In a late night session ending at 1:30 a.m. on Friday,  the Republicans’ seven-year promise to repeal the Affordable Care Act (ACA) appeared to end, at least for the time being. John McCain, who dramatically returned to Washington to vote on health care reform after his brain cancer diagnosis, voted “No” on skinny repeal, sending the bill to defeat by a one-vote margin. The ACA will remain in place—at least for now—but there are huge questions about how the Trump administration will handle key aspects of the law, as deadlines loom for insurers’ decisions about next year. President Trump has been quoted as saying that he will let “Obamacare fail”. In the absence of repeal, the next issue will be whether Republicans continue to authorize the ACA’s cost-sharing reductions, which are the subject of litigation. These CSRs reduce co-payments and deductibles (by $10 billion next year), making them crucial to ACA stability. The political battle over health care reform is likely not dead, but is definitely on life support.