The past few weeks have been a tumultuous time for President Donald Trump and the Republican members of Congress.  Many in the GOP celebrated when the House of Representatives passed the American Health Care Act (AHCA) in May, in anticipation of full repeal of President Barack Obama’s Affordable Care Act. In more recent weeks, however, the Senate has not been able to duplicate the House’s success.

The Senate created a working group of 13 Republican Senators tasked with drafting their own version of a health care reform bill.  They eventually produced the Better Care Reconciliation Act (BCRA) which included many tax cuts (primarily for the wealthy) and a $772 billion cut in funding to Medicaid, the federal health insurance program that serves primarily the poor. The bill also shrank the number of people that would qualify for health insurance subsidies; instead of making the cut-off 400 percent of the poverty level, it lowered it to 350 percent.

The BCRA was scored by the Congressional Budget Office shortly after its release.  The CBO estimated that almost 22 million people over ten years would lose their health insurance if the bill were enacted.  The plan would also save the federal government almost $321 billion over ten years. The earlier House bill would have kicked 23 million off health insurance while saving $119 billion over the next decade.

The Senate bill was perceived by much of the public as deeply flawed. A poll by USA Today found that only 12 percent of Americans supported the Better Care Reconciliation Act.  Surprisingly, almost 53 percent of those polled wanted Congress to leave Obamacare in place. Despite the broad disapproval of the Senate plan, almost 80 percent of Republicans feel that Obamacare should be repealed (only 11 percent of independents and 2 percent of Democrats feel the same).

That may be an important reason why the 52 member Republican majority in the Senate couldn’t secure the minimum 50 votes necessary to pass the bill. Moderate Republicans were unhappy that so many of their constituents would lose health coverage, while more conservative members wanted a more complete elimination of Obamacare.  This divide forced Senate leadership to scuttle the bill.

The Current State of Health Care Reform

With the Senate failing to bring the Better Care Reconciliation Act up for a vote, it appears that the effort to repeal and replace Obamacare has stalled, but that may not be a permanent situation. President Trump recently issued a public statement calling on the Senate to vote on a bill that would only abolish the Affordable Care Act—although it wouldn’t go into effect for two more years—and produce a replacement at some point in the future.  Although Senate Majority Leader Mitch McConnell has agreed to hold the vote, at least three members of the Republican caucus in the Senate have already publicly signaled that they will vote against it, virtually dooming the new bill. The CBO estimates that 32 million Americans would lose their health insurance if only a repeal bill were passed.

Almost immediately after learning that the Senate repeal bill was unlikely to pass, President Trump renewed his effort to push through a repeal and replace approach to health care reform. Considering the widespread support among Republicans in favor of replacing Obamacare as well as years of promises by GOP leaders, it is not surprising that Trump and his Congressional colleagues are eager to continue working on a legislative reform package.

There remains the possibility that the Senate Republicans could reach out to their Democratic colleagues to produce a bipartisan bill.  With the 46 Democrats and two independents united in their opposition to repealing the Affordable Care Act, along with the sad news that GOP Senator John McCain is struggling with a major health issue, a bipartisan effort may be the only way to pass any kind of reform plan.

Democrats have voiced their support for a reform proposal that would fix Obamacare rather than abolish it. Some Republicans have also said that they would be willing to work with Democrats to produce some kind of fixes. Any new bipartisan effort would likely include major compromises, but it would help Trump and the GOP avoid complete failure.

The Future of Health Care Reform

Although the Republican effort to reform health care has stalled for the moment, there are many pressing issues that Congress and the Trump administration need to address. Many of the major health insurers are leaving the Obamacare exchanges.  In 2018, it is expected that 44 U.S. counties will not have any available Obamacare health plans, and 31 percent of U.S. counties will only have one insurer in their market.

This diminishing competition on the insurance exchanges has pushed up premiums for many of these Obamacare plans that remain available. In 2017, the premiums on Obamacare health plans rose, on average 25 percent across the country, but some states experienced premium hikes greater than 50 percent. Combined with the fact that many of these plans include annual deductibles in the thousands of dollars, there is a dwindling appetite to purchase these ACA-sponsored plans.

If the Senate had passed the Better Care Reconciliation Act, it would not have helped lower premiums greatly, nor would it have stabilized the health insurance exchanges. The BCRA, like the House bill, was primarily focused on rolling back Medicaid and lowering the deficit.  If the Senate tries to produce a new health care reform bill, it will likely have to be more focused on improving access to insurance options in these bare counties and limiting premium hikes.

Because any new reform proposal is likely to require the support of Democratic Senators, future reform efforts will likely not include a repeal of the Affordable Care Act. Instead, expect any new Senate plans to concentrate on issues like improving competition, attracting younger enrollees, or changing eligibility requirements for Medicaid.  Although Obamacare appears to be safe from repeal for the moment, expect changes in how it operates.