The uncertainty has reignited the fight to define the health insurance program in the public mind, with Republicans and Mr. Trump painting it as a disaster, and Democrats portraying it as a success that provides security to millions of Americans, many of them Trump voters. Democrats have latched on to their own catchphrase, warning that repealing the law will “Make America Sick Again” — a twist on the Trump campaign’s “Make America Great Again” theme.


The notecard on which Josh Holmes, then a top communications adviser to Mr. McConnell, first wrote the “repeal and replace” slogan for the Republican strategy in opposition to the Affordable Care Act.

Republicans have derided the Democratic message — personally developed by Senator Chuck Schumer of New York, the new Democratic leader — as trite and ineffective. But Democrats like it and believe that it goaded Mr. Trump into a more direct and complicating role in the Republican deliberations over how quickly to propose a replacement for the health care program.

They say Republicans are still relying on Mr. Holmes’s years-old brainchild because they are groping for a replacement with their new unified government days away. Democrats see the confusion as a victory in their push to thwart repeal or slow it down while wringing all the political advantage they can from the attempt.

After a series of late-night Senate budget votes that laid the procedural groundwork for repeal with no certainty on what was to follow, one Democrat delivered a new punch line.

“This is called repeal and run,” Senator Claire McCaskill, Democrat of Missouri, said on Twitter as the Senate was voting. “Chaos is coming.”

Mr. Trump’s involvement has muddled the issue further as he and Republican leaders in Congress have offered differing timetables for when a Republican alternative might be unveiled, underscoring again how difficult it can be to push through an agenda even for a party that controls all the levers of government.

The origin story of the “repeal and replace” mantra is also a reminder of how pivotal strategic messaging has been throughout the health care debate. It has produced some of the more memorable political lines in recent years, from “death panels” to “If you like your health plan, you can keep your health plan” to “Obamacare” itself. After Republicans began throwing that term around as a pejorative, Mr. Obama embraced it.


Senator Chuck Schumer of New York, the Democratic leader, during a news conference this month in Washington on Republican attempts to repeal the health care law.

Zach Gibson/Agence France-Presse — Getty Images

Even before landing on “repeal and replace,” Republicans scorched Democrats with buzzy phrases. In his book “The Long Game,” Mr. McConnell recounted how he instructed his legislative experts to identify special provisions that had been added to the health bill to win over wavering Democrats.

His communications staff would then “brand” these legislative sweeteners with catchy but disparaging nicknames to build opposition and public distrust for the law. The result: the “Louisiana Purchase,” “Gator Aid” and the memorable “Cornhusker Kickback,” to tarnish provisions inserted to woo senators from Louisiana, Florida and Nebraska.

“In some ways, we were enjoying ourselves,” Mr. McConnell acknowledged in his book.

The same communication strategists who originated those terms were brainstorming on March 22, 2010, while Mr. Holmes jotted ideas on a notecard. When he hit on “repeal and replace,” the McConnell team decided it had what it needed. The big question was whether they could get lawmakers to embrace it. That answer would come quickly.

“I think the slogan will be ‘repeal and replace,’ ‘repeal and replace,’” Mr. McConnell told reporters the next day. “No one that I know in the Republican conference in the Senate believes that no action is appropriate.”

Mr. Holmes said a turning point came shortly after, when Representative Mike Pence of Indiana, who was then in charge of political messaging for House Republicans, and is now the vice president-elect, latched on to the phrase. That caused conservative resistance to the “replace” aspect of the debate to evaporate.

Mr. Holmes acknowledged that he had to create only the phrase, not the actual replacement.

“I don’t do policy,” he said with a laugh.

But Republican lawmakers and leaders of the new administration do have to do policy. And they may need to do it fast if they are going to assure Americans that they intend to fulfill their seven-year-old promise to not just repeal the law, but also replace it.

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