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Senate Republicans vote to open debate on a health care bill

Nobody knows what happens now.

Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

Senate Republicans voted Tuesday afternoon to open debate on their health care legislation, without any clear idea of what that bill will ultimately be or how it will affect millions of Americans.

Two Republicans — Sen. Lisa Murkowski (R-AK) and Sen. Susan Collins (R-ME) — voted no. Sen. John McCain, who has brain cancer, flew back from Arizona to vote yes, and Vice President Mike Pence cast a tiebreaking vote for the motion to officially pass.

The Senate will then debate the House’s health care bill for the next day or so, while they scramble to figure out what exactly they want to pass at the end of this process.

Just hours before the vote, the Republican game plan was still changing. Senators are now considering repealing only a few of the most unpopular provisions in Obamacare, including its individual mandate. That means there are three possibilities in play:

  1. “Skinny repeal,” the new proposal, which would get rid of the individual mandate along with a few other unpopular provisions
  2. A full repeal of Obamacare’s spending and health insurance coverage expansion with no replacement (the Obamacare Repeal Reconciliation Act, or ORRA for short)
  3. A repeal-and-replace plan that senators have been working on for months (the Better Care Reconciliation Act, or BCRA)

Senate leaders could end up bringing all three plans to the floor for a vote. The ORRA appears destined to fail, given moderate opposition to repealing much of Obamacare without replacing it. It would lead to 32 million fewer Americans with health insurance in 2026, versus Obamacare, according to the Congressional Budget Office.

The BCRA has struggled to gain acceptance for the whole Republican conference. Moderates are concerned about the plan’s Medicaid cuts and coverage losses (22 million fewer Americans with health insurance 10 years from now). It is also still in a state of flux, after the Senate parliamentarian said that key provisions did not comply with the Senate’s budget rules.

“Skinny repeal” is the last-ditch plan from Republican leaders. As they struggled to find a majority for the other bills, Senate leaders have started promising reluctant senators that if they pass a bill, any bill, they will go into negotiations with the House and fix the legislation there.

In order to get to conference, though, leadership needs a bill that can get 50 votes. Eliminating the penalty for Obamacare’s individual mandate — possibly along with its employer mandate and some of its taxes on the health care industry — might be the only plan that can win such broad support within the Republican conference.

Three lobbyists told Vox that this was the path forward being charted by Senate leadership. One lobbyist said the bill could be narrowed to the “lowest common denominator product.”

Such a plan faces two huge problems. First, repealing the individual mandate risks sending Obamacare’s insurance markets into a death spiral. Without a penalty for going uninsured, only people in poor health who really need health insurance end up buying it. Costs for insurers would rise, and offering plans on the exchanges would start to seem like a bad deal. The Congressional Budget Office estimated repealing the mandate by itself would lead to 15 million fewer Americans having health insurance 10 years from now.

Second, the Republican strategy here would hinge on successful negotiations with the House to craft an entirely new health care plan. But when the House sent over its preferred Obamacare repeal-and-replace bill, a critical mass of Senate Republicans said it was unacceptable and they would never support it.

A path forward will be charted in the next few days.