Senate Republicans on Tuesday narrowly cleared their first hurdle toward repealing Obamacare. What comes next is complicated and unpredictable. At the end, it’s not clear anything will pass.

Senators will start with pretty meaty proposals H.R. 1628 (115) to take the guts out of Obamacare — but after debate, amendments, more debate, the parliamentarian’s rulings, budget points of order and a “vote-a-rama” — it’s highly uncertain whether the GOP will have 50 votes to pass even a “skinny” backup piece of legislation.


“All we have to do today is to have the courage to begin the debate with an open amendment process,” Senate Majority Leader Mitch McConnell said Tuesday, urging Republicans to let the debate begin. “And let the voting take us where it will.”

Here’s what to watch for.

THE REPEAL AND REPLACE PACKAGE

The Senate had to shelve its repeal-replace package because it didn’t have 50 votes — partly because the nonpartisan Congressional Budget Office projected that it would lead to 22 million fewer Americans having health insurance coverage in a decade. That’s partly because of changes to Obamacare — and partly because of sweeping changes to federal financing of Medicaid, a low-income health care program that predated Obamacare by decades.

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The revised version that came up didn't have the votes -- it was defeated Tuesday night on the first substantive vote of the repeal battle. Technically it killed because it didn't have a full Congressional Budget Office score, including all its amendments. But still it served as a starting point and let senators dispatch with various big amendments.

For instance, it included Sen. Ted Cruz’s (R-Texas) amendment, which would let insurers sell skimpy health plans as long as they also sell Obamacare-compliant ones, Critics of Cruz’s provision, including some in his own party, say it would send premiums sky high for people who are older and sicker, and lead the insurance market into a “death spiral.” It also contained Sen. Rob Portman’s (R-Ohio) proposal to add $100 billion to help people who are now covered under Obamacare’s Medicaid expansion shift into the private insurance market.

THE REPEAL-ONLY BILL

The Senate will move to a straight repeal bill, and the vote may occur Wednesday. It’s very similar to the one that the chamber passed in 2015 that then-President Barack Obama vetoed. That’s almost certain to fail too. One big reason: CBO projected it would lead to more than 30 million fewer Americans with coverage. It was easy for Republicans to vote for the measure when they knew that Obama would veto it. Now there are consequences.

Allowing a vote on straight repeal was necessary in order to get legislation to the floor. Conservative hardliners like Sens. Rand Paul (R-Ky.) and Mike Lee (R-Utah) can then tell voters they followed through on campaign promises to dismantle the Affordable Care Act.

It will also give conservative advocacy groups, which are still crusading for repeal, a chance to hold senators who fail to back the bill accountable. They’re likely to seek primary challengers to some of the senators who fail to back straight repeal. They’ve already begun attacking Sens. Lisa Murkowski (R-Alaska) and Shelley Moore Capito (R-W.Va.) as hypocrites for failing to follow through on campaign promises.

VOTE-A-RAMA

Once the Senate burns through its 20 hours of debate, split among Republicans and Democrats, it goes to a vote-a-rama, which at this point looks like it will be late Thursday. Theoretically that allows for unlimited amendments as long as they are relevant. But probably a few dozen will be voted on.

Here’s where Democrats get to offer a laundry list of ideas and force Republicans to take tricky votes. That could include efforts to stabilize the Obamacare markets, such as seeking funding for cost-sharing subsidies that the Trump administration has threatened to eliminate — potentially making the markets implode.

THE PARLIAMENTARIAN

Senate Republicans also face major procedural hurdles in moving forward with legislation. The parliamentarian has determined that several key provisions of their repeal plan — including eliminating funding for Planned Parenthood for one year and banning coverage of abortion in Obamacare insurance plans — don’t meet the strict budget reconciliation rules required to pass legislation with just a majority of votes, and no filibusters.

To keep provisions flagged by the parliamentarian as a no-go, the GOP could try to get 60 votes -- a nonstarter with every Democrat opposed. Or it can try to modify the language to past muster. For instance, it already tweaked language about defunding Planned Parenthood that the parliamentarian had flagged.

MEDICAID

The biggest sticking point for Republicans, particularly in the Senate, has been how to deal with Obamacare’s Medicaid expansion. Senators from states that adopted expansion, such as Ohio and West Virginia, are deeply troubled by the prospect of taking away coverage from low-income people. That’s exacerbated by concerns about the opioid crisis roiling the country, and whether people who are now on Medicaid would no longer have access to treatment.

The Senate’s repeal package cut nearly $800 billion from the program over a decade — and not just from expansion. It also overhauls the funding formula so that federal payments would be capped for each beneficiary.

SKINNY BILL... AND THE HOUSE

When all else fails, McConnell will probably offer senators a “skinny” repeal bill. It could change over the next few days, but the plan right now is simply to scrap the individual and employer mandates and the medical device tax.

Basically no senators will like it — but they may vote for it just to keep the repeal drive going. Passing a skinny bill would enable the Senate to negotiate with the House on a compromise package that can clear both chambers. But it’s not clear that even that stripped-down package can garner the 50 votes from Republicans needed to pass.

Nor is it clear that a deal can be struck with the House, which voted for a far more sweeping repeal and replace package, including the Medicaid changes and state waivers that could wipe out Obamacare patient protections for people with health conditions.

THE WHITE HOUSE

President Donald Trump’s messaging on health care has been a mess. He’s cheered the prospect of the collapse of the Obamacare — and called the House bill “mean.” But he’s hungry for a legislative win. If a repeal bill lands on his desk — fat, skinny, or in between — chances are he’ll sign it.

Rachana Pradhan contributed to this report.