WASHINGTON -- The Senate rejected a proposal Wednesday that would have repealed major parts of the Patient Protection and Affordable Care Act and provided a two-year delay for lawmakers to develop a substitute.
The effort to abolish much of the 2010 health law outright appealed to conservatives but lost the backing of several moderates and more establishment figures, such as GOP Sen. John McCain, R-Ariz.
Overall, seven Republicans voted against the repeal proposal, putting the final vote at 45-55.
It was the second vote over the course of less than 24 hours in which lawmakers rejected proposals to dismantle the health care law. Now many Republicans are expressing willingness to pass a minimalist measure -- which is being dubbed "skinny repeal" -- that abolishes two of the Affordable Care Act's insurance mandates and a single tax on medical devices.
GOP leaders have emphasized the skinny repeal as a way for the Senate to start negotiations with the House, and perhaps the one way they can sustain their seven-year drive to dismantle the health care law, passed under President Barack Obama.
Several lawmakers acknowledged Wednesday that they did not embrace the content of that proposal but suggested they could possibly back it anyway.
"It's a vehicle to get us into conference," said Sen. Lindsey Graham, R-S.C. "That is not a solution to the problem."
There did not appear to be an alternative solution for Republicans, who remain deeply divided over how to revamp the nation's health care system. The GOP has little margin for error, since just three holdout within their ranks will deprive them of the 50 votes they need to pass legislation with the assistance of Vice President Mike Pence, who can cast a tiebreaking vote.
[INTERACTIVE: Compare House, Senate bills with Affordable Care Act]
On Tuesday night, just hours after opening debate, Senate Republican leaders were unable to pass a bill that they had spent weeks crafting but that never gained sufficient traction with the rank and file. The fact that some Republicans have joined with Democrats on each of the votes so far underscored the challenge Senate leaders face in building consensus in coming days.
On Tuesday, 57 senators -- including nine Republicans -- opposed the updated version of the measure, the Better Care Reconciliation Act, while 43 supported it. The nine dissenters included hard-line conservatives such as Sens. Mike Lee, R-Utah, and Rand Paul, R-Ky., as well as centrists such as Sens. Dean Heller, R-Nev., and Susan Collins, R-Maine.
Opening the Senate on Wednesday morning, Majority Leader Mitch McConnell praised lawmakers for taking a "critical step" earlier Tuesday in opening the debate on health care. He signaled a difficult road ahead in the coming days.
"This certainly won't be easy. Hardly anything in this process has been," McConnell said.
Flip-flop from 2015
The repeal measure, advanced by Paul, would have repealed most of Obama's health care law with a two-year delay but no replacement.
Congress passed nearly identical legislation in 2015 and sent it to Obama, who unsurprisingly vetoed it. Yet this time, with Republican President Donald Trump in the White House itching to sign the bill, the measure failed Wednesday on the Senate floor.
The Republican senators who voted against the repeal measure, in addition to McCain, were Collins, Heller, Shelley Moore Capito of West Virginia, Rob Portman of Ohio, Lamar Alexander of Tennessee and Lisa Murkowski of Alaska.
The Congressional Budget Office has estimated that repealing the Affordable Care Act without replacing it would cost more than 30 million Americans their insurance coverage, and that was a key factor in driving away more Republican senators than McConnell could afford to lose.
The result frustrated other GOP senators, some of whom expressed disbelief that their colleagues would flip-flop on legislation they had voted for only two years ago and long promised to voters. Of the current Republican senators, only Collins opposed the 2015 repeal bill.
"Make no mistake: Today's vote is a major disappointment to people who were promised full repeal," said Sen. Ben Sasse of Nebraska. "We still have a long, long way to go -- both in health policy and in honesty."
Hours after the Senate rejected the repeal proposal, Trump, speaking at a jobs announcement at the White House, said he was "hearing good things" on health care.
Trump later urged action, saying, "We better get that done, fellas, please." He told Pence, "We need that so badly."
There was still some hope among lawmakers that the debate can begin anew and perhaps include consideration of measures rejected on the Senate floor this week.
"When you get all done with it in a conference committee, you can come back in and take the most popular items that are out there and put them back into the bill if they gain you votes or if they really improve the bill," Sen. Mike Rounds, R-S.D., said after Tuesday night's vote.
Several senators said they feel a strong imperative to deliver some sort of health care accomplishment after vowing for seven years to unwind the health care overhaul that Obama ushered into law with only Democratic support.
The skinny repeal option would repeal the Affordable Care Act's mandates that individuals buy plans and that employers with 50 or more employees provide coverage, as well as eliminate the law's tax on medical device manufacturers.
Sen. Bill Cassidy, R-La., who had raised objections earlier this month about Senate leaders' proposal to make deep cuts in Medicaid, said he could back a more modest measure as long as he thought it represented some sort of improvement over the current law.
"My endgame is to have something that is fair to patients across the country," Cassidy told reporters Tuesday night. "Now, I'm not quite sure how we get there, but I am all for anything that gets us one step closer to that endgame."
Conversely, Senate Minority Leader Charles Schumer, D-N.Y., said Wednesday that a skinny repeal is a "Trojan horse" that would lead House conservatives to push the plan back to a much more aggressive attack against the Affordable Care Act.
"There is no such thing as 'skinny' repeal; it's a ruse to get to full repeal, with all the concomitant cuts to Medicaid and tax breaks," Schumer said on the Senate floor.
Still, supporters and critics of GOP leaders' strategy said there was no way to predict what sort of legislation those leaders could produce.
Asked by reporters Wednesday whether enough Republicans could support a scaled-back bill at the end of the extended voting process, Senate Majority Whip John Cornyn, R-Texas, replied, "We'll find out."
"This is a high-wire act -- the whole thing," Cornyn said.
Downcast Republicans
The mood among Republicans, meanwhile, was far from the buoyant excitement that some expected to accompany the first votes to fulfill their long-standing promise to repeal the Affordable Care Act.
Instead, GOP senators described feeling frustrated and unhappy with the legislative options at hand.
"The mood is nothing," Sen. Bob Corker, R-Tenn., told reporters after Tuesday's failed vote on the Senate GOP health care bill. "It's perfunctory."
Sen. James Lankford, R-Okla., put it: "There's not a good option that's sitting in front of us."
Paul, the senator from Kentucky, said, "I think it's a good idea to start with what we agree on and see how big we can get the bill from there."
And the Republican infighting that has dominated the health care debate showed no signs of abating. Murkowski, one of just two Republicans to vote against the motion to proceed, said late Tuesday that "there's been a lot of discussion about" a scaled-back bill, but no definitive proposal.
"We'll try to get down to where we can find that agreement, but I don't know if any of us have identified what that may be," she said.
Trump, for his part, took to Twitter on Wednesday morning to criticize Murkowski for voting against beginning debate. "Senator lisamurkowski of the Great State of Alaska really let the Republicans, and our country, down yesterday. Too bad!" he tweeted.
Later, Murkowski remarked to reporters, "I don't really follow Twitter that much."
Senators are working their way through 20 hours of debate. At week's end, rapid-fire voting on a mountain of amendments was expected before moving to final passage -- of something.
Sen. John Boozman, R-Ark., said the Senate legislation he has supported seeks to roll back the Affordable Care Act "as much as we can."
If any of the proposals pass the Senate, they will go to a House-Senate conference committee where lawmakers will further refine the legislation. But for now, he said, Republicans are just trying to come up with a version that can pass.
Internal GOP differences remain over how broadly to repeal the law, how to reimburse states that would suffer from the bill's Medicaid cuts and whether to let insurers sell cut-rate, bare-bones coverage that falls short of the requirements.
"We really don't know what this bill is going to look like," Boozman said. "It might be very broad, it might be fairly narrow in scope."
"Ultimately, this is not going to fix Obamacare, no matter what the result is. We're going to need additional legislation," he said. "We have many, many individuals who are in a situation where they have very high premiums, very high deductibles -- $5,000-$10,000 deductibles. In Arkansas we've seen our insurance go up in the last four years 128 percent. These are serious problems that simply have to be fixed."
Schumer commented on the lack of a precise plan.
"It seems the Republican majority is no clearer on what the endgame is, because there's no good way out of this," Schumer said.
Information for this article was contributed by Kelsey Snell, Juliet Eilperin, Sean Sullivan, Amy Goldstein, Ed O'Keefe, David Weigel and Paige Winfield Cunningham of The Washington Post; by Erica Werner, Alan Fram, Stephen Ohlemacher and Ricardo Alonso-Zaldivar of The Associated Press; by Thomas Kaplan and Eileen Sullivan of The New York Times; and by Frank E. Lockwood of the Arkansas Democrat-Gazette.
A Section on 07/27/2017