The Senate in the early hours of Friday morning rejected a new, scaled-down Republican plan to repeal parts of the Affordable Care Act, derailing the Republicans’ seven-year campaign to dismantle President Barack Obama’s signature health care law and dealing a huge political setback to President Trump.

Senator John McCain of Arizona, who just this week returned to the Senate after receiving a diagnosis of brain cancer, cast the decisive vote to defeat the proposal, joining two other Republicans, Susan Collins of Maine and Lisa Murkowski of Alaska, in opposing it.

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The Senate voted 45-55 Wednesday not to repeal ObamaCare with a two-year delay to replace it, and the only consolation for Republicans is the clarity of seeing who voted to preserve and protect rather than repeal and replace.

Congress had passed and sent to Barack Obama’s desk a similar measure in 2015, with support from every current Senate Republican except Susan Collins of Maine. This time seven voted no, including Rob Portman of Ohio and Shelley Moore Capito of West Virginia, who aren’t up for re-election until 2022 and 2020, respectively. If you’re going to renege on your political promises, better to do it early, we suppose.

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Obamacare gave the federal government a heretofore unprecedented power: the power to force us to buy health insurance irrespective of our desire to do so. Republicans, for both moral and economic reasons, oppose this mandate. The framers of the Constitution never envisioned granting Congress the power to force people to buy a privately delivered financial service. There are also important economic reasons to oppose Obamacare’s mandate. Gross premiums for individually purchased coverage have doubled over the past four years under Obamacare. But the authors of Obamacare don’t need to care about whether they’ve made coverage costlier, because they’re forcing you to buy it anyway. Without a mandate, insurers would have to do what businesses have to do in every other sector of the economy: design products that you voluntarily want to buy because they represent a good value for you. Under Obamacare, they don’t have to.

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Anthem Inc. said that if it doesn’t quickly get more certainty about the future of the Affordable Care Act exchanges, it will likely further pull back its planned participation for next year, a threat that adds to the pressure on Senate Republicans as they struggle to pass health-care legislation.

The big insurer, speaking during its second-quarter earnings call, strongly emphasized that it needed answers about the future of federal payments that help reduce out-of-pocket costs for low-income ACA exchange-plan enrollees. Chief Executive Joseph R. Swedish said that without greater clarity, particularly around the cost-sharing payments, “we will need to revise our rate filings to further narrow our level of participation.” He added that the insurer may make decisions “in a relatively short period of time” and in September at the latest.

Yesterday, Senate Majority Leader Mitch McConnell did the seemingly impossible and got the votes he needed to proceed to consideration of the House-passed plan for repealing and replacing the Affordable Care Act (ACA). At this point, it’s hard to tell what exactly will happen in the coming days, but there is one thing that is fairly certain: if the current Republican effort succeeds in passing a bill, the legislation will make the individual insurance market less stable than it is under current law.

The problem for Senate Republicans is that their principal policy goal is incompatible with the process they are using — budget reconciliation — to pass their legislation.

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Louisiana Republican John Kennedy cracked to Politico this week that “the sight of the gallows focuses the mind,” and perhaps that explains why after months of group therapy Senate Republicans finally voted Tuesday to open debate on repealing ObamaCare. Whatever the impetus, the vote kept GOP reform hopes alive and may have saved the GOP Congress.

The 51-50 vote—with Vice President Mike Pence breaking the tie—was as close as it gets but vindicates Majority Leader Mitch McConnell’s decision to force Senators to be accountable. Maine Senator Susan Collins’s defection was expected, and at least she was consistent with her opposition to repeal in 2015.

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The Senate on Wednesday rejected a measure that would have repealed major parts of the Affordable Care Act but would not have provided a replacement, signaling that the “clean repeal” bill that conservatives have embraced cannot get through Congress.

The vote, 45-55, underscored the bind that Republican leaders have found themselves in. Seven Republicans voted against the measure — Senators Shelley Moore Capito of West Virginia, Susan Collins of Maine, Dean Heller of Nevada, John McCain of Arizona, Rob Portman of Ohio, Lamar Alexander of Tennessee and Lisa Murkowski of Alaska — showing that repealing the health law without an immediate replacement lacks crucial support among Republicans.

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Portions of the Republican bill to repeal and replace ObamaCare will require 60 votes for passage, the Senate parliamentarian said Tuesday evening. The parliamentarian has advised senators that two provisions could be stripped out, according to a document released Tuesday by Sen. Bernie Sanders (I-Vt.), the ranking member of the Senate Budget Committee.

The provisions in question would allow insurers to charge older people premiums up to five times as high as what they charge younger people — which AARP has called an “age tax” — and would allow small businesses to establish “association health plans” that could be sold across state lines. That aspect has been championed by Sen. Rand Paul (R-Ky.)

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All eyes are on the Senate as it debates what to do about ObamaCare. But the House has a last chance this week to abolish one of the law’s most dangerous creations: a board with sweeping, unchecked power to ration care.

The Independent Payment Advisory Board—what critics call the death panel—would be an unelected, unaccountable body with broad powers to slash Medicare spending. But the law contains a living will for IPAB. If the president signs a congressional resolution extinguishing the panel by Aug. 15, it will never come into existence.

The real deadline is closer, since the House plans to recess Friday and not return until Sept. 5. But if the House does act, the Senate will have time to follow, since it plans to remain in session until mid-August.

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Senate Republicans voted to advance to floor debate on their efforts to repeal and replace Obamacare.

Vice President Mike Pence cast the tiebreaking vote. In a dramatic moment, Sen. John McCain returned from Arizona to applause from fellow senators. He cast a necessary Republican vote for the motion after two GOP senators — Susan Collins and Lisa Murkowski — sided with all Democrats in opposition.
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