Trump declared that his plan was now to “let Obamacare fail,” saying Democrats would then seek out Republicans to work together on a bill to bury the Affordable Care Act. If he is determined to make good on that pledge, he has plenty of levers to pull, from declining to reimburse insurance companies for reducing low-income customers’ out-of-pocket costs to failing to enforce the mandate that most Americans have health coverage.
“It’ll be a lot easier,” Trump said at the White House, adding: “We’re not going to own it. I’m not going to own it. I can tell you the Republicans are not going to own it. We’ll let Obamacare fail, and then the Democrats are going to come to us.”
The fate of the repeal effort looked to be sealed on Tuesday, when a last-ditch attempt to force a vote to abolish the health law without a replacement came up short of support. The majority leader, Sen. Mitch McConnell of Kentucky, seemed resolved to force senators to vote next week, but by Tuesday afternoon, it was clear he did not have 50 votes even to clear a procedural hurdle before considering a repeal-only bill.
Sens. Shelley Moore Capito of West Virginia, Susan Collins of Maine and Lisa Murkowski of Alaska, all Republicans, declared that they would not vote to repeal the Affordable Care Act without a replacement: enough to doom the effort before it could gain any momentum. Sen. Rob Portman, R-Ohio, also rejected a repeal-only measure.
The collapse highlighted a harsh reality for Senate Republicans: While they freely assailed the health law when Obama occupied the White House, they could not come up with a workable plan to unwind it that would keep both moderate Republicans and conservatives on board. It was an enormous embarrassment for a party that rode electoral waves to control first the House, then the Senate and then the White House, but has not been able to deliver a major legislative victory.
“This has been a very, very challenging experience for all of us,” McConnell said. “Everybody’s given it their best shot, and as of today, we just simply do not have 50 senators who can agree on what ought to replace the existing law.”
The reaction on Wall Street was muted. Stocks spent most of the day lower as shares of health insurers declined, and the dollar, which has steadily lost ground for most of the year, slipped further.
Trump has considerable leverage to gum up the works of the Affordable Care Act. He could throw insurance markets into a tailspin at any time by cutting off the reimbursement payments to insurers, as he has threatened to do. He could further destabilize the markets by not enforcing the mandate that most Americans have health insurance.
And he could cancel advertising and other efforts to encourage enrollment under the Affordable Care Act when the annual sign-up period begins in November. A barrage of negative statements from the administration could project an official view that the health law is collapsing, creating a self-fulfilling prophecy.
The lack of certainty over the so-called cost-sharing reduction payments, which go toward reducing out-of-pocket costs for low-income people, has been a major concern for insurers. The companies say premiums will be significantly higher without the funding, and some companies that have submitted rates to sell insurance in the market next year could decide to pull out.
“With open enrollment for 2018 only three months away, our members and all Americans need the certainty and security of knowing coverage will be available and affordable for them,” said Justine Handelman, a senior executive at the Blue Cross Blue Shield Association.
While Trump has promised destruction, other Republicans signaled that they wanted to take a more constructive approach. Sen. Lamar Alexander of Tennessee, chairman of the Senate health committee, announced that he would hold hearings in the next few weeks on stabilizing the individual health insurance market.
Members of both parties have ideas about how to secure insurance markets and hold down premiums. One possible action is to provide money for the reimbursement payments. Two Democratic senators, Thomas R. Carper of Delaware and Tim Kaine of Virginia, want the federal government to help pay the largest claims through a backstop known as reinsurance. Senators of both parties also want to help consumers in counties where no insurer chooses to offer health plans through the Affordable Care Act marketplace — a real possibility in some places next year.
The Senate Democratic leader, Chuck Schumer of New York, implored Republicans to defy Trump and work with Democrats to strengthen insurance markets.
“There’s a fork in the road for our Republican colleagues,” he said in an interview. “They can do what Donald Trump said, which is sabotage the system out of anger and out of pique,” or they can work with Democrats on improvements to the health law.
“Whether they can resist Trump, I don’t know,” Schumer said.
On Capitol Hill, Republicans and Democrats alike were trying to make sense of the repeal effort’s apparent downfall — and figure out what comes next.
The beginning of the end was on Monday night, when two Republican senators, Mike Lee of Utah and Jerry Moran of Kansas, came out in opposition to the latest version of McConnell’s bill to repeal and replace the health law. That left Republican leaders at least two votes short of what they needed to start debate.
Two other Republican senators, Collins and Rand Paul of Kentucky, had objected last week.
McConnell responded by outlining plans for a vote on a measure like the one vetoed by Obama in January 2016, which McConnell said would consist of a “repeal of Obamacare combined with a stable, two-year transition period.”
Republican leaders had originally intended to proceed with a similar “repeal and delay” strategy after Trump won the presidency. But in January, Trump made clear he wanted a simultaneous repeal and replacement of the law, and congressional Republicans decided to follow that path.
A repeal-only route would have been disruptive. The Congressional Budget Office said the vetoed bill would have increased the number of uninsured Americans by 18 million in the first year and 32 million by 2026, compared with current law. Premiums, it said, would have increased 20 to 25 percent in the first year and doubled by 2026.
That bill would have eliminated the Affordable Care Act’s expansion of Medicaid and subsidies for the purchase of private insurance. But it would have left in place the law’s requirement that insurers provide specific benefits, and the prohibition on denying coverage or charging higher premiums because of a person’s pre-existing medical conditions.
The repeal-only idea quickly ran into a wall Tuesday.
“I did not come to Washington to hurt people,” Capito said in a statement, taking issue with both McConnell’s bill and the idea of repealing the health law “without a replacement plan that addresses my concerns and the needs of West Virginians.”
Murkowski said, “There’s enough chaos and uncertainty already, and this would just contribute to it.”
The idea of repealing the health law without providing a replacement also spooked a bipartisan group of 11 governors, including Brian Sandoval of Nevada, an influential Republican critic of McConnell’s bill.
“The Senate should immediately reject efforts to ‘repeal’ the current system and replace sometime later,” said the group, which consists of five Republicans, five Democrats and one independent. “This could leave millions of Americans without coverage. The best next step is for both parties to come together and do what we can all agree on: fix our unstable insurance markets.”
McConnell appears determined to drive the effort to a final public defeat with a procedural vote that would let the Senate consider the repeal-only measure. He can afford to lose only two Republican senators, with Vice President Mike Pence breaking the tie. But he already appears to have lost at least three: Collins, Murkowski and Capito.
More could still defect, unwilling to be recorded voting for a procedural step in what is all but certain to be a doomed exercise. But that could be an awkward stance for Republicans who voted for the repeal bill that the Senate passed in 2015 and Obama vetoed.
“If you’re not willing to vote the same way you voted in 2015,” Paul said on Tuesday, “then you need to go back home, and you need to explain to Republicans why you’re no longer for repealing Obamacare.”