Like an egg that rolled off the kitchen counter – briefly in flight then a big, sloppy mess – the Republican plan to repeal the Affordable Care Act (ACA) has left the party with unappetizing options.

Republicans are now faced with either fixing the law popularly known as Obamacare, or undermining it, as Donald Trump has suggested.

So what happens next?

Trump argued Democrats would “own” the ACA’s failures and suggested “when it explodes” Democrats would crawl back “to make a deal”. “I’m open to that,” he concluded.

Just one problem: the law could actually keep growing while Republicans sidestep the issue.

Virginia’s governor, Terry McAuliffe, became the latest governor (albeit a Democratic one) to take advantage of one of the ACA’s central provisions – expanded healthcare for the poor. Right now, there are 31 states that have expanded Medicaid, a public health insurance program for the poor, with the federal government footing most of the bill.

The ACA is the law of the land and it's here to stay. I'm proposing a budget amdt to move forward with Medicaid expansion by Oct 1. pic.twitter.com/3ZWzcVayPN — Terry McAuliffe (@GovernorVA) March 27, 2017

This program was a major sticking point in Republicans’ failed health bill. Though conservatives philosophically opposed the entitlement program, many Republican governors recognized its significant benefits to their constituents. Congressional Republicans would have cut Medicaid by $880bn, forcing dramatic benefit cuts.

McAuliffe became the first governor post-“Trumpcare” to announce his intention to expand Medicaid. An estimated 136,000 Virginians stand to gain health insurance if his state moves forward with the expansion. Nationally, Medicaid has grown by 17 million people since it was expanded. The Republican plan would probably have resulted in 14 million people losing Medicaid.

Undermine or subsidize?

The Trump administration will also need to quickly decide whether to defend the ACA against a lawsuit House Republicans prompted. Yep, that’s right – Trump may need to defend a law he swore to repeal from an action his own party took.

When the ACA was passed, lawmakers promised to pay insurers if losses were larger than expected, in order to entice them into markets where individuals could buy insurance. In the years following the ACA’s passage, when Republicans took control of Congress, the party decided that – in fact – Congress would not agree to pay insurers that money. Some companies are now suing the government for money they believed they’re owed, with some success. Moda Health Plans was the first insurer to win a lawsuit. A judge awarded the company $214m in February. The federal government is likely to appeal. However, for an administration which must now decide whether to stabilize or undermine health insurance markets, depriving insurance companies of a financial backstop might not be good business. Insurance companies are making decisions now about whether to stay in the individual insurance market.

Conservative visions

The Trump administration could mold programs to better conform with conservative ideals. Medicaid is a good example. The agency that administers Medicaid, called the Centers for Medicare and Medicaid (CMS), is now headed by a woman who helped do just that when she worked with vice-president Mike Pence in his home state of Indiana – Seema Verma.

Verma helped conservative states like Indiana and Kentucky as they attempted to add requirements to the program stating that beneficiaries must work. The Obama administration shot those plans down, but Verma is now in a position to approve these more restrictive programs. For a bit of context, the majority of Virginians (51%) who might be covered if Medicaid expands already work.

But the Trump administration will also need to account for its own supporters who gained access to Medicaid under Obamacare and might lose it again to such requirements. In just three southern states that voted heavily for Trump – Arkansas, Kentucky and West Virginia – more than 900,000 people depend on the Medicaid expansion alone.

It’s not just Medicaid that could change

An attempt to change “essential health benefits”, tenets of insurance Americans consider defining such as coverage for hospital visits or maternity care, did not just tank the Republican law – the benefits could also be at the center of one of the first fights to come.

Coverage of contraceptives is the likeliest target for change. For example, the Trump administration could allow more companies to say they are religiously opposed to covering oral contraceptives. That would cause more women to have to pay for the pill themselves. Considering that more than one quarter of US women use birth control pills, this is no small change.

Already under investigation

In the Trump administration’s zeal to prove that Obamacare was “collapsing”, the administration pulled already-paid-for ads from the airwaves just before a sign-up deadline. Critics cried foul, because most people sign up at the last minute, and some thought it could depress enrollment.

The Department of Health and Human Services’ in-house watchdog also thought the move was worth looking into. The day before the Republicans’ health bill failed, the inspector general said it would investigate the agency’s decision to pull the ads.