By Jonathan D. Salant | NJ Advance Media for NJ.com

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Senate Republicans officially pulled the plug Tuesday on their most recent and final attempt to repeal the Affordable Care Act and enact a new law that would increase the ranks of the uninsured by millions of Americans.

The decision was another major loss for President Donald Trump, who still has no major legislative successes to show for his first nine months in office.

Their last gasp was legislation sponsored by U.S. Sens. Lindsey Graham. R-S.C., and Bill Cassidy, R-La., that would cut billions in health care spending and transfer billions more from New Jersey and other states that expanded Medicaid to those Republican-controlled states that refused the federal help that would have let them insure more residents.

"We don't have the votes," Cassidy said after Senate Republicans held their weekly luncheon at the Capitol.

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U.S. Sen. Lindsey Graham, R-S.C., surrounded by other GOP senators, speaks to reporters after it was apparent Republicans lacked the votes to repeal the Affordable Care Act. (AP Photo | J. Scott Applewhite)

McConnell said the idea of repealing the Affordable Care Act was not dead, just delayed until after Congress took up overhauling the tax code.

"I wouldn't be surprised if they try again or any times," said Rep. Frank Pallone Jr., D-6th Dist., the top Democrat on the House Energy and Commerce Committee that has jurisdiction over health care.

The budget resolution that allowed Republicans to exclude Senate Democrats and prevent a filibuster expires Saturday. Unless the GOP passes a new resolution that again allows them to avoid negotiations with the minority, the Democrats will have enough votes to block any repeal.

Here are things you should know about why Trump lost yet again, and what happens next:

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With one Yes vote in hospital & very positive signs from Alaska and two others (McCain is out), we have the HCare Vote, but not for Friday! — Donald J. Trump (@realDonaldTrump) September 27, 2017

We will have the votes for Healthcare but not for the reconciliation deadline of Friday, after which we need 60. Get rid of Filibuster Rule! — Donald J. Trump (@realDonaldTrump) September 27, 2017

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1. Republicans insist the health care law is failing. It's not.

"There's universal agreement in our conference that Obamacare is failing," Graham said.

That's not what health care experts said.

The Congressional Budget Office; the Century Foundation, a progressive research group; and the Kaiser Family Foundation, which specializes in health care, all have reported that the current law is working well in most areas, that spikes in premiums were largely covered by increased subsidies, and the threats of Republicans to repeal the law was a major driver behind higher costs.

"We do not find we any evidence that the market is collapsing or imploding," Cynthia Cox, associate director of health reform and private insurance for the Kaiser Family Foundation, said in July. "It's a stable market."

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U.S. Sens. Lindsey Graham, R-S.C., and Bill Cassidy, R-La.; and Senate Majority Leader Mitch McConnell, R-Ky., face reporters after announcing that their health care repeal efforts lacked the votes to pass. (Drew Angerer | Getty Images)

The only way the law could fail is if Trump and the Republicans sabotage it.

They are trying to: Trump has threatened to end subsidies to insurance companies that lower out-of-pocket costs for low-income policyholiders, and the Department of Health and Human Services not only shrunk the enrollment period for health insurance but decided to use weekends during that period to shut down the website altogether for maintenance.

In addition, the House passed legislation sponsored by Rep. Rodney Frelinghuysen, R-11th Dist., that would stop the Internal Revenue Service from enforcing the requirement that all Americans have health insurance or pay a penalty.

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Those actions, not the law itself, is what led New Jersey's largest insurer, Horizon Blue Cross Blue Shield, to request double-digit rate increases for the coming year.

"A weakened individual mandate, the potential loss of cost-sharing reductions, and the reinstatement of the health insurance tax are going to produce premium increases in New Jersey that are substantially higher than they would otherwise have been," Ward Sanders, president of the New Jersey Association of Health Plans, an industry group, said in July.

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President Donald Trump departsAir Force One in New York en route to a Republican fundraiser. (Mandel Ngan | AFP/Getty Images)

2. Americans didn't want their health care taken away

During the campaign, Trump promised not to cut Medicaid, the health care program for the poor, disabled and elderly, and to not take away health insurance from anyone.

He broke both pledges to endorse the Republican repeal bills, which proved to be extremely unpopular with the American public.

Only 1 in 5 Americans, 20 percent, supported the latest GOP effort, the Graham-Cassidy proposal, according to a CBS News poll. Almost three times as many U.S. adults, 58 percent, disapproved of the legislation.

No wonder just 29 percent of Americans supported Trump's handling of health care in the poll. More than six in 10 U.S. adults, 62 percent, disapproved.

The survey of 1,202 adults was taken Sept. 21-24 and had a margin of error of 3 percentage points.

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3. Doctors and hospitals didn't like the bill either

The medical community was united in its opposition to the Republican repeal efforts.

Six health care groups representing doctors, hospitals and insurers -- the American Medical Association, American Academy of Family Physicians, American Hospital Association, Federation of American Hospitals, America's Health Insurance Plans, and the Blue Cross Blue Shield Association -- released a letter opposing the latest Senate Republican repeal effort.

"While we sometimes disagree on important issues in health care, we are in total agreement that Americans deserve a stable healthcare market that provides access to high-quality care and affordable coverage for all," they wrote.

They said the Graham-Cassidy bill did "not move us closer to that goal" and "the Senate should reject it."

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4. Freedom's just another word for plenty to lose

Every Republican repeal effort involved cutting hundreds of billions of dollars from Medicaid under the guise of giving states more freedom to regulate health insurance.

All those cuts meant that millions of additional Americans would be unable to get affordable coverage, especially those with pre-existing conditions, according to the CBO. It also made it impossible for Republicans to accurately claim that their legislation would increase health coverage rather than take it away.

"It does take money out of the system," MaryBeth Musumeci, associate director of the Kaiser Family Foundation's program on Medicaid and the uninsured, said when the bill first was proposed. "It's hard to anticipate what states will do with the money they will have and what the coverage will look like."

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Senate Majority Leader Mitch McConnell, R-Ky., at a Capitol news conference as Republicans said they didn't have the votes to repeal the Affordable Care Act. (AP Photo | J. Scott Applewhite)

5. Blowing up legislative norms don't work

In contrast to the months of committee hearings and floor debate before the Affordable Care Act was enacted, Senate Republicans held just one hearing, blocked all Democratic amendments, limited debate, wrote their bills in secret, and tried to rush through the measure before the CBO could fully analyze it.

Indeed, Graham-Cassidy was being rewritten up until the time McConnell pulled the plug.

That secrecy led U.S. Sen. John McCain, R-Ariz., to cast the deciding vote to kill an earlier Senate GOP repeal bill, and to come out against this latest version, dooming it as well.

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Now let's return to regular order - hearings, open debate and amendments. https://t.co/NlTmMn79cX — John McCain (@SenJohnMcCain) September 26, 2017

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Rep. Josh Gottheimer, D-N.J., left, and Rep. Tom Reed, R-N.Y., right, listen as President Donald Trump speaks during a meeting with a bipartisan group of lawmakers at White House Sept. 13. (AP Photo | Evan Vucci)

6. Will this force Republicans to work with Democrats?

Senate Health Committee Chairman Lamar Alexander, R-Tenn., was working on fixes to the Affordable Care Act with the panel's ranking Democrat, Patty Murray of Washington, before Senate Republican leaders killed the bipartisan effort.

In the House, members of the Problem Solvers Caucus, led by Reps. Josh Gottheimer, D-5th Dist., and Tom Reed, R-N.Y., offered their own bipartisan changes to the legislation. They reiterated their desire to work across party lines in a letter to legislative leaders on Wednesday.

"We won’t all get everything we want, but we can work together to reduce health care costs, especially to address the looming deadlines that will dramatically impact next year’s premiums," Gottheimer and Reed wrote.

Pallone said that there is sentiment in both chambers to make necessary changes to the health care law without killing it.

"I think the majority of Republicans actually believe the ACA is working and they would repair it than repeal it," he said.

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7. The law needs fixing

Democrats acknowledge that the Affordable Care Act has shortcomings. Some of the topics to be addressed include the need to ensure the cost-sharing payments, reinsurance plans to hold down premiums, efforts to attract more insurers, and ways to give states more flexibility.

"We must strive for bipartisan solutions to stabilize the individual marketplace, provide relief to job-creating small businesses, cut out-of-pocket costs and improve care for all Americans," Gottheimer and Reed wrote in their letter.

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WHAT'S NEXT: Taxes

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The White House never looked more beautiful than it did returning last night. Important meetings taking place today. Big tax cuts & reform. — Donald J. Trump (@realDonaldTrump) September 25, 2017

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"Where we go from here is tax reform," McConnell said.

Republicans plan to use the same parliamentary maneuver that they did for health care, allowing to cut Democrats out of legislating, eliminating the filibuster and enabling them to pass a tax bill with just 50 votes in the Senate.

That didn't turn out so well with the Affordable Care Act repeal.

First, House and Senate Republicans have to pass a budget resolution, and it remains to be seen if they can include health care repeal along with overhauling the tax code in its provisions.

Otherwise, any efforts to repeal the Affordable Care Act will require 60 votes in the Senate, dooming them until at least 2019.

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Jonathan D. Salant may be reached at jsalant@njadvancemedia.com. Follow him on Twitter @JDSalant or on Facebook. Find NJ.com Politics on Facebook.