Republican senators voted to begin debate on a health care bill to repeal and replace the Affordable Care Act on Tuesday, despite acknowledging that they woke up that morning not knowing the way forward.
While the vote revived a mission that appeared near-dead at times, it’s still far from certain that Republicans in Congress can pass a bill to deliver on their seven-year process, even as a possible fallback plan emerged to repeal a few crucial ACA taxes and mandates later this week.
The tally was 51-50, with Vice President Mike Pence required to cast a rare vote to win a tie on the slimmest of margins, as GOP Sens. Susan Collins of Maine and Lisa Murkowski of Alaska joined all of their Democratic colleagues voting no.
On Tuesday evening, the Senate began considering amendments, including a revised version of the GOP leadership’s Obamacare-replacement plan, known as the Better Care Reconciliation Act. That effort failed by a wide margin, and the Senate was then slated to take up another repeal bill that would give Republicans two years to come up with a replacement. That was also expected to fail. The latest scores by the Congressional Budget Office found that the BCRA would increase the number of uninsured by 22 million people over 10 years, while the repeal-only bill would increase the number of uninsured by 32 million.
On Tuesday, another option surfaced: a less-ambitious bill repealing unpopular mandates and taxes under Obamacare that doesn’t make dramatic changes to other regulations and Medicaid. The bill would eliminate the ACA’s individual mandate, employer mandate, and tax on medical devices, according to a lobbyist and a senior Senate GOP aide, who cautioned that there was still work to be done on it at press time. If successful, that option would at least keep the issue alive and set up negotiations with the House.
While the vote was a victory for Senate Majority Leader Mitch McConnell, the outcome is still uncertain. McConnell was, as usual, subdued in a press conference on Tuesday.
“This is just the beginning,” he said. “We’re not out here to spike the football.”
McConnell dropped norms in consolidating power over the drafting process, averting committee hearings and other measures that allow for public debate. Even rank-and-file Republican senators grew frustrated with McConnell, but few dared to cross him.
Just days after finding out he has brain cancer, GOP Sen. John McCain of Arizona returned to the Senate on Tuesday to cast a deciding vote in favor of opening debate, before urging his colleagues to “trust each other” and “return to regular order.” He said he wouldn’t ultimately support the “shell of a bill” unless changes are made to it.
Republican Sen. Ron Johnson of Wisconsin publicly criticized the process as overly secretive and rushed, repeating at one point that he needed more time so he could evaluate the information. On Tuesday, he echoed other colleagues in the Senate, saying, “I don’t know what I’m voting on yet.”
McConnell explained the plan during a lunch in the Capitol. GOP Sen. Bob Corker said McConnell’s pitch “wasn’t impassioned,” but simple. “He said, ‘This is the moment we've been talking about for seven years,’” Corker said.
That argument wasn’t new. But after a heated discussion on the Senate floor with McConnell, Johnson voted yes, saying, “I was happy to join Senator McCain."
In the first six months of the Trump administration, McConnell has had many doubters. The top priority in Congress has been to repeal and replace Obamacare, and it’s taken months longer than initially expected, delaying progress on any other major legislative goal.
“We’re getting nothing done,” McCain said on Tuesday. “All we’ve really done this year is confirm Neil Gorsuch to the Supreme Court.”
Without much experience leading the passage of such a major piece of legislation, McConnell has had to navigate a number of very difficult political and policy problems in crafting a health care bill. Cutting government benefits is always hard, and the Affordable Care Act is the most popular it has ever been, finally cracking the 50 percent approval threshold this year. The Republican alternatives have polled about half of that.
McConnell also has a math problem: With 52 Republican senators, only three could kill a bill—and enough did to sink their leadership’s past proposals. A group of senators representing states that expanded Medicaid fought with conservatives like Sen. Pat Toomey of Pennsylvania, who has succeeded in including a proposal in the Senate GOP ACA-replacement bill to rein in the entitlement program for low-income Americans. Yet McConnell got a key vote on Tuesday—from Sen. Rob Portman of Ohio—in part by agreeing to add an additional $100 billion to a stability fund to help those on Medicaid transition to private insurance.
But even as McConnell succeeded in getting the debate started, the odds of a major overhaul of Obamacare passing Congress were perceived to be low.
“I’m hard-pressed to figure out, without Democratic votes, how you create this magical unicorn that passes the House and passes the Senate,” said a second health care lobbyist, who requested anonymity due to the sensitivity of the discussion. “Unless it’s this skinny little thing that’s much more symbolic than it is substantive.”