Congress choked. Obamacare lives.

House Republicans are at an unfamiliar crossroads after their seven-year effort to repeal the law collapsed. The direction they and the Trump administration choose will determine whether Obamacare survives, or faces new threats as political opposition continues to simmer and flaws recognized even by its supporters go unaddressed.


Bruised and divided by the repeal push, Republican leaders are expressing little enthusiasm for plotting what, if anything, might come next. “We're going to move on with the rest of our agenda because we have big, ambitious plans to improve people's lives in this country,” House Speaker Paul Ryan said Friday after pulling the bill before it went down to a humiliating defeat.

Here's what the future could hold for a law that just won't die after more than 60 Republican repeal votes, four national elections and multiple Supreme Court battles.

Trump: Let it implode

President Donald Trump has often said he’d be perfectly happy to let the law implode — and blame the Democrats.

“The best thing we can do politically speaking is let Obamacare explode — and it's exploding right now,” Trump said Friday. “It’s imploding and soon it will explode.”

Republicans could take several steps to hasten, if not force, such an explosion. They won a lawsuit last May seeking to stop the law’s cost-sharing subsidies that help low-income enrollees pay their out-of-pocket costs. Those payments were allowed to continue pending an appeal. They could decide now to end those payments, which would likely prompt insurers to flee the individual insurance market.

And even if the unpopular mandate requiring most Americans to have insurance remains as a matter of law, the administration could stop enforcing it. The individual mandate is a pillar that keeps the insurance markets stable – weakening it could provoke a crisis that forces Congress to respond with a drastic health care overhaul.

But those would be risky, high-stakes plays. While Trump has expressed confidence Democrats will bear the blame for a collapsed health care system, Republicans could get caught in the backlash if they take explicit steps to bring down Obamacare.

Claim ownership and fix it

House Speaker Paul Ryan told lawmakers they had one shot at repealing Obamacare. When that foundered, he acknowledged, “We’re going to be living with Obamacare for the foreseeable future.”

For some in the House, that means the mission is over.

“We tried. We tried our hardest. There were people who were not interested in solving the problem,” said House Energy and Commerce health subcommittee Chairman Michael Burgess, who is also a physician. “We’re done with this.”

But now that it’s on the GOP’s watch — and voters may hold them accountable for its problems — Republicans could decide grudgingly to work to shore up the individual insurance market that even Obamacare supporters acknowledge need fixes. The first urgent task would be for the White House and Republicans to resolve the question of funding the cost-sharing subsidies that insurers offer low-income Americans.

They’d also have to take a new look at how and whether they can lure companies back into a market they’ve said for months is on the brink of collapse.

The administration has already taken small steps to do that, including shortening the sign-up period and cracking down on enrollees who miss their payments. But insurers may need greater assurances that the administration is committed to keeping the system intact and willing to explore new ways to attract younger and healthier people to offset the costs of the older, more expensive individuals who account for the biggest share of enrollees.

Adopt Obamacare — but paint it red

Republicans have a lot of ideas for how the health care system should look. They could use regulatory authority to develop some of them even if Obamacare remains on the books.

Health and Human Services Secretary Tom Price has pledged to unwind many regulations and give states more freedom. He and CMS administrator Seema Verma have already signaled plans to rewrite coverage rules and allow states to impose work requirements on low-income Americans covered under Obamacare’s Medicaid expansion, for instance.

They could also relax the rules of the road for insurers that sell plans through HealthCare.gov. One option would be to loosen oversight of the package of benefits the ACA requires. Republicans say not everyone wants to have to buy all those health services, which drive up premium prices.

Whether Price will move ahead with such aggressive actions after the stunning rebuke on Capitol Hill is unclear. That failure came about in part because some Republicans were worried about people losing their health care. So Price won't have a repeal-hungry Congress to back him up.

The department could also easily throw out rules requiring plans to offer contraceptive coverage at no additional cost to consumers. That won’t topple Obamacare but it would be a big change politically.

If at first you don’t succeed…

Some Republicans promised on Friday they would keep trying to repeal Obamacare, reiterating warnings about the law’s imminent collapse that they’ve used in the past.

“If you buy a car and it’s a lemon and now you own it and try to fix it, it won’t be fixed,” said Rep. Tim Murphy (R-Pa.), a moderate who threw his support behind the bill after winning $15 billion in funding for services like mental health care and maternity coverage. “The blame goes to the one who made the car.”

It’s too soon for any clear road map, but conservatives eager for a simple repeal of Obamacare could eye a measure like the one House Republicans passed in 2015. Once that goal is fulfilled, they say, they can start in on a separate replacement measure.

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“Sometimes you’ve got to take a couple shots at something to get it,” said Rep. Scott Perry (R-Pa.), a member of the Freedom Caucus, before Ryan pulled the bill. “I’m confident that what I’m going to do is do everything I can to repeal and replace the ACA.”

Work with Democrats — and push choices to the states

Given the mood on Capitol Hill right now, it’s hard to see any opening for bipartisanship. But Trump himself told the Washington Post Friday afternoon that he wanted to work with Democrats – right after he ranted about Obamacare’s implosion.

"When it explodes they [Dems] come to us and we make one beautiful deal,” he said.

Democrats have always said they’re willing to work with Republicans on heath reforms and fixes – as long as they don’t resemble anything close to the end of Obamacare.

Lawmakers may also look for ways to shift more of the responsibility — and choices — to the states.

Sens. Bill Cassidy (R-La.) and Susan Collins (R-Maine) have a middle-of-the-road plan that would let states opt to keep Obamacare if they like it, or move to a brand new system. It didn’t get any traction when House Republicans were full bore on repeal — but the moment could come, in the future, for a second look.