The Republican senators who qualify as “moderates” in today’s Congress are running out of chances to stop legislation they have said repeatedly would be bad for their constituents and bad for the country.

But it’s not clear whether they realize what’s happening ― or, ultimately, if they even care.

For the last several weeks, attention has focused on several GOP senators who have criticized the impact that their leadership’s bills would have on the millions of people who depend upon the Affordable Care Act for their health insurance.

Most come from states that expanded their Medicaid programs, taking advantage of extra federal matching funds Obamacare made available. In states like Ohio and West Virginia, Medicaid now provides coverage to hundreds of thousands of additional people, many of them working in low-wage jobs that don’t provide coverage, while simultaneously funding treatment of opioid addiction in the places where the epidemic is most acute.

Every Republican proposal that’s officially on the table includes deep cuts to Medicaid and other changes that would cause anywhere from 22 million to 32 million to lose insurance, according to Congressional Budget Office projections.

The Washington Post via Getty Images Republican Sens. Susan Collins of Maine (left) and Lisa Murkowski of Alaska (right) held their ground against moving forward on the GOP push to repeal Obamacare, despite heavy pressure from President Donald Trump and other party leaders.

On Tuesday, Lisa Murkowski of Alaska and Susan Collins of Maine, the two Republican senators who have spoken out against such cuts most consistently, voted against the key procedural step that allowed the debate on health care legislation to go forward. They sat together in the Senate chamber and, at least metaphorically, they were also sitting alone.

The other GOP senators who have warned they can’t support legislation that produces big coverage losses ― including Shelley Moore Capito of West Virginia, Bill Cassidy of Louisiana, Dean Heller of Nevada, and Rob Portman of Ohio ― all voted yes. So did Arizona’s John McCain, who made a dramatic return from brain surgery.

‘Moderates’ Keep Giving McConnell The Support He Needs

Tuesday’s vote did not resolve what has become the defining tension of the repeal effort ― the contradiction between Republican promises to provide “great coverage for everyone,” as President Donald Trump likes to put it, and the party’s proposals that would take coverage away from many millions.

The pitch by Senate Majority Leader Mitch McConnell (R-Ky.) to the moderates has basically been a plea for time, in the hopes he can eventually find a compromise. The ones who voted yes on Tuesday’s procedural motion went out of their way to say they were taking McConnell at his word ― that, by allowing the debate to go forward, they were not signaling support for the bills on the table already.

“If the final product isn’t improved for the state of Nevada, then I will not vote for it,” Heller said in a statement. More emphatic still was McCain, who made his point while speaking from the floor: “I voted for the motion to proceed to allow debate to continue and amendments to be offered. I will not vote for the bill as it is today.”

But hours after the procedural vote, the Senate took up the Better Care Reconciliation Act ― the proposal from GOP leadership that would leave 22 million more people uninsured, by CBO’s reckoning. McCain voted aye. So did Capito, Cassidy, Heller and Portman ― with the latter citing, as his reason, an amendment he’d helped obtain providing $100 billion in extra funding to help people pay their out-of-pocket medical costs.

In theory, Portman’s amendment would offset the effects of ending the Medicaid expansion. In reality, that money would not be nearly enough to make up for the cuts, as new reports from the Center on Budget and Policy Priorities and the Urban Institute make clear.

The bill needed 60 votes, because of parliamentary rules, and got just 43. Because everybody knew in advance it would fail, the vote was effectively a free one ― and potentially a chance for the likes of Capito and Portman to get some credit for supporting repeal, even if they end up opposing whatever comes up for a final vote when this week’s deliberations end.

The Bill Is Likely To Get Worse ― And Harder To Oppose

Quite possibly that legislation will be what’s come to be known as a “skinny bill.” One of McConnell’s fallback plans is to winnow the health care measure down to a handful of elements, including repeal of the individual mandate that penalizes people who have access to insurance but decline to buy it, on the theory that such a modest bill would be mutually acceptable the different factions in his caucus.

The point wouldn’t be for that legislation to become law. Rather, the goal would be to start negotiations between the House and the Senate, in the hopes of producing a bigger bill that eventually could get support in both chambers. That might be enough to keep the likes of Capito and Heller in the fold on the skinny bill. They could say, once again, they were simply voting to keep the debate going ― to give GOP leaders just a little more time to work out the details and craft a compromise that would do right by their constituents.

It’s impossible to know what would happen then. Even veteran congressional staffers are having trouble gaming this all out. But if the Senate walks into negotiations with a skinny bill, then the House health care bill that passed in early May is likely to become the basis for writing final legislation.

That bill includes a set of cuts to Medicaid and to private insurance tax credits that look an awful lot like the ones in the Senate leadership bill defeated Monday night. The House bill would leave 23 million additional people uninsured, according to CBO, which means that even a milder version would mean massive losses of coverage.

Any final compromise would still require approval of the House and Senate, which means the moderates would still get one last chance to vote against the legislation ― to reject the kinds of cuts they keep saying, over and over again, they can’t tolerate. But unlike now, when the options are diffuse and the process opaque and it’s easy to pin blame for failure on somebody else, any vote following a House-Senate negotiation will be a clear up-or-down, make-or-break decision on repeal. Saying no at that point, after GOP leaders put in so much effort, could be much tougher.

We’ve Seen This Movie Before ― Just A Few Months Ago

McConnell and his allies surely know this. And they remember what happened in the House, where Republican leaders eventually crafted an extremely conservative piece of legislation and got moderate holdouts to go along by badgering them and offering token concessions for the sake of appearances. If House-Senate negotiations produce a conservative bill that dramatically cuts coverage, leaders can use the same combination of pressure and guile to get anxious moderates in line.

The consequences for the moderates’ constituents would be devastating. In West Virginia, for example, the number of people who would lose their Medicaid coverage under the House bill could approach 200,000, according to an Urban Institute projection. That would be nearly half the program’s non-elderly population.

Mark Wilson via Getty Images A House-Senate negotiation on a health care bill is likely to give House Speaker Paul Ryan (right) and his conservative colleagues a great deal of leverage.

But to prevent those consequences, at least one more moderate probably has to vote no at some point. And although each may be waiting for one of the others to take the plunge, there’s probably more safety in numbers. A group dissent might even kickstart a bipartisan conversation that could actually produce legislation to shore up coverage ― as Republicans say they will do, even now ― and give the GOP political points for governing successfully.

Of course, all of that assumes Capito, Heller and the others mean what they have said about protecting their constituents. After Tuesday, that’s not at all clear.

CORRECTION: A previous version of this article incorrectly stated that 47 senators voted for the Republican-sponsored Better Care Reconciliation Act on Tuesday night. The correct number is 43.