Debate over the Affordable Care Act (ACA) often revolves around three Rs: repeal, replace and repair. American Hospital Association (AHA) President and CEO Rick Pollack thinks after the failure of the American Health Care Act (AHCA), two more can be added: Republican and revolt.

Speaking remotely from Washington, D.C. to the American College of Healthcare Executives (ACHE) Congress in Chicago March 28, Pollack and Tom Nickels, AHA’s executive vice president for government relations and public policy, gave their assessment of what went wrong with the Republican-led attempt to replace the ACA and what they expect the Trump administration to do with the insurance markets in the near future.

Nickels gave the same reasons as House Speaker Paul Ryan and President Donald Trump to explain why the bill failed: It didn’t have enough support among Republicans. No attempt was made to get Democrats on board, he said.

While the Republican Party’s majorities in Congress had been able to pass a bill repealing the ACA when President Barack Obama was still in office, Nickels said lawmakers knew that such a bill would be vetoed. With a chance for a repeal to become law, their strategy changed.

“This time it was real,” Nickels said. “They realized that, in order to get it through, they had to have some ‘replace’ as part of their initiative because they couldn’t just leave people high and dry.”

The “replace” part is where the trouble began, Nickels said, as groups of conservative and moderate Republicans both had issues with what was included.

With the AHCA declared dead, there have been “mixed signals,” as Nickels put it, as to what the next version of healthcare reform may look like. The administration and congressional leaders could take several paths, ranging from changing ACA regulations, making a replacement bill “more Republican” or adopting an approach that may attract Democratic votes—which Nickels thinks Trump is seriously considering.

“Now that means a much different product than they had on the House floor," he said. “That means he’s going to have to move more toward the center.”

In the meantime, both Pollack and Nickels emphasized the administration should take action to stabilize the ACA marketplace, as insurers will have to submit rates for 2018 to state regulators in the coming weeks. That could mean extra reinsurance or risk adjustment funds, possibly as part of a compromise package to avoid a government shutdown at the end of April.

What could destabilize the market, Nickels said, is if the Trump administration takes action on an older lawsuit filed by House Republicans that challenges the legality of cost-sharing subsidies paid to insurers.

“You have to have these subsides,” he said. “If the subsidies go away, insurers have the right to drop out of the market and they probably will. So it will create enormous disruption.”

The need to pass a continuing resolution to get the government open, along with other legislative priorities, may prevent a quick second attempt at an ACA replacement. The next opportunity to discuss a big healthcare bill, according to Nickels, won’t come until October 1. That’s both the beginning of the federal fiscal year and when the Children’s Health Insurance Program (CHIP) is up for renewal.

“That could become a magnet for other action,” Pollack said.

Until then, both Pollack and Nickels said hospitals and healthcare leaders should keep a close watch on regulatory actions regarding the ACA. For example, Nickels predicted with Seema Verma now in place as CMS Administrator, more states will seek waivers to test out ideas, including new eligibility requirements, within their Medicaid programs.