Senate Republicans' bid to dismantle and rewrite Obamacare is officially dead. Any effort to pick up the pieces and move ahead requires staring down monumental challenges, starting with healing deep divisions among Republicans deflated by failure to deliver on a defining promise.

But with Obamacare’s popularity rising and repeal's popularity diminishing, they’ve got little room to maneuver to get 50 out of 52 Republican senators on board. Conservatives want to repeal more; Moderates don't want to see huge coverage losses. Senate Majority Leader Mitch McConnell has now proposed a straight up repeal vote — without an immediate replacement — but that too is a hurdle. Here are five reasons why Republicans just can’t get over the hump on Obamacare repeal after seven years of trying:


Town Hall pressure works

Just weeks before Sen. Jerry Moran (R-Kan.) made his opposition official and helped kill the bill, H.R. 1628 (115), he faced down hordes of constituents at a town hall pleading with him not to repeal Obamacare — in conservative Kansas. The raucous event put Moran on the defensive, and prompted him to pledge to defend protections for people with pre-existing conditions. Heated protests — because many senators stopped having the town halls — occurred in Arizona, Colorado, Ohio and other states with undecided or hesitant senators.

Outspoken voters hardened moderate Sen. Susan Collins' resistance to the repeal effort too, and have made life difficult for Republicans throughout their six-month attempt to dismantle Obamacare. The Senate failure is only likely to further inspire the law's most ardent defenders, and make GOP senators think twice about heading home again to defend another repeal bill.

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Medicaid's newfound popularity and its moderate champions

The Senate’s overhaul of Medicaid went far beyond what Obamacare itself had done to expand the health care program for the poor; it made the biggest changes since the program’s creation in the 1960s. Several Republican moderates found it increasingly difficult to support the move to cap federal spending and take $800 billion out of the program. Collins and Lisa Murkowski (R-Alaska), for instance, argued that the repeal bill shouldn’t include such sweeping entitlement reform.

Medicaid now covers 74 million people, roughly one in five Americans. About half of those covered are children; in some states, Medicaid covers more than half of all births. It is also the largest source of funding for long-term care in the U.S. And the millions of people added to the rolls through Obamacare expansion only added to its popularity.

Governors from both parties — including key Republicans like Ohio’s John Kasich, Nevada’s Brian Sandoval, Arizona’s Doug Ducey and Arkansas’ Asa Hutchinson — had also criticized the GOP’s efforts on Medicaid, which would have blown big holes in state budgets. The Senate bill would have led to 22 million more uninsured people, roughly 15 million of them from Medicaid.

The full repeal brigade — shunning partial repeal and replacement

In 2015, virtually every Senate Republican voted for a straight repeal of Obamacare — secure in the knowledge that then-President Barack Obama would veto it. Two years later, almost all of them were willing, even eager, to settle for much less. They tried to split the difference between eliminating unpopular parts of the law, like the individual mandate, while preserving popular benefits, like protections for people in poor health and some subsidies to make insurance more affordable.

Except Sen. Rand Paul. The Kentucky Republican was steadfast in his refusal to vote for a bill that preserved Obamacare's framework, further complicating the GOP's already-tight path toward 50 votes. Other conservatives sympathized, including Mike Lee (R-Utah) who announced Monday night that he’d block it. Paul and a few fellow conservatives are likely to jump on the bill's failure as a fresh opportunity to push for a straight repeal — and McConnell late Monday night indicated they may have a chance to cast that vote.

The polls for the Senate bill were terrible

The Obamacare repeal effort has seen abysmal ratings in polls and been buffeted by protests from liberal groups and raucous town hall meetings around the country. It’s hard for Republicans to vote for a bill with dismal approval ratings — that keep getting worse.

Just three weeks ago, the Quinnipiac poll found that voters more than three to one oppose the GOP’s health care plan. In the meantime, Obamacare’s popularity has only risen. According to the Kaiser Family Foundation monthly tracking poll, over the past year the 2010 health law has seen a modest increase in support among the general public, with 51 percent expressing favorable views and 41 percent expressing negative opinions. Roughly half of the public viewed Obamacare more favorably than the GOP’s replacement.

Infighting on the right

When Senate Republican leaders added a conservative provision to the bill that let insurers sell cheap, deregulated plans, it was supposed to secure the crucial support of Sens. Ted Cruz (R-Texas) and Lee. But it failed to lock in Lee, who said it didn’t do what it was intended to do. Instead, it ended up motivating him to be a deciding vote to doom the bill.

The problem: The amendment he crafted with Cruz was modified when it was inserted into the legislation, it preserved Obamacare's ban on splitting the individual insurance market between healthy and sick people. That may sound like a technicality — it has to do with whether healthy people subsidize sicker ones — but it proved a dealbreaker for Lee, and serves as a fresh warning to Senate leaders who think they can negotiate a last-minute compromise between their moderate and conservative wings — or even among independent minded conservatives.