The vote, 45-55, underscored the bind that Republican leaders have found themselves in. Seven Republicans voted against the measure â Senators Shelley Moore Capito of West Virginia, Susan Collins of Maine, Dean Heller of Nevada, John McCain of Arizona, Rob Portman of Ohio, Lamar Alexander of Tennessee and Lisa Murkowski of Alaska â showing that repealing the health law without an immediate replacement lacks crucial support among Republicans.
But a more comprehensive measure that would have repealed major parts of the law with a ready replacement also came up short on Tuesday night.
With neither approach viable, Senate Republican leaders may have no choice but to fall back on a third choice: Push a far more limited measure that repeals parts of the Affordable Care Act, such as its mandate that most people have insurance and a tax on medical devices, but leaves most of President Barack Obamaâs signature health law in place. Senators would then take their narrow bill into negotiations with the House, which passed a comprehensive measure to repeal and replace the Affordable Care Act.
Where did everything leave off Tuesday night?
Understandably, confusion is rife over what the heck is happening on the Senate floor: What was that vote Tuesday night? Why did Senator John McCain, Republican of Arizona, give that impassioned speech saying he would not vote for the Senate health care bill as it stands, then turn around and cast a yes vote on Tuesday night?
When the Senate voted 51-50 to begin debating the repeal of the Affordable Care Act, technically senators were bringing the repeal bill that was passed in the House to the Senate floor. For now, that is the bill that senators are trying to reshape.
On Tuesday night, Senate Republican leaders brought to the floor their most complete version of a plan to repeal and replace the Affordable Care Act. That measure had been worked out behind closed doors by the majority leader, Senator Mitch McConnell of Kentucky, and it would dismantle major parts of the current health care law, including the requirement that most people have health insurance.
But it also included an overture to Senate conservatives, a measure championed by Senator Ted Cruz, Republican of Texas, that would allow insurance companies to sell stripped down, low-cost insurance plans as long as they also offer insurance policies that comply with federal standards, including the requirement that plans cover âessentialâ services like maternity care, mental health treatment and prescription drugs.
For moderates, the legislation includes $100 billion to help pay out-of-pocket medical costs for low-income people.
Because that broad version of the Senate health care measure had not yet been assessed by the nonpartisan Congressional Budget Office, it needed 60 votes to overcome a Democratic objection that it violated Senate rules.
But it got only 43 votes, demonstrating that even after weeks of refining the legislation, Senate leaders still fell far short of enough support for their replacement plan, from both ends of the partyâs ideological spectrum.
Mr. McCain had previously made clear that he wanted to secure amendments to that broad repeal-and-replace bill. The vote on Tuesday night could be interpreted as a sign of support for that general approach.
The debate goes on.
And what does McCain actually want?
On Wednesday, the Arizona Republican let his leaders know what he wants. Mr. McCainâs office said he had filed three amendments meant to address concerns from leaders in his home state of Arizona, including the governor, Doug Ducey, a Republican.
Arizona is one of 31 states that expanded Medicaid under the Affordable Care Act, and the amendments would all address Medicaid. One of them would extend the phase out of the Medicaid expansion to 10 years, considerably longer than the bills under consideration. Another would increase the growth rate for Medicaid payments to states to better reflect health care inflation.
âAny reform to our health care system must reward states like Arizona that are responsibly managing their health care services and controlling costs â not penalize them,â Mr. McCain said in a statement, adding that the amendments would âensure our citizens who are most in need do not have the rug pulled out from under them.â
Whatâs happened so far on Wednesday?
Mr. Trump opened the day by attacking Ms. Murkowski.
But Mr. Trumpâs public shaming is not an effective strategy for Ms. Murkowski, who has dealt with worse from her party. In 2010, Ms. Murkowski retained her Senate seat in a historic win as a write-in candidate. She had lost Alaskaâs Republican primary that year to a Tea Party challenger and was largely abandoned by Republican leadership. Since then, she has not felt beholden to her party.
Blue Cross Blue Shield warns the Senate
The Blue Cross Blue Shield Association warned senators on Wednesday that repealing the Affordable Care Actâs mandate that nearly everyone have health insurance would be disastrous if Congress fails to replace it with another measure that ensures that people get and maintain insurance coverage.
âIf there is no longer a requirement for everyone to purchase coverage, it is critical that any legislation include strong incentives for people to obtain health insurance and keep it year-round. A system that allows people to purchase coverage only when they need it drives up costs for everyone. Immediate funding for the cost-sharing reduction program also is essential to help those individuals most in need with their out-of-pocket costs, so they can access medical services. And dedicated funds must be provided to help pay for the care of those with significant medical conditions.
In order to ensure a stable individual insurance marketplace, any final legislation must include these crucial elements to avoid steep premium increases and diminished choices that would make coverage unaffordable and inaccessible.â
The association appeared to be worried about a so-called skinny repeal bill that would do away with the Affordable Care Actâs individual mandate and require that most employers offer insurance to their workers, but would include little else. Republican leaders believe that such a narrow bill may be the only measure that can get through the Senate.
Now what happens in the Senate?
Senators are set to consider a different repeal measure on Wednesday.
This measure would repeal major parts of the health law but would not provide a replacement. The legislation resembles a bill that passed the Senate in 2015 but was vetoed by President Barack Obama in early 2016.
Senator Rand Paul, Republican of Kentucky, supports that approach. But some Republicans worry that repealing the law without providing a replacement would leave many Americans without health care coverage. Such a ârepeal onlyâ measure is not expected to garner enough votes for passage.
The vote for this measure had been expected to take place around midday Wednesday, but it has now been delayed until later in the afternoon.
Then what happens?
Republicans are using special budget rules to try to pass a repeal bill, so the debate is limited to 20 hours, and Democrats cannot delay it with a filibuster. Later this week, the Senate will hold what is known as a vote-a-rama, an exhausting marathon of amendment votes.
The nine Republicans who voted against the comprehensive replacement measure on Tuesday night are an indication of the problem that Senate Republican leaders continue to confront: The party caucus still does not agree on what should be in a health care repeal bill that would have enough support to win Senate approval.
One solution might be to pass a pared-down health plan that has support from at least 50 of the 52 Republican senators, and then turn to working out a compromise with the House.