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Senate Republicans on Tuesday took a tentative step toward fulfilling seven years of promises to repeal the Affordable Care Act (ACA), something they achieved only after the dramatic return of Senator John McCain, who was diagnosed last week with brain cancer.

The procedural vote, which passed without the support of a single Democrat, allows the Senate to open debate on repealing and replacing the ACA, popularly known as Obamacare, even though it remains unclear exactly what legislation they will be voting on.

Fifty Republicans voted yes, and two Susan Collins of Maine and Lisa Murkowski of Alaska voted no. Vice-president Mike Pence’s tie-breaking vote was required to pass the measure.

The fact that a vote simply to open debate was seen as a victory for the Republicans is a measure of how difficult the GOP has found it to overhaul Barack Obama’s healthcare law, which extended health insurance to nearly 20 million more people.

Donald Trump praised the Senate for what he characterized as “a giant step to end the Obamacare nightmare”.

The president said: “As this vote shows, inaction is not an option, and now the legislative process can move forward as intended to produce a bill that lowers costs and increases options for all Americans.

“The Senate must now pass a bill and get it to my desk so we can finally end the Obamacare disaster once and for all.”

Of the two dissenting Republicans, Trump called their votes “very, very sad … for them”.

Senate Republicans will now probably be forced to choose between a number of unpalatable options, including: a discarded and possibly untenable plan to replace the 2010 healthcare law; a measure that repeals it without implementing a replacement; and a so-called “skinny repeal”.

The clean repeal measure appeared not to have enough support among Republicans to pass. The replacement plan will require 60 votes because of a special budget rule – and therefore will almost certainly fall far short of that. The clearest path that has emerged from the uncertainty is the “skinny repeal”, which would eliminate certain pieces of the law, including the requirement that all Americans have healthcare coverage or face a penalty.

A chaotic process will follow, during which the Senate can consider numerous amendments to the bill, including complete replacements. Senators will be forced to cast a number of contentious votes that could haunt those facing tough re-election battles.

The Senate’s struggles were illustrated on Tuesday night when a vote on the Senate replacement plan failed as nine Republicans defected. For procedural reasons, it required 60 votes. Opposition from both moderate and conservative Republicans meant that it only received 43.

Mitch McConnell, the Senate majority leader, called the procedural vote on Tuesday afternoon a “first step” and said he expected Republicans to pass a repeal bill of some kind by the end of the week.

“It’s just the beginning. We’re not out here to spike the football,” McConnell said. “This is a long way, but we’ll finish at the end of the week, hopefully, with a measure that can either go to the House and be taken up or go to conference.”

After the vote, Democrats joined protesters outside the Capitol, striking a defiant tone and urging the activists to keep the pressure on wavering Republicans.

“We are in the fight of our lives,” Ron Wyden, a Democrat of Oregon, said, rallying the protesters.

As McConnell called for the vote to begin, protesters inside the Senate gallery began shouting “Kill the bill! Kill the bill!” followed by chants of “Shame!” as security escorted them outside the chamber.

McCain returned to the Senate, a fresh scar above his left eye, to a loud round of applause from lawmakers. The Arizona senator voted in favor of the motion to proceed, consistent with his prior statements on the issue.

Several Republicans caved in the final moments leading up to the vote, in a dramatic reversal from their previous reservations.

Senator Dean Heller, who is facing a tough re-election battle in Nevada in 2018, was among the most stunning Republican turnarounds. Just last month, Heller publicly lambasted the proposal put forth by party leadership, and said it was a “lie” that the plan would lower premiums. Heller said he still had concerns about the legislation proposed thus far and would only support a final product if it addressed his needs.

“If the final product isn’t improved for the state of Nevada, then I will not vote for it; if it is improved, I will support it,” he said.

Similar statements came from other Senate Republicans who had previously opposed the party’s direction on healthcare. Shelley Moore Capito of West Virginia, Rob Portman of Ohio, Jerry Moran of Kansas and Mike Lee of Utah all cast votes in favor of advancing to a debate, while expressing their hope that negotiations would lead to a better outcome.

The Wisconsin senator Ron Johnson, another swing vote, was among the last to vote for moving forward. Johnson, who has publicly criticized McConnell in recent weeks, could be seen having a lengthy exchange with the majority leader on the Senate floor. Although he bristled in speaking to reporters in the hallway about the process, he nonetheless fell in line with the rest of his party.

Democrats will almost certainly portray a vote by their opponents to advance the bill as a vote in favor of the legislation, irrespective of whether a vote on repealing and/or replacing Obama’s healthcare law ultimately succeeds.

Complicating the vote are a pair of estimates by the nonpartisan Congressional Budget Office (CBO). One found that the latest draft of the Republican bill would leave 22 million more people uninsured, compared to current law, by 2026. A plan to repeal without an immediate replacement would see an estimated 32 million people lose out by 2026.

Activists and constituents have pleaded with lawmakers not to repeal the ACA, inundating their office telephone lines and confronting them at town halls. Liberal groups have also ratcheted up the pressure with rallies, protests and acts of civil disobedience.

Republicans are, meanwhile, contending with a marked shift among voters over the law and the role government should play in ensuring healthcare coverage. Opinion polls show growing support for the ACA, compared with dismal approval ratings for the replacement plan.

After years of promising to repeal the ACA, a popular position that helped fuel the rise of small-government conservatives, Republicans face a growing consensus that the government has a responsibility to guarantee healthcare.

 

Nearly 20 million people gained healthcare coverage under Obama’s Affordable Care Act. The law requires all Americans to have insurance or face a penalty, and offered states funding incentives to expand Medicaid coverage for people with low incomes.

Nearly 74 million people receive coverage through Medicaid, the joint federal- and state-funded insurance program for low-income people, and its sister program Chip, which covers low-income children.

Despite voting to begin debate, moderate Republicans still have concerns over steep cuts to Medicaid under the proposals laid out by party leaders. It would take just three GOP senators to kill a final bill.

In an impassioned speech after the vote, McCain urged his colleagues to hold hearings in public, not behind closed doors. Although he voted to advance the measure to a debate, McCain declared: “I will not vote for this bill as it is today.”

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