factions? As the Democrats did in 2008. It’s not like they only regained control of Congress this year.

And why wasn’t their caucus willing to take half a loaf when the full loaf was virtually impossible?

Several reasons come to mind. The House leadership wasn’t serious about repeal and replace. It’s easy to pass bills that are certain to be vetoed. Much like a high school kid inviting a Victoria’s Secret model to be his prom date, then not knowing what to do if she says yes.

Many in Congress didn’t expect or want Donald Trump to win the presidency. After all, many Congressional Republicans were part of the #NeverTrump brigade, including Paul and Mitch at many points during the campaign. Presumably they drank the beltway and media Kool-Aid, believing until about 9 PM on election night that Clinton would win the presidency in a landslide. Meaning that they could continue to send repeal legislation crashing into Clinton’s veto pen.

Conservatives in the Freedom Caucus wanted more of a full repeal, which would not make it through the Senate. I’d like that too, along with a flat income tax and term limits for Congress, but politically those ideas are going nowhere. Half a loaf versus a full loaf.

As of now, 7 years of promises turned out to be a big nothing burger. Not even a vote. But lots of recrimination and blame. Who’s fault? Trump’s? Ryan’s? Both?

For President Trump, surely a disappointment, but I’m sure this isn’t the first deal he worked hard for, felt confident in, but at the moment of truth had to walk away from as it was a loser. In his most famous book, Trump wrote,

"I never get too attached to one deal or one approach. For starters, I keep a lot of balls in the air, because most deals fall out, no matter how promising they seem at first."

Despite being one of his major campaign promises, Obamacare repeal isn’t the only promise. Immigration reform, tax and regulatory relief, fair trade deals, and jobs, are other initiatives he can pivot to. And despite the desires of the President, legislation begins in Congress. Trump himself can’t repeal or replace Obamacare.

What now? Several options going forward.

They can certainly leave Obamacare alone and let it follow its current trajectory toward implosion. Will the Democrats be begging for help as Trump predicts? Or will they, with ample help from the media, blame the Obamacare demise on the GOP? I predict the latter. The Republicans will be blamed for not fixing it when they had the chance. Great campaign message for the 2018 midterms. Broken promises. Squandered opportunities.

The House can craft a repeal and replace bill satisfying to their coalition. All of it. If the Democrats could do this, why can’t the Republicans? The Democrats will likely filibuster the bill and it will go nowhere. Then they can at least be rightly blamed for perpetuating the failing Obamacare law. Except the Democrats and their media fanboys will spin it as the GOP’s fault.

They can overrule the Senate Parliamentarian, allowing the bill to be passed under reconciliation, or blow up the filibuster. Would all of the Republican Senators go along with this? Would #NeverTrump Senators McCain, Flake, Gardner, Collins and a few others vote against these rule changes simply to spite President Trump? Is their hatred of Trump greater than their political principles and campaign promises? Answer that yourself.

Or will Trump-the-deal-maker bypass political partisanship and work with willing Democrats, assuming there are any. In his speech after the cancelled House vote, he said of the Democrats, “If they got together with us and got a real health care bill, I'd be totally open to it, and I think that's going to happen.”

Trump is not a political ideologue; instead I suspect he will cross political lines to keep his campaign promises and advance his agenda. He is more about fixing problems than political posturing. How could he work with the Democrats?

Give them something they want, a limited form of universal coverage, catastrophic coverage for everyone. I have written about this as has Benjamin Domenech in a recent and rare conservative NY Times op-ed piece. I called it “Medicaid-for-all,” as Medicaid provides the necessary infrastructure for such insurance. But limited and catastrophic coverate,  not simply an expansion of existing Medicaid. For conservatives, provide a totally free-market based private insurance market without mandates, essential benefits and other onerous regulations. Something for everyone, even if not ideal for all. Maybe this would garner enough votes for a full repeal of Obamacare with a more practical replacement alternative.

But wait! Are you suggesting another entitlement? Sorry but that ship sailed long ago. From the New Deal to the Great Society, we are now the Entitlement Society, cemented in law and culture. Want to eliminate health care as one of our many entitlements? Good luck. Try running for national office on that platform.

Like most other developed countries, we have both a public and private health care system. But unlike these other countries, we are trying to mix both together, and it’s not working. We get the worst of both systems and the best of neither. What I described above at least attempts to separate the two existing systems so each can serve its purpose.

Short of getting Democrats to vote to repeal Obamacare (won’t happen) or getting Republicans to blow up the filibuster (good luck getting majority support), repeal isn’t going anywhere in the current Congress. Trump likely realizes this and may choose pragmatism over politics, doing an end run around political gridlock to deliver on his campaign promise.

Brian C Joondeph, MD, MPS, a Denver based physician and writer. Follow him on Facebook  and Twitter.