Senate Republicans overcame a range of internal fissures in narrowly voting on Tuesday to begin debate on their health-care overhaul, but GOP senators said they recognized they still must resolve the thorny policy disagreements that have stymied them for months.
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In a dramatic day at the Capitol, Vice President Mike Pence broke a 50-50 tie, allowing Senate Republicans to clear a procedural hurdle and setting up a days-long stretch of debate and amendment votes on the GOP effort to dismantle and replace much of former President Barack Obama's 2010 Affordable Care Act.
The two GOP defections came from Sens. Susan Collins of Maine and Lisa Murkowski of Alaska, who joined all Senate Democrats in voting against proceeding to debate the legislation.
The vote, punctuated by an emotional last-minute appearance by Sen. John McCain (R., Ariz.), who was diagnosed recently with brain cancer, delivered a come-from-behind victory for President Donald Trump and Senate Majority Leader Mitch McConnell (R., Ky.), who persuaded Republicans skeptical of the GOP bill to band together long enough to begin debate.
Mr. Trump said after the vote that his party had taken "a big step" that would "move forward to truly great health care."
Even with their surprise win on the procedural motion, which seemed a long shot just last week, Republicans were subdued Tuesday about their prospects of passing a sweeping overhaul of the ACA by week's end.
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"We knew this wasn't going to be easy, and there's a lot of work ahead of us," said Sen. John Thune of South Dakota, a member of the Senate GOP leadership.
The Senate late Tuesday began the 20 hours of debate allotted to the health-care bill, which will culminate later this week in a marathon session of amendment votes whose final outcome remained unclear. GOP leaders don't currently have the 50 votes needed to pass any of the various proposals to repeal or replace the ACA, fueling the uncertainty over where the week's legislative twists will end.
Democrats said that while the ACA can be improved, it has provided health insurance to 20 million Americans, and it should be built upon rather than dismantled. Many Republicans say it has resulted in higher premiums and less choice, and that an entirely new approach is needed.
In a memorable moment on the Senate floor, Mr. McCain made clear that he didn't support the current bill, despite flying across the country to prevent the procedural motion from falling short due to his absence. He delivered a sobering rebuke to GOP leaders, even while agreeing that they should at least begin debate on the health legislation.
"It's a shell of a bill right now," Mr. McCain said. "We've tried to do this by coming up with a proposal behind closed doors in consultation with the administration, then springing it on skeptical members, trying to convince them it's better than nothing, asking us to swallow our doubts and force it past a unified opposition. I don't think that is going to work in the end. And it probably shouldn't."
Mr. McConnell on Tuesday pitched GOP senators on a backup proposal, if they can't agree on any other plans for repealing and possibly replacing the ACA. Under this "lowest common denominator" proposal, Republicans would cobble together just the elements that they all agree on, including repealing the individual and employer mandates and a tax on medical devices.
That would knock down the most controversial elements of the ACA, including the requirement that most people pay a penalty if they don't have insurance. But it would likely increase the number of people without insurance, compared with the ACA, making it a potentially hard sell for centrist senators. But centrists may like the fact that it would leave the Medicaid program for low-income Americans unchanged, unlike the current bill's $756 billion in cuts to federal Medicaid funding.
"We'll see where we get to in the end," said Sen. Bob Corker (R., Tenn.). "They're going to see what the broadest measure is that they can get people to support."
GOP leaders hope that passing just a scaled-back bill as a default would at least start negotiations with House Republicans over their version of a health overhaul, which passed in May, keeping alive the effort to repeal the ACA.
It could also provide the nonpartisan Congressional Budget Office more time, while those negotiations are under way, to provide an estimate of the cost and coverage impact of some Republican proposals that could be incorporated into the legislation.
Those measures include an additional $100 billion so states can assist people who lose Medicaid coverage due to the Republican bill, as well as a proposal to allow insurers to sell less expensive plans with fewer benefits if they also sell more robust plans.
Still, it's not clear Republicans can secure 50 GOP votes for the scaled-back repeal plan. Sen. Lindsey Graham (R., S.C.) called the proposal a "political punt," and other senators uneasy over the bill could also emerge as opponents.
Many Republicans said opening debate was a good first step, while generally being cautious about the path ahead. "This vote is the first step toward solving the problems created by Obamacare," said Sen. Tom Cotton (R., Ark.). "And as the Senate continues to deliberate, I will be carefully monitoring any legislative changes that are proposed. It's important we get this right."
Democrats said the "skinny repeal" strategy exposed Republicans' difficulties in coalescing around a health-care plan, despite promising voters for seven years they would repeal the ACA as soon as they took power in Washington.
"It shows the bankruptcy of Republicans' policy efforts," said Sen. Chris Coons (D., Del.), calling the plan "a naked political move to get it off the floor of the Senate" that "does nothing to move us closer to actually addressing the health-care needs of Americans."
The vote itself Tuesday was somewhat dramatic, in part because the outcome was not entirely certain when it began.
When Sens. Collins and Murkowski voted no, it became clear that just one more defection would end the GOP health overhaul push for now. Mr. McCain's plane from Arizona was landing in Washington around the same time, and he raced to the Capitol.
Meanwhile, Sen. Ron Johnson (R., Wis.), who hasn't always seen eye-to-eye with GOP leaders, withheld his vote until the last minute, engaging in a long talk with Mr. McConnell on the Senate floor. Mr. Johnson later said he had been discussing with Mr. McConnell how he could continue "to be a positive influence."
Democrats, for their part, refrained from voting until all Republicans had cast their votes, saying they wanted to highlight all of the GOP senators who were voting to advance an effort that has been broadly unpopular in recent polls.
--Louise Radnofsky, Byron Tau and Janet Hook contributed to this article.
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