Where to begin? Perhaps at the end, where things stand now. As the clock neared 2:00am this morning, Senate Majority Leader Mitch McConnell (R-KY) threw in the towel on health care reform, pulling the bill from the floor. Minutes before, the Senate had rejected an amendment that had come to be known as “skinny repeal” by a vote of 49-51. At that point, it was apparent to everyone involved that Senate Republicans didn’t have 50 votes for any iteration of a proposal and that any hopes of changing the Affordable Care Act would require Democratic votes. As such, it became unnecessary to continue debating a bill on reconciliation instructions (which require only a majority vote for passage), so Senators decided to not go through with a long and torturous vote-a-rama and instead close the floor.
Throughout the week during which the Senate technically considered the House-passed American Health Care Act but practically were searching for a different proposal that could garner 50 votes in the upper chamber, Republican leadership constantly made the argument that members needed to vote aye on what came forward in order to move the process along. At first, on Tuesday, members were told that voting in favor of the motion to proceed was necessary so that a debate on the floor could actually happen. By the end, after failed attempts to “repeal and replace” and “repeal and delay,” Senators were told that the point of skinny repeal was to get a bill to conference to come up with something better there. In the end, these promises of a better bill on the horizon were bridges too far, and the votes simply weren’t there.
On Tuesday, Senator John McCain (R-AZ) made a dramatic return to the Senate from recent surgery to deal with late stage brain cancer in order to vote aye on the motion to proceed to debating health care reform. He gave a roaring speech in which he challenged his fellow Senators to get things done instead of engaging in the destructive partisanship that is undermining the chamber’s tradition. GOP Leadership needed his vote as Vice-President Mike Pence needed to be called in to break a 50-50 tie (Senators Roberts and Moran both voted aye). Once on the bill, (and after the Democrats forced the clerk to read the entire thing, burning a good hour on the floor), the amendments started piling up because any bill considered under reconciliation instructions has an open process with all amendments receiving a vote if requested by the sponsor. Many of these amendments were designed to extract as much political blood as possible from the majority party. The mandatory 20 hours of debate started, and things were off and running.
First up was the Better Care Reconciliation Act, better known as “repeal and replace.” Many Republican senators had already lined up to vote against the BCRA including Senator Jerry Moran. Between the haggling that had gone on last week and the vote that occurred this week on this doomed amendment, the Senate Parliamentarian ruled that major aspects of the BCRA violated the Budget Act’s guidelines for consideration under reconciliation instructions, and so the amendment version of it would require 60 votes rather than a simple majority. Since it was obvious it wasn’t going to pass anyway, they went ahead with the vote without trying to change it, and it failed on a vote of 43-57. Senator Roberts voted aye and Senator Moran voted no.
The next amendment to be voted on, this on Wednesday morning, was “repeal and delay.” As indicated, this amendment would repeal almost all of the ACA in two years, thus putting a ticking time bomb on the legislative process to encourage bipartisan action on crafting a replacement. More than 2 Republican Senators had already come out against this proposal meaning that a majority wasn’t possible, so it was obvious that this would go down as well. It did, by a score of 45-55. Senators Roberts and Moran both voted aye.
Then the waiting game began as Senators geared up for voting on what appeared to be the real deal: so-called “skinny repeal.” The thing was, nobody really knew exactly what would be in the amendment. Leadership was working within certain constraints that made simply removing the mandates and certain taxes (their goal) difficult. First, it had to reduce the deficit by more than $2 billion over 10 years, making total repeal of these items practically impossible without big cuts elsewhere. Second, it had to remain compliant across the board to the reconciliation process, meaning that it couldn’t have any items that would create new law. Third, it needed to satisfy 50 Republicans, something that nothing so far could achieve.
The proposal turned out to be a permanent repeal of the individual mandate, an 8-year repeal of the employer mandate, and a 3-year delay on the implementation of the medical device tax among other more minor things. The Congressional Budget Office estimated that premiums on the individual marketplace would jump by 20% next year and that 16 million Americans would lose health insurance. Things became farcical yesterday afternoon as a group of three Republican Senators, McCain, Lindsey Graham (R-SC), and Ron Johnson (R-WI) said they wouldn’t vote for it unless the House promised not to pass the exact same bill. Senator Graham went so far as to call it a “policy disaster” and a “fraud.” They wanted assurances that there would be a conference and a chance at another version of replacement. House Speaker Paul Ryan seemed to ameliorate Graham and Johnson with the assurances they were seeking, but McCain remained silent throughout the afternoon and evening.
The showdown came after midnight. Once time had expired on debating the bill, one motion to recommit was followed by the vote everyone was waiting for. Rarely ever is the outcome of a vote in question when it’s called (that’s why the majority party has whip operations, after all), but this time it genuinely was. Senator Susan Collins (R-ME) voted no, as expected. So did Senator Lisa Murkowski (R-AK). They Senator McCain sealed the bill’s fate by casting no vote to audible gasps in the chamber.
What happens now? It’s anyone’s guess. This isn’t like the time Speaker Ryan pulled the AHCA from the House floor in March before votes started to close off options. The Senate has voted on all the options, and all were found wanting. The next big questions facing the ACA have to do with cost-sharing reduction payments and the administration’s willingness to continue to fund them or allow insurance marketplaces to enter a possible death spiral. Will Congress try to fix Obamacare in a bipartisan manner, or are we done legislating for the year? These are the questions that will hover over Congress as they go into their August recess.