4 questions on the fight over Obamacare and what happens next

When Republicans retook the House of Representatives, one of their first votes was to repeal Obamacare. The date was Jan. 19, 2011.

The vow to repeal echoed across four elections and drew roars of approval at rally after rally. Now, exactly six years and six months later, that cause hit a brick wall in the Senate. After four senators, each for their own reasons, declared they would not support the Republican health care plan, Majority Leader Mitch McConnell stated the blunt truth.

"It's pretty clear that there are not 50 Republicans, at the moment, to vote for a replacement for Obamacare," McConnell told reporters July 18 after a closed session with his colleagues.

How did we get here? What should we watch for next? Here’s what six experts from different backgrounds had to say.

Republicans won control of Congress and the White House, but on health care, they had never coalesced around any clear policy, said Tevi Troy with the American Health Policy Institute, a policy group representing large employers.

"While they agreed that they disliked Obamacare, they did not agree on what should replace it," Troy said.

One of the fundamental disagreements was which one of the many parts of the Affordable Care Act required the biggest fix. As the Senate bill took shape, the Medicaid program drove the deepest wedge into the Republican ranks. Studies vary, but at least half of all the insurance gains under Obamacare came through offering Medicaid to all poor adults. (Before the law, Medicaid was open to only poor people who were also elderly, disabled, young or pregnant.)

While 20 Republican senators from expansion states wanted to preserve coverage, the senators from the states that did not expand Medicaid (like Florida) were concerned with fairness and parity.

Senators from expansion states "wanted to keep theirs," said Joe Antos at the pro-market American Enterprise Institute. But "the ones from non-expansion states were saying, ‘Where’s mine?’ "

Antos said that was partly a fight over money, but the Medicaid arguments also reflected deeper fault lines in the party.

Those fault lines go back decades, agreed Robert Blendon, professor of health policy at Harvard University.

"Ever since President Ronald Reagan, there’s been a core belief in the GOP that the federal government should not play a major role in providing universal coverage," Blendon said. "Meanwhile, you had Republican governors and some senators who said that once you’ve given health insurance to 20 million people, you can’t just go back."

In short, the Affordable Care Act itself reshaped policy divisions inside the Republican party.

That debate went beyond Medicaid to include protections for people with preexisting conditions and subsidies for the working poor. Blendon said the repeal effort divided Republicans into pragmatists who wanted to work with the existing law and those who held firm to small-government ideals.

So far, there has not been enough money and not enough common policy ground to bridge the gap.

Republicans were caught in a web of policy and politics that gave them little room for error. Gail Wilensky, a former health adviser to President George H. Bush, said their 52-48 majority in the Senate presented a challenge that people outside Washington might not fully appreciate.

But that aside, Wilensky said the mantra of repeal-and-replace became a box that Republicans couldn’t escape.

"When you are the party that has promised that for six years, and you’ve won, it’s really hard to switch horses," she said.

The insistence on repeal made winning Democratic votes essentially impossible, and under Senate rules, the only path forward that Republicans could control without any Democratic help was the legislative process called reconciliation, which limits the timing and the content of the legislation. Only matters of taxing and spending can be handled by reconciliation.

"Much of the Affordable Care Act has nothing to do with the budget," Wilensky said.

Jonathan Oberlander, a health policy professor at the University of North Carolina-Chapel Hill, said it didn’t help that the Republican plan lacked popular support.

"The GOP managed to help make Obamacare more popular, that’s how wrong this went for Republicans," Oberlander said.

Antos at the American Enterprise Institute faults President Donald Trump for doing little to focus the debate on the Republican side.

"Unlike any other modern president, Trump came in with no clear policy agenda," Antos said. "And that meant the various factions wandered all over the pasture."

Experts both right and left of center agreed that if Republicans had wanted a better shot at success, the work should have started decades ago.

"They didn’t work things out within the party," Harvard’s Blendon said. "The leadership should have thought, is there any common ground for what we could pass? But that was not the discussion they had."

In theory, Republicans could have reached out to Democrats. Antos said GOP leaders "had to make the first move, and they didn’t make a convincing one."

But that itself would have presented its own risks, said William Galston, senior fellow in governance studies at the Brookings Institution.

"Republican leadership could have said, ‘Well, we’ve looked at this and we don’t think Obamacare is that bad. We can repair and retain rather than repeal and replace.’ But while you could make a case for that on the merits, I don’t think it was politically possible."

The flaws and benefits of the law continue.

"Most of the expanded coverage came through Medicaid," Wilensky said. "That won’t change. In the individual market, people getting premium subsidies will still get them. But premiums will continue to go up, and the people really getting caught are those who make too much to get a subsidy."

Several of the experts we reached warned that insurance companies will continue to wrestle with unpredictable federal policy. According to a recent Kaiser Family Foundation study, there are signs that the overall market has stabilized and insurers are making a profit. However, some might pull out of certain markets.

"The Affordable Care Act will continue to provide coverage to tens of millions of Americans and protect millions more through insurance regulation," said Oberlander. "But its problems will go unfixed, and could worsen over time."

If Congress fails to act, the next move is in Trump’s hands. The single most important factor has to do with payments to insurance companies to cover the costs of low-income policyholders. The price tag is $7 billion this year and $10 billion in 2018.

The payments were designed as part of Obamacare, but after a legal challenge by House Republicans, they now sit in a legal limbo. The White House has to decide every three months whether to cut the checks to insurers.

The companies have lobbied for more certainty, but so far, that’s been elusive. Without the subsidies, premiums go up.

"The next thing to watch is whether Republicans want to try to stabilize the exchanges, or if they exacerbate the problems," Troy said. "Trump seems inclined to ‘let Obamacare fail’ but it’s not clear that congressional leadership will have the same approach."

Blendon noted that the administration can take several steps to undermine the Affordable Care Act. It can loudly refuse to enforce the requirement for people to buy coverage. It can reduce enrollment by shortening the sign-up period and cutting off spending for marketing.

Those moves still fall short of the repeal that many Republicans were hoping to accomplish.

"They can weaken the Affordable Care Act, but not in a way that can permanently damage it," Blendon said.