Updated on July 25 at 10:08 p.m. Eastern
Senate Republicans have voted to begin debate on legislation to dismantle the Affordable Care Act, clearing a key procedural hurdle even as it remains unclear what—if any—legislation the party might ultimately pass.
The vote was as narrow as it gets: With two Republicans out of their slim majority of 52 opposing Majority Leader Mitch McConnell’s motion to proceed on Tuesday afternoon, Vice President Mike Pence broke a 50-50 tie to formally launch deliberations that had taken place almost entirely in private for two months. The vote was briefly delayed as Senate officials removed protesters shouting “Kill the Bill! Kill the Bill!” from the balcony of the chamber.
As recently as 24 hours before the vote, Senate aides were predicting it would fail, delivering yet another blow to the GOP’s hopes of at least partially repealing and replacing Obamacare after seven years of campaign promises. But the return of Senator John McCain of Arizona after a brain-cancer diagnosis and McConnell’s success in wooing his fellow Kentucky hardliner, Senator Rand Paul, gave the motion some late momentum. In a dramatic moment, McCain entered the chamber long after most Republicans had voted to cast a crucial vote to begin debate. But even with McCain’s support, McConnell still had to persuade Senator Ron Johnson of Wisconsin, who has criticized his handling of the issue, to vote with the party. After a lengthy one-on-one discussion with the majority leader, Johnson cast the 50th vote after McCain had entered the chamber to a round of bipartisan applause.
All 48 Democrats protested the move by initially abstaining from the vote before they all voted no. Senators Susan Collins of Maine and Lisa Murkowski of Alaska were the only two Republicans to oppose the motion.
In a statement, Trump hailed Senate Republicans “for taking a giant step to end the Obamacare nightmare.” And during a press conference soon after, he suggested that the initial procedural vote would prove to be more difficult than the ones that followed. But McConnell and his fellow Senate leaders knew the opposite was likely true.
“This is just the beginning. We’re not out here to spike the football,” McConnell said after the vote. Senator John Thune of South Dakota added: “Obviously we have our work cut out for us.”
Indeed, it was McCain who threw McConnell’s plan into more jeopardy just minutes after he cast a decisive vote in favor of debating the bill. In a speech on the Senate floor, the Arizonan sharply criticized both the underlying proposal and the secretive, partisan process McConnell used to write it. “I will not vote for this bill as it is today,” McCain said with a characteristic jab of his finger. “It’s a shell of a bill right now.” He said the proposal must include changes demanded by Arizona’s governor, Doug Ducey, in order to win his vote.
Then McCain turned to the process, not naming McConnell but implicitly indicting his handling of health care. “We try to do this by coming up with a proposal behind closed doors in consultation with the administration, then springing it on skeptical members, trying to convince them that it's better than nothing. That it's better than nothing?” McCain said. “Asking us to swallow our doubts and force it passed a unified opposition. I don't think that's going to work in the end, and probably shouldn't.” He predicted the effort would “likely” end in failure, in which case he said Republicans should work with Democrats through the normal committee process.
Though this vote does not commit senators to supporting final passage, Democrats have vowed to attack Republicans merely for advancing the process of repealing the ACA and replacing it with a law that the Congressional Budget Office predicts could result in tens of millions of people losing insurance. A handful of Republican holdouts bowed under intense pressure from McConnell and President Trump to at least allow a floor debate on health-care legislation, despite not even knowing which bill would come up for a vote. They included Senator Dean Heller of Nevada, who voted with party leaders despite ripping McConnell’s replacement plan a few weeks ago and indicating he would vote to block it from coming to the floor. Senator Shelley Moore Capito of West Virginia also voted in favor after earlier saying that she would not support a motion to proceed if she did not back the underlying replacement bill.
"Obamacare isn’t the answer, but doing nothing to try to solve the problems it has created isn’t the answer either,” Heller said in a statement. “If the final product isn’t improved for the state of Nevada, then I will not vote for it; if it is improved, I will support it.”
That Republican leaders struggled so mightily just to bring legislation up for debate underscores how precarious their effort to repeal and replace Obamacare has become. Despite the successful procedural vote on Tuesday, there is no obvious path for any of the GOP’s various proposals to pass out of the Senate in the coming days. Republicans who voted yes to begin debate warned that they still planned to oppose final passage if the amended legislation was not to their liking. The Senate will now move to an amendment process, but if none of the ensuing proposals can get 50 Republican votes, the party will be stuck again.
In a blow to McConnell, nine Republicans voted against his replacement bill, the Better Care Reconciliation Act, after it came up as the first substitute amendment on Tuesday night. The proposal had faced procedural hurdles and needed 60 votes to pass because two of its provisions had not been scored by the Congressional Budget Office. That eliminated any doubt about the outcome of the vote, but the breadth of the GOP opposition was surprising. Senators Lindsey Graham of South Carolina, Bob Corker of Tennessee, and Tom Cotton of Arkansas all voted against it after giving little previous hint of their opposition. Less surprising “no” votes came from Collins, Paul, Murkowski, Heller, and Senator Jerry Moran of Kansas. Curiously, McCain voted in favor of the amendment just hours after insisting he would oppose it without significant changes.
On Wednesday, the Senate plan to vote on an amendment that revives a bill the GOP-led Congress passed in 2015 that repeals much of Obamacare but replaces none of it. Then-President Barack Obama vetoed it at the time, but several Republican moderates are opposed to voting for a repeal bill with no replacement ready. It is not expected to pass.
If both of those proposals fail this week, McConnell told Paul he might bring up a more limited repeal that only gets rid of Obamacare’s insurance mandates and some of its taxes. That would be a significant scaling back of the party’s ambition, but the goal would be to set up a conference committee for more negotiations with the House. But it’s unclear if even that “skinny repeal” option could get the 50 votes needed.
After 20 hours of debate over the next two days, the Senate will begin a marathon amendment process known as a “vote-a-rama” in which senators from either party can propose changes that abide by the rules. McConnell’s goal is to finish the bill—pass or fail—by the end of the week. But even he would not predict success.
“It’s really impossible to predict in a reconciliation process what amendments will be offered and what amendments will succeed,” he told reporters. “It’s wide open.”
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