The failure of the GOP’s health care bill in the senate means the Affordable Care Act is still law. NPR’s Noel King speaks with Julie Rovner of Kaiser Health News about where things might go now.

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Republican Sen. James Lankford of Oklahoma talks to NPR’s Robert Siegel about why he’s disappointed that the health care vote failed. His state has only one insurer available to Oklahomans on the exchange, and premiums have increased an average of 76 percent.

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The Senate effort to undo the Affordable Care Act failed dramatically early Friday morning, with Sen. John McCain casting a deciding “no” vote. The promise of repeal has animated the Republican Party for seven years, and the defeat was a devastating loss for the GOP and President Trump.

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For 25 years, the Rev. Noel Hickie, 74, and Marcia Hilton, 70, helped families during their most trying moments.

Hickie was working as a hospital chaplain and Hilton as a bereavement counselor when the two met at a hospital in Eugene, Ore. The pair often worked together on hospice teams, helping patients and their families through illness and death. They spent decades of their lives doing this work, but in the beginning, neither was sure they were cut out for it.

“I thought that I would never want to be around sick people,” Hickie says.

Hilton, who hadn’t spent much time in hospitals before this work, says she had the same doubt at the beginning.

“I had never seen blood hanging on an IV pole,” Hilton says. “Just the hubbub of a hospital was really frightening to me … and I can remember thinking, ‘What am I doing here?’ “

But eventually they both found their place, though Hickie recalls that his role was misunderstood at times.

“I remember years ago, one of the nurses asked me to go out and talk to a patient,” he says. “I said, ‘What am I supposed to talk to her about?’ “

Hickie says the nurse told him that the patient was afraid, so maybe he could “take her fear away.”

“I said, ‘You know if I could do that I wouldn’t be working here, [I] would be the richest man in the world,” Hickie says with a chuckle.

Similarly, Hilton remembers one of her first counseling situations: She had gone to the intensive care unit, where a young man died from a gunshot wound after his best friend accidentally shot him.

“I remember getting on that elevator, my knees were just knocking,” Hilton says. “I walk into this room where the family is gathered and there must have been 25 people in there. The mother was in the corner, rocking back and forth and moaning, and siblings, grandparents, aunts and uncles, cousins, the young man who had shot his friend. I remember sitting there having absolutely no idea what I had to offer.”

Hilton says she sat with the family in the room for at least half an hour before finally asking, “I didn’t know Jim. Could you tell me about him?” (The patient’s name has been changed to protect the privacy of the family.)

“The whole conversation started around the room of people sharing reminiscences about this young man,” Hilton says. “It was just a miraculous transformation, what happened in that room. I was OK. They were OK. They would be OK. And I think that was part of when things happened for me and my realization that maybe I could do this work.”

Audio produced for Morning Edition by John White.

StoryCorps is a national nonprofit that gives people the chance to interview friends and loved ones about their lives. These conversations are archived at the American Folklife Center at the Library of Congress, allowing participants to leave a legacy for future generations. Learn more, including how to interview someone in your life, at StoryCorps.org.

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In another full day of discussion about repealing and replacing the Affordable Care Act, there are still no clear options on the table on which the Senate can vote.

Democrats are united in opposition to any bill that would undo President Obama’s legacy on health care. Republican leaders are pinning their hopes on a last ditch effort that senators are calling “skinny repeal.”

Senate Majority Leader Mitch McConnell and others continued to work on it all day. The goal is to offer legislation that does the minimum in terms of undoing Obamacare, as the Affordable Care Act is commonly known. That would allow Republican lawmakers to return to their home states during the August recess and say they’ve taken action on an issue that’s been one of their key campaign promises for years.

The bill’s language is not yet final or public, but as NPR’s Sue Davis reports on All Things Considered, it is said to involve some combination of repealing the individual mandate, some of the taxes in the ACA, defunding Planned Parenthood for at least a period of time and allowing states to opt out of some of the minimum standards of coverage for insurance plans that the Affordable Care Act requires.

In an impromptu press conference held Thursday evening, Sen. Lindsey Graham, R-S.C., along with three other Republican senators, stressed they would vote for the “skinny repeal” bill only with more assurances that the bill, if passed, would actually not become law. They want it to proceed to a conference committee, where House and Senate members would work on crafting another bill that combines each chamber’s version — instead of having the Senate bill sent directly to the House floor for a vote.

Graham called the “skinny” bill “a disaster” and “a fraud.”

“I’d rather get out of the way and let it collapse than have a half-ass approach where it is now our problem,” Graham said.

Sen. John McCain, R-Ariz., who joined his friend Graham at the press conference, said the Republican effort to replace Obamacare deserves more time and consideration than it was being given.

“I believe one of the major problems with Obamacare is that it was rammed through Congress by Democrats without a single Republican vote,” McCain said. “I believe we shouldn’t make that same mistake again.”

McCain added, “It’s time we sat down together and came up with a piece of legislation that addresses this issue.”

However, it is unlikely that if the bill makes it to conference with the House that it will involve Democratic input, if its stated goal continues to be repealing the Affordable Care Act.

Graham and McCain were joined at the press conference by Sen. Ron Johnson, R-Wisc., and Sen. Bill Cassidy, R-La.

The strategy of supporting the “skinny repeal” is not one a lot of Republicans want to get behind. If it does become law and a “death spiral” could begin—which means that without a mandate to buy insurance, younger people who tend to be healthier will drop their insurance, keeping sicker people in the market and then premiums go up. The bill may leave in place subsidies, however.

But all day lawmakers were either unclear what would be in the bill, or suggesting that they would pass whatever it might be, simply to extend the process. From passage, the bill could go straight to the House floor for a vote, or move into a conference committee.

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NPR’s Robert Siegel talks with Governor of Montana, Democrat Steve Bullock, about a bipartisan letter he signed to with his colleagues to oppose the “skinny repeal” of the Affordable Care Act.

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Senate Majority leader Mitch McConnell forced Republicans to take a vote on a measure that would have repealed parts of Obamacare and saw that effort fail. The Senate will continue those efforts.

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Tom Nickels of the American Hospital Association talks with Rachel Martin about the showdown over repealing the Affordable Care Act.

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Betting that thin is in — and might be the only way forward — Senate Republicans are eyeing a “skinny repeal” that would roll back an unpopular portion of the federal health law. But health policy analysts warn that the idea has been tried before, and with little success.

Senators are reportedly considering a narrow bill that would eliminate the Affordable Care Act’s “individual mandate,” which assesses a tax on Americans who don’t have insurance. The bill would also eliminate the ACA’s penalties for some businesses – those that have 50 or more workers and fail to offer their employees health coverage.

Details aren’t clear, but it appears that — at least initially — much of the rest of the 2010 health law would remain, under this strategy, including the rule that says insurers must cover people who have preexisting medical problems.

In remarks on the Senate floor Wednesday, Sen. Minority Leader Charles Schumer, D-NY, said that “we just heard from the nonpartisan Congressional Budget Office that under such a plan … 16 million Americans would lose their health insurance, and millions more would pay a 20 percent increase in their premiums.” The CBO posted its evaluation of the GOP’s proposed plan Wednesday evening.

Earlier in the day, some Republicans seemed determined to find some way to keep the health care debate alive.

“We need an outcome, and if a so-called skinny repeal is the first step, that’s a good first step,” said Sen. Thom Tillis, R-N.C.

Several Republican senators, including Dean Heller of Nevada and Jeff Flake of Arizona, appear to back this approach, according to published reports. It is, at least for now, being viewed as a step along the way to Republican health reform.

“I think that most people would understand that what you’re really voting on is trying to keep the conversation alive,” said Sen. Bob Corker, R-Tenn. “It’s not the policy itself … it’s about trying to create a bigger discussion about repeal between the House and Senate.”

But what if, during these strange legislative times, the skinny repeal were to be passed by the Senate and then go on to become law? States’ experiences with insurance market reforms and rollbacks highlight the possible trouble spots.

Considering the parallels

By the late 1990s, states such as Washington, Kentucky and Massachusetts felt a backlash when some of the coverage requirement rules they’d previously put on the individual market were lifted. “Things went badly,” said Mark Hall, director of the health law and policy program at Wake Forest University.

Premiums rose and insurers fled these states, leaving consumers who buy their own coverage (usually because they don’t get it through their jobs) with fewer choices and higher prices.

That’s because — like the Senate plan — the states generally kept popular parts of their laws, including protections for people with preexisting conditions. At the same time, they didn’t include mandates that consumers carry coverage.

That goes to a basic concept about any kind insurance: People who don’t file claims in any given year subsidize those who do. Also, those healthy people are less likely to sign up, insurers said, and that leaves insurance companies with only the more costly policyholders.

Bottom line: Insurers end up “less willing to participate in the market,” said Hall.

It’s not an exact comparison, though, he added, because the current federal health law offers something most states did not: significant subsidies to help some people buy coverage. Those subsidies could blunt the effect of not having a mandate.

During the debate that led to passage of the federal ACA, insurers flat-out said the plan would fail without an individual mandate. On Wednesday, the Blue Cross Blue Shield Association weighed in again, saying that if there is no longer a coverage requirement, there should be “strong incentives for people to obtain health insurance and keep it year-round.”

Individual mandate is still unpopular in voter polls

About 6.5 million Americans reported owing penalties for not having coverage in 2015.

Polls consistently show, though, that the individual mandate is unpopular with the public. Indeed, when asked about nine provisions in the ACA, registered voters in a recent Politico/Morning Consult poll said they want the Senate to keep eight, rejecting only the individual mandate.

Even though the mandate’s penalty is often criticized as not strong enough, removing it would still affect the individual market.

“Insurers would react conservatively and increase rates substantially to cover their risk,” said insurance industry consultant Robert Laszewski.

That’s what happened after Washington state lawmakers rolled back rules in 1995 legislation. Insurers requested significant rate increases, which were then rejected by the state’s insurance commissioner. By 1998, the state’s largest insurer — Premera Blue Cross — said it was losing so much money that it would stop selling new individual policies, “precipitating a sense of crisis,” according to a study published in 2000 in the Journal of Health Politics, Policy and Law.

“When one pulled out, the others followed,” said current Washington Insurance Commissioner Mike Kreidler, who was then a regional director in the federal department of Health and Human Services.

The state’s individual market was volatile and difficult for years after. Insurers did come back, but won a concession: For a time, the insurance commissioner lost the power to reject rate increases. Kreidler, first elected in 2000, reclaimed that authority.

Predicting the effect of removing the individual mandate is difficult, although Kreidler said he expects the impact would be modest, at least initially. Subsidies that help people purchase insurance coverage — if they remain as they are under current law — could help blunt the impact. But if those subsidies are reduced — or other changes are made that further drive healthy people out of the market — the impact could be greater.

“Few markets can go bad on you as fast as a health insurance market,” said Kreidler.

As for employers, dropping the requirement that those with 50 or more workers must offer health insurance or face a financial penalty could mean some workers would lose coverage. But their jobs might be more secure, said Joseph Antos, a health care economist and resident scholar at the American Enterprise Institute.

That’s because the requirement under the ACA meant that some smaller firms didn’t hire people or give workers more than 30 hours a week — the minimum needed under the ACA to be considered a full-time worker who qualified for health insurance.

The individual mandate, he added, may not be as much of a factor in getting people to enroll in coverage as some think, because the Trump administration has indicated it might not enforce it anyway — and the penalty amount is far less than most people would have to pay for health insurance.

However, the individual market could be roiled by other factors, Antos said.

“The real impact would come if feds stopped promoting enrollment and did other things to make the exchanges [— the state and federal markets through which insurance is offered —] work more poorly.”

Kaiser Health News is a nonprofit health newsroom, an editorially independent part of the Kaiser Family Foundation. You can follow KHN senior correspondent Julie Appleby on Twitter @Julie_Appleby Congressional reporter Rachel Bluth also contributed to this report.

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