The Senate health-care bill is not definitively dead, but it’s unmistakably ailing—and the prognosis is not promising.

The prognosis was never promising. All the various Republican health-care proposals circulated since 2010 would remove health-insurance coverage from tens of millions of people, many of them the GOP’s most loyal voters. Look for example at the dilemma facing Kentucky’s Rand Paul.

Four hundred and forty thousand Kentuckians have gained coverage under the ACA; Kentucky’s uninsured rate tumbled from 20 percent in 2013 to 7.5 percent in 2015. Even more strikingly, it is Kentucky’s Appalachian Southeast that has seen the biggest gains from the ACA. And it so happens that southeastern Kentucky voted more staunchly for Paul’s 2016 reelection than did any other section of the state. Paul won 76.6 percent of the vote in Clay County, where 15.6 percent of the total population has gained coverage via the ACA’s Medicaid expansion. He won 81.5 percent of the vote in Jackson County, where 15.1 percent owe their Medicaid to the ACA. He won 84 percent in Leslie County, where 18 percent would lose Medicaid if Obamacare were repealed.

Senator Paul resolved his dilemma in a shrewd way: He spoke to ensure that he kept his standing as the purest of the ideologically pure—and acted to ensure that the white poor of southeastern Kentucky retained their Medicaid coverage.

The current #healthcarebill does not repeal Obamacare. It does not keep our promises to the American people. — Senator Rand Paul (@RandPaul) June 22, 2017

Other Republican senators found their own excuses to arrive at the same result for their own states. It’s generally reckoned that half the people who gained coverage under the Affordable Care Act did so via Medicaid expansion. The Republican ACA alternative would undo that expansion. Unlike the many regulatory changes Republicans had in mind, such a stripping away of an existing benefit is easy to understand—and a natural target for political payback. No surprise then that the senators flinched.

What Republicans have been trying to do all this year is both impressively bold and bizarrely futile. Democratic societies almost never repeal major social insurance programs. The very rare exceptions—like the catastrophic care supplement to Medicare enacted in the last year of the Reagan administration and repealed the following year—are pulled up before they sink deep roots. The determination of Republicans to invest so much time and energy in a doomed struggle represents a certain kind of idealism, but not the kind of idealism on which a governing majority can be constructed. To quote something I wrote after the House GOP fumbled its first vote on ACA repeal-and-replace:

In that third week in March in 2010, America committed itself for the first time to the principle of universal (or near universal) health-care coverage. That principle has had seven years to work its way into American life and into the public sense of right and wrong. It’s not yet unanimously accepted. But it’s accepted by enough voters—and especially by enough Republican voters—to render impossible the seven-year Republican vision of removing that coverage from those who have gained it under the Affordable Care Act. Paul Ryan still upholds the right of Americans to “choose” to go uninsured if they cannot afford to pay the cost of their insurance on their own. His country no longer agrees.

Which is how we got to where we are now.