The Republican effort to pass healthcare legislation is in trouble.

Senate Majority Leader Mitch McConnell, R-Ky., having made changes to the initial Senate legislation in an attempt to woo holdouts, is still scrambling for support ahead of an expected vote this month. Even if he manages to pass something, senators will have to run for re-election defending a bill that is widely unpopular, and that is unlikely to win over the public as its patchwork of policies start getting implemented.

Given the problems, it would be easy to point the finger at President Trump, who after all, is the chief executive. He stormed into Washington on a promise to fix the healthcare mess and deliver a beautiful piece of legislation as only an expert deal-maker could. But the truth is that Republicans problems on healthcare are much deeper than Trump.

To be sure, it isn't as if Trump has been helpful to the process. His lack of policy understanding, short attention span, lingering unpopularity, conflicting statements, and social media outbursts have hampered the process. He has promised, at various times, to increase coverage, make insurance more comprehensive, and cheaper, with lower deductibles, less federal spending, and fewer taxes. He has promised to repeal and replace Obamacare and also not cut Medicaid spending. There's no way to achieve all of those things simultaneously.

Trump lobbied House Republicans to support a healthcare bill that he subsequently attacked to GOP senators as "mean." Instead of using the bully pulpit to sell the legislation, Trump has been distracted by settling scores on Twitter. His thin grasp of details has made it difficult for him to take the lead in negotiations, because he doesn't have a keen understanding of what individual lawmakers want or need to support the bill.

So, it's true that a more engaged and informed president may have helped along the process more than Trump has, but it's also true that at the end of the day, Trump is going to sign anything Republicans can get through Congress and he will boast that it is a major win and the greatest piece of legislation in galactic history. The chaos we're seeing, thus, goes way beyond Trump.

Republicans, for decades, have always struggled to have a coherent healthcare policy agenda. For Democrats, it's pretty simple. They believe that comprehensive health insurance coverage is a basic right that should be guaranteed by the federal government. They have no ideological objection to taxing more, spending more, and regulating more to achieve their aims. Their internal arguments ultimately boil down to political strategy. Do we push full single-payer now or is that too disruptive and risky? Should we take an incremental approach? Over time, they have made progress toward their aims when they have legislative windows in which they have attained sufficient power — passing Medicare and Medicaid after Lyndon Johnson's 1964 landslide, and Obamacare after two consecutive election wins gave them the presidency and overwhelming control of Congress. Now, well over 100 million Americans depend on those programs for coverage and many more are subject to their regulatory reach.

For Republicans, things are much more complicated. When playing to conservative audiences, they tout the benefits of limited government, free market solutions, lower taxes and spending, and less burdensome regulations. And the more ideologically conservative and libertarian members of Congress genuinely believe in those things. But beyond those relatively few politicians, most elected Republicans are afraid to say they don't believe that there is a right to health insurance, or that they don't think that the federal government should guarantee coverage. Or heck, it would even be hard to find many elected Republicans to say, "We can never insure one hundred percent of the population against one hundred percent of the hazards and vicissitudes of life," as Franklin Roosevelt, the father of the modern welfare state, did when he signed the Social Security Act into law.

When Republicans are in opposition, it's much easier to thread the needle. They can attack government takeovers of the healthcare system. They can point to the losers of any major legislative overhaul whose lives are being disrupted. In the case of Obamacare, this meant seizing on whatever was in the headlines at a given time — people losing coverage, young and healthy individuals seeing their insurance skyrocket, those middle class Americans just above the income cutoff for Obamacare subsidies who are struggling with high premiums and lack of choices, business owners trying to figure out how a web of new regulations affects them. And when asked for an alternative, they could speak more vaguely about a more market-oriented approach.

Now that it's time to legislate, however, it's become much more difficult to square this circle. You have a group of conservatives who actually want to hold Republicans to what they've been saying all along about "root and branch" repeal of Obamacare that offers a genuine market-based alternative. But then you have a lot of other Republicans experiencing varying degrees of discomfort at scrapping parts of Obamacare that some groups are benefitting from. The problem for Republicans is that they cannot have all things. They cannot simultaneously have a cheaper, less regulated market, with lower taxes and spending, that provides relief to Obamacare's victims — without being willing to accept that a certain amount of disruption will occur to the law's beneficiaries.

Trump, if anything, merely exploited the contradictions that were already embedded within the Republican Party. He was just brasher and bolder in his ability to make promises to both sides — those wanting less government and those wanting guarantees of cheaper, better, universal health coverage.

So, this is how Republicans ended up where they are now, struggling to cut deals to win votes for a bill that isn't governed by any clear vision, and thus isn't representative of coherent policy.