Updated at 2:20 p.m. ET

The defeat of the GOP Senate health care bill is a major blow to all Republicans involved.

President Trump, whose approval rating is lower than any recent president this early in his term, is now staring at an agenda imperiled. Despite his boasts, he has achieved little of significance through Congress. That failure is compounded by the fact that his party controls both chambers.

The position of Republican Senate leader Mitch McConnell, hailed for all of his senatorial maneuverability, does not appear so enviable Tuesday morning. He showed he could gum up the system and manipulate the rules to deny a president of a different party, but he has not shown the ability to control his caucus in order to govern — the way past great Senate leaders have.

The goal, after all, of any truly great legislator has always been to see problems and come up with constructive solutions. Instead, the GOP continues to have growing pains in overcoming its image as the "party of no" in the Obama years. Unfortunately for Republicans, now they're saying no to themselves.

It raises a host of questions about the status of the Republican Party, which is led in the White House by a right-wing nationalist outsider who ran against the establishment and exploited a culture seething at Washington, and in Congress by those very Washington insider establishmentarians. Who is in control?

The conservatives from within, though, are not necessarily aligned with Trump. In fact, they have shown they are not afraid of either Trump or McConnell. That could mean big problems ahead for what Republicans can get done. Tax reform is a priority for McConnell and Trump. Trump also said he wants to address the nation's aging, crumbling and, in places, dangerous infrastructure and has talked about doing so with a mix of public and private funding intended to generate $1 trillion in infrastructure spending.

But there is a reason a tax overhaul hasn't happened for more than 30 years. And infrastructure went nowhere in the Obama years after the stimulus plan — despite an economic collapse and a willingness on both sides to do it. It failed because Democrats and Republicans couldn't agree on how to pay for it.

This health care bill failure makes it all the more difficult, not just for momentum — and that's no small thing — but because of the hundreds of millions (originally $1 trillion) in tax cuts that the health care bill would have provided. That would have been a big head start on tax cuts.

McConnell had already delayed the bill's vote after Arizona Sen. John McCain was hospitalized because of a serious surgery to remove a blood clot in his head. Now, with the loss of support from two more senators — conservatives Mike Lee of Utah and Jerry Moran of Kansas on Monday night — the bill is effectively dead.

Trump offered plenty of advice: advocating full repeal and then building another plan. He even declared that Democrats would jump on board.

McConnell put out his own statement and seemed to agree. He wants senators to vote to put the House health care bill on the floor and allow a vote to repeal major pieces of the Affordable Care Act, also known as Obamacare.

"Regretfully, it is now apparent that the effort to repeal and immediately replace the failure of Obamacare will not be successful," McConnell said. "So, in the coming days, the Senate will vote to take up the House bill with the first amendment in order being what a majority of the Senate has already supported in 2015 and that was vetoed by then-President Obama: a repeal of Obamacare with a two-year delay to provide for a stable transition period to a patient-centered health care system that gives Americans access to quality, affordable care."

There were, however, obvious fissures about how to proceed, and they proved impossible to overcome. Less than 14 hours after McConnell announced the path forward, it was again blocked when three Republicans announced their opposition.

At the White House, Trump said he was "disappointed" and cast a wide net of blame for everyone but himself and his White House.

"For seven years, I've been hearing repeal and replace from Congress," Trump said of congressional Republicans. "I've been hearing it loud and strong, and when we finally get a chance to repeal and replace, they don't take advantage of it."

He also called Democrats "obstructionists" who "have no ideas" and "no thought process."

But on whether he bears any blame, Trump said, "We're not going to own it; I'm not going to own it."

The episode raises questions about the Republican brand. After Democrat Jimmy Carter left the White House, the GOP branded itself the party of management, the small-government alternative to what it lampooned as a Democratic Party that believed in bloated government.

That is what helped Newt Gingrich's rise to power as speaker of the House with his "Contract with America" and the 1994 Republican Revolution. That sweeping election gave Republicans control of the House for the first time since the 1950s.

Since the 1994 takeover, Democrats have controlled the House in just two sessions of Congress, from 2007 to 2011. That was when the Iraq War was raging and the economy collapsed under a Republican president and then in the first two years of the historic Obama presidency.

On the heels of outrage over the Affordable Care Act, the Tea Party wave pushed Republicans back into power. And the GOP is fundamentally changed. This is not the same Republican Party that relented power a decade ago.

Factionalization, led by ideologues, prevented deals from being struck between Speaker John Boehner and Democratic President Barack Obama. It led to the downfall of Boehner, who was never able to control his rowdy conference flush with hard-line newbies.

Back in May 2012, six months before Obama would be re-elected, Boehner famously said, "It's hard to keep 218 frogs in a wheelbarrow long enough to get a bill passed."

Current House Speaker Paul Ryan has faced the same problems in the early months of the Trump presidency. His hard-right faction initially prevented the passage of the House health care bill. That led Ryan to declare that "Obamacare is the law of the land."

Boehner had more to say after his "frogs in a wheelbarrow" line. He added, "I want to do more, too. But Republicans are still a minority here in Washington. Democrats control the Senate, we've got a Democrat in the White House, and our members are pretty frustrated."

That reason has expired. Republicans are in the majority, and yet they are still running into the same problems. The inability of leaders in both parties to broker deals and work constructively across party lines has meant the general public is looking at a Congress legislating in the same-old, same-partisan ways.

Some prominent Republican senators want the caucus to try to legitimately work with Democrats. McConnell attempted to use that very threat — working with Democrats — as a cudgel to get conservatives to vote for it. Apparently, that was a bluff, as he intends to see how far he can push governing along party lines.

But to what end? There aren't much more than two options when it comes to overhauling health care — government-run single-payer or a market-based hybrid system similar to the Affordable Care Act.

And Republicans are the ones who came up with the market-based system as an alternative to "HillaryCare," the health care plan Hillary Clinton was working on as first lady in the 1990s.

Afraid of upsetting their base, though, Republicans have refused to work with Democrats on health care in any serious way.

And they don't look ready to do so any time soon, especially with "Obama" still attached to the law's name.

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