THE PROGNOSIS

Sen. John McCain (R-Ariz.) was the third Republican to vote against a “skinny” Obamacare repeal bill last night, ending the Republican health-care effort for now. (Photo by Melina Mara/The Washington Post)

Republicans’ seven-year quest to wipe out President Obama’s Affordable Care Act came to a crashing halt around 1:30 this morning, when Sen. John McCain (R-Ariz.) shockingly bucked his party and voted against a scaled-down repeal bill that emerged as the Senate’s last-ditch effort. It’s now clear that replacing Obamacare — or even repealing small parts of it — may be forever a pipe dream for President Trump and the GOP, whose deep divisions over the U.S. health-care system proved unbridgeable in the end.

Gasps broke out around the Senate chamber early this morning as McCain walked to the dais and uttered “no” on the “skinny repeal” bill. Two other Republicans — Sens. Susan Collins of Maine and Lisa Murkowski of Alaska — had already opposed it, making McCain the third GOP no vote and the senator to ultimately sink the measure. It was a surreal scene; until the end, McCain wasn’t among the senators expected to defect. Earlier this week, McCain made a quick return visit to Capitol Hill after surgery related to his recent diagnosis of brain cancer to help Republicans start health-care debate, for which Trump had praised him warmly. This seems oh-so-long ago, already:

So great that John McCain is coming back to vote. Brave – American hero! Thank you John.

— Donald J. Trump (@realDonaldTrump) July 25, 2017

While the health-care debate will never really be over — and lawmakers are still under pressure to respond to some Obamacare marketplace ills — Republicans appear to have landed at a dead end on their top legislative priority six months into Trump’s presidency. 

The House is soon departing for the long August recess and the Senate will follow in another week or two. The aim was to start work on a tax rewrite, another key GOP priority, once members return in September. One thing seems apparent: Republican leaders are unlikely to have any more appetite for prolonging the sour health-care debate they’ve tried to press for the last few months, judging from Senate Majority Leader Mitch McConnell’s (R-Ky.) eulogy-style speech on the floor last night, right after the vote failed:

“This is a disappointment, this is a disappointment indeed,” McConnell said. “I regret our efforts were simply not enough this time.”

“What we tried to accomplish for the American people was the right thing for the country and our only regret tonight is that we didn’t achieve what we had hoped to accomplish,” he added.“It’s time to move on.”

But if McConnell’s chief aim was to show he’d tried his darndest to pass an Obamacare repeal bill, that is something the leader appears to have accomplished. The week started out painfully and turned excruciating, as Senate Republicans took up and then rejected multiple iterations of ACA rollback plans. First, they barely managed to start debate. Thenm they failed to pass a repeal-replace bill that was McConnell’s brainchild. Then, they failed to pass a repeal-only bill. Just when McConnell thought he had scraped the votes together for his “skinny repeal” measure, McCain revolted.

While viewed as the only bill that could possibly unite the GOP’s hard-line conservatives and pragmatic moderates, that final “skinny” bill faced strong resistance from all corners, similar to its beefier siblings. Insurers hated it because it repealed the law’s individual mandate to buy coverage while still requiring them to offer generous benefits and accept all comers regardless of their health status. Conservatives didn’t like the fact it repealed only small parts of Obamacare and would drive up premiums. Moderates charged that “skinny repeal” wouldn’t improve, and could even worsen, the marketplaces, where premiums are rising and insurers are withdrawing.

That’s where McCain landed, in the end. “Skinny repeal” didn’t fix Obamacare, he tweeted shortly after the vote:

Skinny repeal fell short because it fell short of our promise to repeal & replace Obamacare w/ meaningful reform https://t.co/tZISIvccOO

— John McCain (@SenJohnMcCain) July 28, 2017

McCain had also repeatedly criticized McConnell for skipping public hearings and input from Democrats while crafting health-care legislation. Republicans shouldn’t make the same mistakes as Democrats in 2010 when crafting and passing the ACA without any GOP support, he said.

“We should not make the mistakes of the past that has led to Obamacare’s collapse,” McCain said. “We must now return to the correct way of legislating and send the bill back to committee, hold hearings, receive input from both sides of aisle, heed the recommendations of nation’s governors, and produce a bill that finally delivers affordable health care for the American people.”

(Check out my colleague Paul Kane’s amazingly prescient take last week on McCain and what he learned from the late Sen. Ted Kennedy (D-Mass.)

The failure is a huge political blow to Trump, who had promised during his campaign to sign a repeal bill on “Day One” of his presidency. The president had been heaping pressure and blame on Republicans over the past several weeks, intensifying his rhetoric over the past few days. Trump tweeted this about 45 minutes after “skinny repeal” failed:

3 Republicans and 48 Democrats let the American people down. As I said from the beginning, let ObamaCare implode, then deal. Watch!

— Donald J. Trump (@realDonaldTrump) July 28, 2017

Besides repealing the individual mandate, “skinny repeal” would have also suspended for eight years the ACA’s employer mandate to offer coverage and repealed just one of its taxes, the medical device tax. Additionally, it would have raised the contribution limit for tax-free health savings accounts, extended some more latitude through waivers in how states could run their marketplaces and blocked Medicaid funds from Planned Parenthood clinics for one year.

But its repeal of the individual mandate would have had the biggest effect on insurance coverage. The Congressional Budget Office estimated it would result in 15 million fewer Americans insured within a few years and a 20 percent average increase in premiums.

Republicans weren’t ignorant of those outcomes. That’s why the whole effort nearly folded even before the final vote, when McCain, Lindsay Graham of South Carolina and Ron Johnson of Wisconsin refused early Thursday evening to vote for the measure without a promise that the House wouldn’t pass it. House Speaker Paul D. Ryan ultimately won Graham and Johson over, after issuing a measured statement expressing openness to a House-Senate conference where the bill could be rewritten. But McCain wouldn’t budge.

“If moving forward requires a conference committee, that is something the House is willing to do,” Ryan said. “The House remains committed to finding a solution and working with our Senate colleagues, but the burden remains on the Senate to demonstrate that it is capable of passing something that keeps our promise.”

Of course, Ryan no longer has to follow through on the that promise since the Senate has failed to pass a health-care bill at all.

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AHH, OOF and OUCH

Senate Majority Leader Mitch McConnell goes on and off the floor during a late-night session to consider the Republican health-care bill. (Photo by Melina Mara/The Washington Post)

AHH: Last night’s scene on the Senate floor was the most dramatic The Health 202 has ever seen. The Senate started voting at midnight on sending the “skinny repeal” back to committee, offered by Democrats. The plan was to immediately turn to an up-or-down vote on “skinny repeal” after that, but McConnell delayed and delayed, clearly short of the 50 votes he needed. The Post’s Ben Terris paints the scene for us in this must-read:

“Journalists had fanned out around the Capitol, searching for the Arizona senator, a man they believed controlled the fate of the so-called ‘skinny repeal’ bill. The fact that Papa John’s pizza had been delivered to his Russell building office was a good sign he was in there somewhere, but the cleaning crew that kept popping in and out was a sign that maybe he wasn’t,” Ben writes. “The clock struck midnight, and out he came. The hero or the villain, depending on which side you were on, and neither side knew which yet.”

“It’s very hard to do the right thing,” McCain said into a bright red phone pressed to his ear. And then he gave some hints of his plan to jump ship:

Freelance reporter Matt Laslo:

“Have you decided how you’ll vote?” press corps.

“Yes,” Sen. John McCain.

“How?”

“Wait for the show.”

— Matt Laslo (@MattLaslo) July 28, 2017

HuffPost editor Igor Bobic:

McCain walking into the Senate just 3 hours ago told reporters to “wait for the show.”

And what a show it was.

— Igor Bobic (@igorbobic) July 28, 2017

It slowly became clear that the partial repeal bill would fail, judging from the body language in the chamber and the interactions between lawmakers on both sides of the aisle. The Post’s Mike DeBonis observed cheerful Democrats surrounding McCain:

John McCain is entertaining a lot of cheerful Democrats rn pic.twitter.com/hRsEfwsOPa

— Mike DeBonis (@mikedebonis) July 28, 2017

Democratic Sens. Amy Klobuchar of Minnesota and Diane Feinstein of California embraced McCain. Per CNN’s MJ Lee: 

McCain has now stepped out. On his way out, Klobuchar put her hands on McCain’s shoulders and they hugged.

— MJ Lee (@mj_lee) July 28, 2017

USA Today’s Eliza Collins:

McCain and Feinstein hug, I’m not positive but you usually don’t hug someone voting for something you hate

— Eliza Collins (@elizacollins1) July 28, 2017

At another point, McCain patted the hand of his GOP colleague Sen. Orrin G. Hatch of Utah. From Bloomberg’s Sahil Kapur: 

And now Orrin Hatch approaches McCain to chat. Watch how McCain ends this. pic.twitter.com/CttBfOkgT9

— Sahil Kapur (@sahilkapur) July 28, 2017

Just before the vote started, there was an interaction between McCain and Democratic leader Charles E. Schumer:

I have no clue what it means but here’s an interaction between McCain and Schumer that just happened on the floor. pic.twitter.com/6fcLkcgQTr

— Sahil Kapur (@sahilkapur) July 28, 2017

McConnell’s body language read NOT HAPPY with McCain, per Mother Jones’s Clara Jeffery: 

“McConnell just walked by McCain on the floor and did not acknowledge him”– CSPAN (!)

— Clara Jeffery (@ClaraJeffery) July 28, 2017

Once McConnell started the voting on “skinny repeal.”, things moved pretty quickly. Here’s the climactic moment when McCain voted “no:”

Schumer had apparently been working McCain for days. The Hill’s Peter Sullivan:

Wow Schumer says he’s been talking to McCain four to five times a day for three or four days

— Peter Sullivan (@PeterSullivan4) July 28, 2017

Schumer on McCain: “He’s a hero. He’s a hero of mine.”

— Igor Bobic (@igorbobic) July 28, 2017

Many re-upped this tweet from Obama speechwriter Cody Keenan from earlier this week:

What a remarkable moment it would be if a war hero, fighting cancer, returned to the Senate to say “this is wrong, America must be better.”

— Cody Keenan (@codykeenan) July 25, 2017

Sen. Susan Collins (R-Maine) (Photo by Melina Mara/The Washington Post)

OOF: Let’s not forget it wasn’t just McCain who blocked the repeal bill — Collins and Murkowski did, too. Everyone had expected Collins to defect, but you could see GOP leaders working Murkowski on the floor:

HuffPost’s Matt Fuller: 

Rubio is working McCain.

Thune, Blunt, Tillis, and Sullivan are working Murkowski.

Murkowski might be the weakest link here.

— Matt Fuller (@MEPFuller) July 28, 2017

MSNBC’s Joy Reid: 

Tomorrow the headlines will focus on McCain, but let’s not forget it was Susan Collins and Senator Murkowski who held the line all the way. https://t.co/J2TWixYHC9

— Joy Reid (@JoyAnnReid) July 28, 2017

At first, Schumer only praised McCain:

But Democrat Amy Klobucher reminded him not to forget Murkowski/Collins. The Guardian’s Lauren Gambino: 

As Schumer praised McCain, Klobuchar interjected: “And can we also not forgot the two women senators who were there from the beginning.”

— Lauren Gambino (@laurenegambino) July 28, 2017

OUCH: Senate Republicans failed to pass their health-care bill on the same day the Senate passed Medicare and Medicaid 52 years ago, several onlookers pointed out:

Emma Sandoe, a former flack at the Department of Health and Human Services under Obama and a self-described Medicaid lover:

At midnight it will be the 52 years TO THE DAY since the Senate passed Medicare and Medicaid.

— Emma Sandoe (@emma_sandoe) July 28, 2017

Sen. Bob Casey (D-Pa.):

On a day we should be celebrating Medicare/Medicaid’s 52nd anniversary, the @SenateGOP will vote to take health care away from millions.

— Senator Bob Casey (@SenBobCasey) July 28, 2017

TRUMP TEMPERATURE

Vice President Pence, center, heads to the Senate as the Republican majority in Congress remained stymied by their inability to fulfill their political promise to repeal and replace Obamacare. (AP Photo/Cliff Owen)

–Vice President Pence, who was in and out of the Senate chamber throughout the night, gave perhaps the best hint the whole thing was about to go down in flames. When the voting started, he wasn’t presiding at the dais, where he’d need to be to cast a tie-breaking vote.

Politico’s Seung Min Kim:

Pence is NOT in the chair.

— Seung Min Kim (@seungminkim) July 28, 2017

HuffPost’s Matt Fuller reported that the White House called Pence while he was in the chamber: 

Source tells me the White House called for Pence. They couldn’t get Pence off the floor. The White House hung up.

— Matt Fuller (@MEPFuller) July 28, 2017

And CNN’s Phil Mattingly said Trump called McCain before the vote to no avail: 

i’m told at one point Pres. Trump spoke to McCain when McCain was huddling w/ Pence before the vote. Last minute effort didn’t work.

— Phil Mattingly (@Phil_Mattingly) July 28, 2017

Health and Human Services Secretary Tom Price kind of ignored the failure in a statement. Instead he said his team “has taken numerous steps to provide relief to Americans who are reeling from the status quo, and this effort will continue.” Full statement, per Vox’s Sarah Kliff:

Price statement on failed Obamacare repeal vote. pic.twitter.com/Udk0ZUchRr

— Sarah Kliff (@sarahkliff) July 28, 2017

HEALTH ON THE HILL

Senate Majority Leader Mitch McConnell leaves the Senate chamber. (AP Photo/J. Scott Applewhite)

–What’s next for Republicans and health care? I laid out a list of issues they’re going to have to deal with in the coming months, from whether to fund extra Obamacare cost-sharing subsidies to how to convince more insurers to participate in the marketplaces to whether to enforce the individual mandate. 

In the meantime, Democrats, other supporters of the ACA and basically the entire health-care industry is waking up this morning unbelievably relieved:

Former top Obama adviser David Axelrod: 

.@SenJohnMcCain has endured far more in his life that the pressure he came under tonight. But what a courageous vote!

— David Axelrod (@davidaxelrod) July 28, 2017

Former McCain chief strategist John Weaver: 

Thank you my old friend.

— John Weaver (@JWGOP) July 28, 2017

House Democratic Leader Nancy Pelosi:

The American people have spoken loud & clear. It’s time to move beyond #Trumpcare & work to improve the ACA in a bipartisan manner. pic.twitter.com/gP2KN8IPg0

— Nancy Pelosi (@NancyPelosi) July 28, 2017

Protesters gathered outside the Senate following the vote, from Politico’s John Bresnahan: 

There are a couple hundred protesters outside Senate right now. You can hear their chants in hallway near Senate floor

— John Bresnahan (@BresPolitico) July 28, 2017

The conservative world ain’t so happy. Heritage, per Sarah Kliff:

This isn’t over yet — immediate Heritage statement urging Senate to act on Obamacare repeal. pic.twitter.com/pMeQpFTKlR

— Sarah Kliff (@sarahkliff) July 28, 2017

Some helpful perspective from Politico’s Dan Diamond:

Obamacare
· Survived by one vote in the Senate in 2010
· Survived by one vote in SCOTUS in 2012
· Survived by one vote in the Senate in 2017

— Dan Diamond (@ddiamond) July 28, 2017

Sen. Dean Heller (R-Nev.) speaks to members of the media. Photographer: Andrew Harrer/Bloomberg

–Of several amendments the Senate voted on yesterday, members did approve 52-48 a measure offered by Nevada Republican Dean Heller to repeal the “Cadillac tax.” The 40 percent excise tax on high-cost health plans — designed to discourage employers from offering extremely cushy benefits that can drive up health spending — was included in the ACA. But it had previously been delayed by Congress and was scheduled to take effect in 2020. Of course, it’s moot now that the underlying bill has failed.

From Heller:

Proud to see the Senate pass my amendment to permanently repeal the Cadillac Tax with bipartisan support: https://t.co/Za2vQCRlPj

— Dean Heller (@SenDeanHeller) July 28, 2017

Sen. Steve Daines (R-Mont.) speaks on Capitol Hill. (AP Photo/Susan Walsh, File)

–Earlier in the day, the Senate rejected a single-payer amendment introduced by Republican Sen. Steve Daines of Montana, which was designed to test vulnerable Democrats on whether they would vote for the controversial idea. Indeed, four red-state Democrats — Sens. Heidi Heitkamp of North Dakota, Joe Manchin III of West Virginia, Sen. Joe Donnelly of Indiana and Jon Tester of Montana — and an independent, Angus King of Maine, joined Republicans to oppose it. The rest of the Democrats voted “present” on the amendment, which failed 0-57. My colleague Dave Weigel had reported Wednesday night that Democrats had planned all along to reject the amendment, calling it a “sham.” 

“I suspect that what Sen. Daines is doing is nothing more than an old political trick, trying to embarrass Democrats,” Sanders said on the Senate floor yesterday.

“But I do hope, by the way, at some point within this debate, if we can — if not, certainly in the near future — to in fact be introducing a Medicare-for-all, single-payer program,” Sanders added. “It will be somewhat different than my friend John Conyers Jr.’ bill in the House, but what it will do is say that in America, if you are rich or if you are poor, if you are a man, woman, and child, yes, you are entitled to health care as a human right and not a privilege.”

Mic’s Emily Singer: 

Sanders says Democrats will vote present on the legislation since Daines put it up as a “political trick”

— Emily C. Singer (@CahnEmily) July 27, 2017

A few more interesting reads:

MEDICAL MISSIVES

DAYBOOK

(Photo by Zach Gibson/Getty Images)

Coming Up

  • A health-care rally is planned for Saturday in Washington, D.C. 
  • Brookings Institution is holding an event on “Procedure and politics in the 115th Congress” on August 2.  

SUGAR RUSH

How the Obamacare repeal failed, in two minutes:

Watch a reporter inadvertently drop a notebook on a senator during votes: 

So-called “baby boxes” for newborns to sleep in were first introduced in Finland in the 1930s. The Finnish tradition has recently caught on in the United States:

And in case you missed the story on White House Communications Director Anthony Scaramucci’s profanity-laced interview in the New Yorker… Stephen Colbert’s take on the interview: 

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