When Donald Trump not only won the presidency, but also found himself in the White House with Republican majorities in both Houses of Congress, it was assumed by many that Trump would have his way. House Republicans would get to work in January to pass the Trump agenda. First, they would pass healthcare reform, after campaigning for the past 7 years on a repeal-Obamacare platform. A comprehensive tax reform bill would follow, and then infrastructure. The first step in this process, however, repealing and replacing the Affordable Care Act, has proved challenging.

Back in March, Republicans gave their first attempt at an ACA reform bill, introduced by Speaker of the House Paul Ryan. However, conservatives among Republican senators, such as Ted Cruz and Mike Lee, were worried about the continual role of the government in healthcare markets, while moderates such as Susan Collins were worried about drastic federal cuts to Medicaid and the Congressional Budget Office projections of 22 million people losing coverage under the plan. In July, Republicans failed again at passing what was dubbed the “skinny-repeal” of the ACA, with the conservative wing of the party not getting enough votes, and moderates worried about what a repeal-before-replace would look like.

In late September, Republicans tried their luck once again. Introduced by South Carolina Sen. Lindsey Graham and Louisiana Sen. Bill Cassidy, the “Graham-Cassidy” bill would’ve undid many of the ACA’s central tenets. At its core, the bill would’ve lumped together the money spent on two ACA programs to expand health coverage: subsidies for private insurance and an expansion of the Medicaid program, and, perhaps most important to Republicans, would have eliminate the individual mandate of the ACA that every individual who is able to must buy health insurance. Graham-Cassidy was not in a position to, however, repeal higher ACA taxes on the rich, and on health industries such as tanning salons.

Graham-Cassidy stood as the Republicans’ third shot at a central promise of theirs for years, to repeal and replace Obamacare, having until September 30th to use a temporary procedural vehicle, which would allow them to pass a healthcare bill with 50 votes, rather than the normal 60 (50 votes would send the tiebreaker to Vice President Mike Pence, who is under the Constitution President of the Senate). However, it didn’t go in the GOP’s favor. Defections once again abounded. Susan Collins of Maine and John McCain of Arizona were worried about what current cuts to Medicaid would look like to recipients in their state. Rand Paul of Kentucky, as usual, scoffed at the idea of a continued government presence in the healthcare system. As in the past, divisions within the Republican party proved a roadblock in the way of their legislative agenda.

Nonetheless, the fight for the future of healthcare in the United States is not over, even if it looks like the latest attempt may be dead in the water.