Republicans are under renewed pressure to shore up the fragile US healthcare system after they knocked out a pillar of Obamacare in landmark tax legislation, but did not attempt to stabilise it. Party leaders differ over whether to make healthcare a signature issue, stung by their failure to repeal Barack Obama’s reforms entirely in the summer. But the tax bill has made it harder for Congress to do nothing in the coming election year, say experts.

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Thirty years before Republican lawmakers imperilled President Donald Trump’s hopes of uprooting Obamacare, the property mogul penned some negotiating tips in The Art of The Deal. “The worst thing you can possibly do in a deal is seem desperate to make it,” he wrote.

In a week when his party’s inability to repeal and replace his predecessor’s health programme bordered on farce, Mr Trump has appeared to be following that tip. “Let Obamacare fail, it will be a lot easier,” he said, suggesting that if there was to be no deal on an orderly overhaul of the system, it should be left to collapse on its own.

With disarray over healthcare ranking among the ignominies of the president’s first six months in office, the let-it-fail mantra injected a fresh dose of chaos and confusion and drew accusations of callousness. Next week the Senate may attempt another vote on Obamacare, also known as the Affordable Care Act, but whether it will be repeal-only, repeal-and-replace or something else remains undecided.

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The last man to pull out of the Republican race against Donald Trump was John Kasich, the Ohio governor, a long-shot contender for the presidential nomination whose chances had long since faded. But he has returned to the role of thorn in Mr Trump’s side as Republicans in Washington struggle to reform Obamacare, leading a group of governors trashing their own party’s plan.

The intra-party revolt is rooted in Republican proposals to gut Medicaid, a programme for the poor that provides insurance to 69m Americans. Republicans have long seen it as an emblem of mismanaged welfare programmes that distend government and discourage people from working. But Mr Kasich is showing change is afoot.

He was one of 16 governors from Republican-led states that took an option to expand Medicaid offered by Obamacare, adding 700,000 Ohioans to the programme, despite the broad distaste for Barack Obama’s reforms in his party. In recent weeks he has stressed its vital role in treating people ravaged by opioids and other drugs, which killedan average of 11 Ohioans each day last year, and those suffering from schizophrenia, bipolar disorder and other mental illnesses.

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Republicans are facing a critical test of Senate unity in the Trump era as leaders prepare to unveil a healthcare bill that they have grappled over in secrecy to reconcile the conflicting demands of party factions.

President Donald Trump’s policy ambitions depend on Republicans’ ability to bridge deep internal divisions, and after false starts on healthcare in the House of Representatives earlier this year the drama now moves to the Senate.

Mitch McConnell, the Senate majority leader, has promised to release a draft healthcare bill on Thursday, incorporating substantial revisions to a measure that passed the House in May. But whether it will secure enough votes to pass the Senate remains in doubt.

Healthcare reform has become a quagmire for Mr Trump, who campaigned on a pledge to repeal his predecessor’s Obamacare reforms. But he has seen efforts falter as his party disagrees on who should get health insurance and how it will be paid.

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In the latest Trump administration gamble, senior White House officials have predicted a vote to overhaul Obamacare this week even though party chiefs on Tuesday did not have enough support to pass a bill.

Grace-Marie Turner, who advises Republican lawmakers on healthcare as president of the Galen Institute think-tank, said: “Obamacare handed Republicans a bucketful of hand grenades and they are now trying to work out how to stop them going off.”

Ms Turner said Republicans’ healthcare struggles stemmed partly from the fact they had done a poor job explaining to voters what their proposals would mean. “They’ve not had enough time to spend on core messaging to persuade people that you are going to be OK, that [Obamacare] is going to stay in effect while we move to a better system,” she said.

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