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WASHINGTON -- The Senate on Tuesday voted to proceed with debate on a bill to repeal and replace the Affordable Care Act -- except that no one knows exactly which bill that will be.

The vote was mostly along party lines, with senators Susan Collins (R-Maine) and Lisa Murkowski (R-Alaska) being the only Republicans to vote against proceeding. That left a 50-50 tally; Vice President Mike Pence cast the deciding vote to break the tie.

Sen. John McCain (R-Ariz.) returned from Arizona to vote in favor of proceeding, greeted with a standing ovation and even a hug from Minority Leader Sen. Charles Schumer (D-N.Y.); on Wednesday, McCain's office announced that McCain has glioblastoma, an aggressive form of brain cancer. The cancer was discovered when McCain had surgery to remove a blood clot above his eye.

Going into Tuesday's vote on the motion to proceed, senators were unclear which bill they would actually proceed to consider: it could be the current BCRA bill, or a 2015 bill that would repeal the ACA's mandate for individual and employer-sponsored coverage but would keep the law's other provisions. That so-called "skinny repeal bill" would also repeal the tax on medical devices. Now an actual bill will be hammered out.

The vote Tuesday was not without drama. All Democrats waited to cast their votes against proceeding until the very end. Just before the vote was about to begin, protesters in the Senate gallery began shouting "Don't kill us! Kill the bill!" and "Shame! Shame!" before they were forcibly removed.

Prior to Monday's vote, Senate leaders from both parties tried to sway their colleagues to their side. "If the Senate manages to pass something to get to conference in the House, the likely compromise is either a full repeal of the ACA or something close to it," said Schumer. "It will certainly mean drastic cuts in [Medicaid], huge tax cuts for the rich, no help for people with preexisting conditions, and millions and millions losing healthcare, particularly in poorer and rural states. That's the only thing Republicans are able to agree on."

"Seven years after Obamacare was imposed on the country, we will vote on a critical first step to move beyond its failure," said Senate Majority Leader Mitch McConnell (R-Ky.). "I am aware of the pain Obamacare has caused for literally millions of families. Premiums have skyrocketed; insurance options have declined, leaving people with little insurance choose from ... Many of us made commitments to our constituents, and now we have a real opportunity to keep those commitments by voting to begin debate."

Health policy experts weren't surprised by the vote. "I expected the motion to proceed to pass," Gail Wilensky, PhD, senior fellow at Project HOPE, in Bethesda, Md., wrote in an email. "It would have been an affront to the leadership to have a different outcome ... other than on principle of not approving the procedures used thus far."

"Now the serious debates start," added Wilensky, who headed the Centers for Medicare & Medicaid Services under President George H.W. Bush. "The next vote, whatever it's on, will be much tougher."

"There are two obvious outcomes of today's procedural vote: President Trump and the Republican leadership will tout this as a great legislative success, and persons with Obamacare coverage will become ever more nervous about their future," Jonathan Weiner, DrPH, professor of health policy and management at Johns Hopkins University, in Baltimore, wrote in an email. "Beyond that, the implications of today's vote for health care reform are far from clear. Stay tuned."

“This is so clearly not about a policy debate and how to improve the ACA. It’s just a political gesture to make good on a promise that we know now was void of any back-up plan,” JoAnn Volk, senior research fellow and project director at the Georgetown University Center on Health Insurance Reforms, told 番茄社区app.

“The debate still seems largely about the backroom deals to get to 50. It’s just a numbers game and not about people,” she continued.

As for whether a repeal bill could pass, G. William Hoagland, senior vice president at the Bipartisan Policy Center, said he didn’t think one could, but “never underestimate McConnell.”

McConnell has roughly $340 billion of “walking around money” because the Senate bill only has to match the House-passed bill in terms of its deficit reduction and the Senate bill exceeds the House in such savings, he told 番茄社区app, on a phone call during which a press representative was present.

Those monies could be earmarked for Medicaid or for stabilizing the markets or otherwise used in a way that could potentially sway those in the “no” camp, such as Murkowski and Collins, Hoagland added.

Others like Kavita Patel, MD, nonresident fellow at the Brookings Institute and a practicing primary care internist at Johns Hopkins Medicine, suggested that Republicans would first try to pass a repeal-only bill and then a repeal-and-replace bill.

Only after those efforts fail, and she believes they will, will Republicans home in on the “skinny bill” which repeals the individual and employer mandates as well as the medical device tax.

“I actually think that could pass” she said, noting that it’s not a benign bill.

“It still destabilizes the insurance market. It creates a true cost-related death spiral, because insurance premiums will continue to go up and the only people who will buy insurance are the people who need it.”

“The BCRA is going to have to go through a lot of stripping down under the Byrd Rule,” noted Timothy Jost, JD, emeritus professor at Washington and Lee University School of Law in Lexington, Va., referring to the Senate Parliamentarian’s objection to major pieces of the bill.

As for the “skinny bill,” Jost noted that any new bill would need to show it reduces the deficit by at least as much as the House-passed bill.

“I don’t think they would know that,” he said.

“I’m bewildered as to whether they intend to pass things without a CBO score, or whether they can even do that,” Jost said.

The Republicans also have a clear numbers problem, Patel noted. McCain in his speech following the vote said that he planned to return home to treat his cancer.

“[Republicans] need his vote to get to 51 somehow… So if he’s gone then what happens?”

McCain’s address to his colleagues drew many plaudits from scholars. Charles Sauer, a policy fellow at the Goodman Institute, called it “one of the more important speeches of the last decade or maybe even longer.”

“We don’t know what amendments will be offered, we don’t know what amendments will be voted on or what the debate will look like, but we do know that Sen. McCain called for restoration of regular order,” Sauer said.

“I love the Senate and I hate what the Senate has been reduced to, and it’s both parties that are responsible,” Sauer said. Having someone “as distinguished as McCain rebuking his colleagues” was something that needed to happen.

“I think he voted the way he needed to for his party, and I think the speech is a reflection of what he really wants,” Patel said. “But I think most people will remember the vote.”

Monday's vote capped several weeks of turmoil among Republicans over the drafting of a bill to repeal and replace the Affordable Care Act. On June 22, Senate Republican leaders released their repeal-and-replace bill, known as the Better Care Reconciliation Act (BCRA). That original measure would result in 22 million fewer people having health insurance in 2026 compared with current law, according to an estimate issued on June 26 by the non-partisan Congressional Budget Office (CBO).

That number was just shy of the 23 million people who would lose Medicaid coverage under the House Republican's repeal-and-replace bill, known as the American Health Care Act, which the House passed on May 4.

After the initial CBO estimate was issued, Senate Republicans revised their bill; however, the new CBO estimate on the revised measure showed little difference in the number of those who would lose coverage; it remained at 22 million.

The deficit reduction is bigger than would have been achieved under the original BCRA, the analysis found, because it put back some of the taxes authorized under the ACA that the initial bill would have repealed. The revision also added extra money for premium subsidies and opioid abuse prevention and treatment. Provisions covering Medicaid that would dramatically alter the program were essentially the same in the revision.

To further complicate matters, on Friday, Senate Parliamentarian Elizabeth MacDonough ruled that some provisions in the BCRA would be subject to the Senate's Byrd rule, which would mean they would require 60 votes in favor of passage in order to avoid a filibuster. Senate Republican leaders had hoped to pass the bill using a process known as reconciliation, under which only 50 votes in favor of passage would be required.

Washington Correspondent Shannon Firth contributed to this story.

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