/></p> <p class=No one who was awake in the middle of the night watching the Senate debate on ACA repeal will soon forget the rising tension as it became more and more apparent that the repeal effort was foundering – culminating in the dramatic “thumbs down” from Senator McCain. And, of course, many have correctly pointed out that McCain’s gesture would have been meaningless were it not for the steadfast opposition of Senators Collins and Murkowski.
 
With the failure of the Senate to reach an agreement, the effort to dismantle the coverage expansions in the ACA and to shift more of the cost of the Medicaid program onto states, providers and beneficiaries came to an abrupt stop. However, we know the effort is not dead.

Three Reasons Repeal Is Not Dead: Motive, Means and Opportunity

First, the Trump administration and many in Congress still actively desire repeal. Less than 24 hours later, the administration and various factions in the House and Senate were attempting to jump-start the rollback.
 
The Trump administration has not only repeated its threat to actively sabotage the ACA but has also threatened to take health insurance coverage away from members of Congress and their staff as well as to default on the US’s debt obligations, risking a global economic crisis, if the Senate didn’t pass something, apparently anything, that they could label ACA repeal. While there is little reason to believe that these threats will have any impact on the future action of lawmakers, they underscore the fact that the desire to repeal the ACA remains very much alive.     
 
In addition, while Senator McConnell pulled the repeal bill off the Senate floor, the absence of a vote on final passage means that if Senate leadership can strike a deal with 50 Senators, a bill could still move forward. In addition, while repeal was defeated dramatically, it was not defeated decisively. If only one of the three ‘no’ votes were to shift position, repeal momentum would resume.
 
Still, the comparative calm (perhaps ending by the time this blog goes live if rumors about Trump’s plan to cancel cost-sharing reduction payments to insurers are true) gives us a chance to asses both how we got to this point and what is likely to come next.
 
You May Ask Yourself, How Did I Get Here?
 
The interaction between proponents and opponents of repeal produced the denouement on early Friday morning. Let’s look at some of the key ingredients that brought the repeal effort to a halt.
 

The Many Mistakes of the Repealers:
 

1. Reality Bites

One great mistake that Republicans made (and apparently continue to make) is believing their own propaganda. They have consistently exaggerated the ACA’s shortcomings and understated its benefits. However, as the science fiction writer Philip K Dick observed, “Reality is that which, when you stop believing in it, doesn’t go away.” The reality is that the ACA has helped millions of people, and those people became a potent force opposing the rollback of consumer protections and financial assistance.
 
A second reality-related problem for the Republicans was that they created what has been an unbridgeable chasm between their critique of the ACA and their proposed changes. In particular, they criticized the ACA for having premiums and cost sharing too high while proposing to make both go up.

2. Misreading the Tea Leaves

On a deeper level, Republicans seemed to think the unpopularity of the ACA would be enough to give them the political cover. But the opposition – especially of Republicans to “Obamacare” – was almost entirely due to their dislike of Obama and had very little to do with the actual content of the law. For years, ACA supporters fretted over the problem that while the individual components of the law were mostly popular, the law itself was not. But now this dynamic is operating in the reverse. The repeal is a repeal of specific provisions of the law, and people like those provisions and don’t want to see them go. What people really seem to want is for the benefits of the ACA to sweep in and help those who have been left out.

3. No Coherent Alternative

In addition, while antipathy toward the ACA was pretty close to universal among Republican members of Congress, this surface unity masked a deep division between the more “Main Street” Republicans and the more ideologically extreme Koch brothers/ Tea Party/ Freedom Caucus wing. As long as Obama was in the White House, confronting these divisions seemed like an all pain, no gain exercise. However, when they unexpectedly became the governing party in November, they were unprepared to offer a coherent alternative to the ACA.
 
the scorched earth campaign they had been running against the ACA for seven years compounded this inability to put forward a coherent replacement. Anything that looked like ‘ACA-lite’ was immediately suspect, but the ACA’s blend of tax credits, private insurance markets and personal responsibility were essentially a use of conservative means for liberal ends. Since they could not publicly disavow the ends (though they sometimes tried), they were left without any real policy direction. President Trump made matters even worse by continuously shifting his position–for example, praising the House bill one minute and calling it “mean” the next.

4. A Bridge Too Far

A final critical problem for the would-be repealers has been over-reach. Not satisfied with rolling back the ACA, Congress went after deep cuts in the core Medicaid program. The desire to use health care legislation as a stealth vehicle to enact large tax cuts for the wealthy necessitated these cuts. But the Medicaid cuts multiplied many times over the universe of people who would be hurt by the proposed repeal and created an existential threat to much of the health care system. Congress also launched an attack on access to reproductive health services for women, and this attack played a large part in prompting the crucial opposition of Senators Collins and Murkowski.

Advantage to the Defenders

On the other side, those opposing repeal had several key advantages, despite holding none of the levers of power. First, it is always easier to stop something than to pass something. Repeal opponents did not have to agree on all the fixes they would like to see in the ACA, they only had to agree that they didn’t want repeal. As a result, there was unity (and solidarity) across groups opposing repeal as well as among Democratic members of Congress.
 
Second, opponents of repeal mobilized rapidly and benefited from an “enthusiasm gap.” Not only do most people oppose repeal, but they are also much more intense in their feelings than are repeal supporters. In the real world, repeal of the ACA is a life or death matter for many people, and they were not prepared to go quietly.

Waking the Sleeping Giants

While the early opposition of an engaged citizenry that called, wrote, filled up town hall meetings and public forums, and staged protests and sit-ins was critical, in the end it wouldn’t have been sufficient if virtually all of the main economic actors in healthcare (OK, not the device manufacturers) had not joined it. The determination of Republicans in Congress to inflict deep wounds on both providers and insurers ultimately created a strong voice of opposition that helped influence other powerful actors, including the nation’s governors and many in the business community. It was this combination of inside and outside opposition that was so powerful.

It Ain’t Over ‘Til It’s Over (and It Ain’t Over Yet)

What is truly alarming is that despite the many missteps made by the proponents of the repeal effort and the massive outpouring of opposition, repeal very nearly succeeded and still could. The undead bill remains undead. Even though it is resting in the ground right now, it can still reemerge to terrorize the poor and the sick. In addition, many other threats lie ahead, including sabotage of health insurance markets, administrative actions and inactions that erode coverage gains, a failure to renew funding for the CHIP program, and new proposals to cut Medicaid (and perhaps Medicare) in upcoming deliberations about tax reform, the debt ceiling and the 2018 budget.
 
So, for now, we can celebrate a hard-earned the victory, but we recognize that the fight is far from over. Tomorrow, back to the battlements.

With thanks to Quynh Chi Nguyen, policy analyst, for her assistance.