For the health-care system, it’s back to square one.

Insurers, hospitals and state officials are facing the prospect that the Affordable Care Act will remain the law of the land for now at least, but they also are left with huge questions about how key aspects of the law will be handled under the Trump administration as deadlines loom for insurers’ decisions about next year.

The collapse of Republicans’ overhaul effort spares health companies and states major cutbacks in Medicaid that many had opposed. That means a major source of the coverage gains under the ACA is likely to remain intact for the foreseeable future, a boon for hospitals, doctors and officials in states that chose to expand the program.

The bill would have “ended Medicaid as we know it,” said John Jurenko, vice president of government relations at NYC Health & Hospitals, which runs New York City’s 11 public hospitals. That relief was temporary, he said, as he considered the continuing uncertainty. “I was very happy for a few minutes,” he said. “We need to be vigilant.”

For insurers, the results are mixed. They fought to kill a provision in the latest Senate billthat they said would have blown up the ACA’s marketplaces, but they supported Republicans’ efforts to kill the law’s tax on health-insurance plans.

Insurers said they still face major uncertainty about how the ACA will be administered going forward. “We have to make business decisions here, and it’s like, ‘is it going to be A or B?’” said John Baackes, chief executive of L.A. Care Health Plan, which offers exchange coverage as well as Medicaid. “You can’t operate that way.”

The impact will likely play out differently in different places, depending on state policies and market realities.

Companies are now calling for fast efforts to provide more certainty and stability in the marketplaces, which are strained in several states as insurers are pulling back and seeking large rate increases for next year. In an estimated 38 counties across Nevada, Indiana and Ohio, no insurer has yet agreed to offer coverage through an exchange next year.

Most immediately, companies offering health plans in the ACA’s exchanges are concerned key federal payments that help reduce health-care costs for low-income enrollees may now be halted, as President Donald Trump has threatened in the past. The Senate bill would have locked them in for 2018 and 2019. The president raised their alarm with a tweet on Tuesday suggesting, “let ObamaCare fail and then come together and do a great healthcare plan. Stay tuned!”

“If he wants to destroy Obamacare, all he has to do is stop” the payments, said Jerry Dworak, chief executive of Montana Health Co-op, a nonprofit offering marketplace plans in Montana and Idaho. “That would probably end it right there. I don’t know if he’s bluffing.”

Montana Health Co-op proposed only about a 4% rate increase on marketplace plans in its home state for next year, Mr. Dworak said, but that would have to increase by around 20 percentage points if the cost-sharing payments ceased.

The Blue Cross Blue Shield Association said that, “with open enrollment for 2018 only three months away, our members and all Americans need the certainty and security of knowing coverage will be available and affordable for them,” and the cost-sharing payments must have “certain funding.” The group also said it supported federal and state moves to “stabilize insurance markets in the short term.”

Insurers said they also need firmer direction about the future enforcement of the ACA’s individual mandate for people to have insurance. Many insurers fear consumers will assume because of Republican efforts that the requirement is no longer being enforced, even though no law repealing it has passed, leading younger, healthier people to avoid marketplace plans.

“I’d like to see clarity” around the mandate, said Diane P. Holder, chief executive of UPMC Health Plan in Pittsburgh.

Senate Majority Leader Mitch McConnell (R., Ky.) had previously raised the prospect of working with Democrats on efforts to stabilize the marketplaces, and pressure for that outcome from the health-care industry and states is likely to rapidly grow.

A group of governors, including Ohio’s John Kasich, Nevada’s Brian Sandoval and Pennsylvania’s Tom Wolf, said in a statement Tuesday that “the best next step is for both parties to come together and do what we can all agree on: fix our unstable insurance markets.”

Hospital executives said they, too, are worried about seeing more patients losing coverage if the insurance marketplaces aren’t stabilized. Seeing more uninsured would strain hospital finances, said Robin Wittenstein, CEO of hospital operator Denver Health, who was in Washington on Tuesday to lobby Congress as the Senate’s legislative agenda rapidly shifted. “It would have a devastating effect,” she said.

In addition to funding for the cost-sharing payments, insurers would like to see funding for reinsurance to help manage the risk of covering costlier, sicker enrollees, and other steps.

Pamela Morris, chief executive of CareSource, a nonprofit that offers exchange plans in four states, said her company is considering offering plans in some counties in Indiana and Ohio that currently lack a marketplace insurer for 2018. Locking in the cost-sharing payments and a reinsurance program would “make it a win-win for us” to offer plans in those counties, she said. “That would seal the deal.”

Meanwhile, states are increasingly taking their own initiatives to bolster exchanges—reflecting the reality that the ACA has played out very differently in different places. In the states facing possible bare counties with no exchange insurers, officials are wooing companies to stick around. Other states’ marketplaces are in steadier condition.

“Every state out there is realizing that the worst scenario is a collapse of your individual markets,” said Mike Kreidler, Washington state’s insurance commissioner, who, like officials in many states, is working on a proposal to get a federal waiver to tweak aspects of the ACA. “You can’t just sit back and wait for bad things to happen.”

Alaska, which had been facing large rate increases and retains only one insurer in its exchange, recently won federal approval for an effort built around a reinsurance setup. Iowa is seeking a nod from federal officials for a more ambitious program that would rewrite large portions of the ACA in the state. Several other states are considering or moving forward on similar efforts.

“We will see a difference in states,” said Gary Cohen, a vice president at Blue Shield of California, a state that boasts an exchange that has been far more stable than many others. “The Obama administration took a more rigid view and were less welcoming to those state initiatives than the Trump administration has indicated it will be.”

Updated July 18, 2017 8:09 p.m. ET

Write to Anna Wilde Mathews at and Melanie Evans at

Appeared in the July 19, 2017, print edition as ‘Insurers See New Uncertainty After GOP Bill Fails.’

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