The rush to bring the Cassidy-Graham health-care plan to a vote buckled under the bill's opposition on Sept. 26. (Jenny Starrs,Jordan Frasier/The Washington Post)

Republicans are facing one final decision on their doomed effort to repeal the Affordable Care Act: Should they bother to hold yet another vote in the Senate that they know they will lose, or should they acknowledge that it’s over, at least for this year?

“Everybody knows that’s going to fail,” Sen. Orrin Hatch said of the Cassidy-Graham bill, now that three Republican senators — Rand Paul, John McCain and Susan Collins — have officially stated their opposition, with perhaps more to follow. But Republicans will decide today whether to hold a vote. “I think there is some advantage to showing you’re trying and doing the best you can,” said Majority Whip John Cornyn (R-Tex.).

While repeal will never be truly dead until Democrats take back either a house of Congress or the presidency, this latest GOP failure gives us a chance to take stock of what we’ve learned. The lessons are many:

1. Republicans don’t care about policy. For seven years, they railed against the ACA and promised that when they had the chance, they’d repeal it and offer something better. Yet for all that time, they never bothered to sit down and work out what their replacement might look like. Then when they got control of the entire government, they still couldn’t make a serious attempt to tackle the policy challenge. The bills they came up with were hastily thrown together, full of contradictions and catastrophic consequences, and sponsored by people whose public comments made clear that they barely understood the first thing about what they were proposing.

In President Trump’s immortal words, “Nobody knew that health care could be so complicated.” The truth was that everyone who had ever taken the issue seriously knew it — but that didn’t include more than a handful of Republicans.

2. The overwhelming majority of Republicans are more than happy to vote for bills with catastrophic consequences. All of the GOP health-care bills that were offered promised upheaval — tens of millions losing their insurance, skyrocketing premiums, death spirals in the individual markets. Yet there were never more than a few Republicans willing to say no. The rest were ready to set off a tidal wave of human suffering if it meant that they could give the finger to Barack Obama.


(Manuel Balce Ceneta/Associated Press)

3. Fewer people having health coverage isn’t a bug of Republican plans; it’s a feature. Every one of the GOP plans would have resulted in millions upon millions of Americans losing their health coverage, and that was the whole point. As they’ve proved again and again, Republicans would rather see someone go without coverage than get their coverage with help from the government, whether directly through a program such as Medicaid or indirectly through subsidies.

4. Yet Americans actually like government health coverage. This realization came as a shock to Republicans, who thought they could gut Medicaid and replace it with the promise of “freedom,” and no one would mind. But they discovered to their chagrin that Medicaid is extremely popular. Republicans believed their own rhetoric, which holds that when the government does something it’s always inefficient, incompetent and cruel. But it turns out that most Americans don’t share that dogmatic belief. If government insurance is a good deal, they’re happy to get it.

5. Many of the ACA’s protections are no longer negotiable. This was a fear that many in the GOP had about the ACA from the beginning, that once you gave people benefits it would be very hard to take them away. And so it has come to pass. That’s why most Republicans tried to argue that their bills protected those with preexisting conditions, even when they didn’t: They knew that the public will not tolerate the removal of those protections. Likewise, they had to keep the ACA’s mandate that young people can stay on their parents’ insurance. Even the requirement to cover essential health benefits looks very hard to take away.

6. No one should listen to any Republican complaints about procedure again. Democrats have long charged that Republicans use procedural complaints as a weapon when Democrats are in power, then abandon all adherence to norms and rules once they’re in charge. While this has always been true, it has never been on such vivid display as it has recently, first with the roadblocked nomination of Merrick Garland to the Supreme Court and now with health care.

Republicans have been complaining for years that the ACA had been “rammed through,” even though it was debated for a year and subjected to nearly 200 hearings, hundreds of amendments (including many offered by Republicans) and multiple Congressional Budget Office scores. But the GOP just tried to remake the entire American health-care system with but a single farcical hearing, no expert testimony, no full CBO score and barely any floor debate.

7. The current Republican leadership is not very good at legislating. Although Paul Ryan did manage to get one version of the bill passed in the House — remember that triumphal ceremony Trump held in the Rose Garden? — it was dead on arrival in the Senate. And Republicans were never able to arrive at a bill that could meet the approval of their caucuses in both houses. Mitch McConnell could neither craft a bill that could pass the Senate nor cajole his members into voting for the different ones that other Republicans concocted. McConnell was brilliant as a leader of the opposition but has proved to be inadequate to the task of governing.

8. Trump will, through his ignorance and impulsiveness, undermine any attempt by Republicans to pass complex legislation. Every time the president injected himself into negotiations or public debate on health care, he made things harder for Republicans in Congress, often by promising things they had no intention of delivering. He never bothered to learn anything about the subject or about the bills he was promoting, and that made everything harder for them. Just watch: The same thing is going to happen on tax reform, and on any other ambitious legislation Republicans attempt.

9. Republicans are terrified of their base voters, but still treat those voters like fools. “I could maybe give you 10 reasons why this bill shouldn’t be considered,” Sen.  Chuck Grassley (R-Iowa) told reporters last week. “But Republicans campaigned on this so often that you have a responsibility to carry out what you said in the campaign. That’s pretty much as much of a reason as the substance of the bill.”

We heard this again and again from Republicans: Sure, this bill is awful, but if we don’t pass some kind of repeal, then we’ll be punished by our base for not doing what we told them for seven years we’d do. Yet they never respected that base enough to tell them that repeal wouldn’t be easy, which left Republicans trapped.

10. Health care is no longer an abstract debate, and citizens still have power. Republicans began thinking they could toss around pleasant words such as “freedom” and “choice” and that would obscure the human consequences of what they were proposing. But up against cancer patients describing how the ACA had enabled them to get life-saving care, or people with disabilities literally putting their bodies on the line to protest getting their Medicaid taken away, those words lost all their power.

While there were many facets to the campaign to stop these bills, what mattered most was ordinary people, people who organized and called and wrote and shouted and protested and through their efforts made just enough politicians understand what was really at stake. That’s a lesson that shouldn’t be forgotten.