A Senate Republican bill that largely repeals and replaces the Affordable Care Act (ACA) with coverage provisions that would save billions of dollars but swell the ranks of the uninsured was voted down decisively tonight, 43 to 57.

The defeat of the Better Care Reconciliation Act (BCRA) comes just hours after Senate Republicans won a dramatic vote to begin debate on a yet-to-be determined healthcare reform bill that would undo the ACA. Vice President Mike Pence cast his vote to break a 50-50 tie. Sen. John McCain (R-AZ), recovering from an emergency craniotomy to remove a blood clot and recently diagnosed with brain cancer, showed up to help give the GOP its narrow margin of victory.

Earlier this month, Senate Majority Leader Mitch McConnell (R-KY) canceled a scheduled vote on the BCRA when he could not muster at least 50 supporters among the 52-member GOP caucus for passage, counting on Pence for a tie-breaker. Moderate Republicans in the Senate were balking, saying that instead of preserving coverage gains under the ACA, the measure would erase them.

The latest version of the bill would add some 22 million more Americans to the ranks of the uninsured by 2026, in part by cutting off federal funding of Medicaid expansion in 31 states and Washington, DC, according to the Congressional Budget Office (CBO). In the process, the BCRA would reduce the federal deficit by $420 billion over 10 years, a cost savings prized by Republicans.

The BCRA was offered tonight as an amendment to — and a full-scale substitute for — an ACA repeal-and-replace bill passed by the House in May with little chance of success in the Senate. The original plan for the BCRA was to secure a simple majority for passage under a Senate voting procedure called budget reconciliation, which prevents opponents from filibustering a measure. However, the BRCA did not qualify for budget reconciliation because recent amendments had not yet been analyzed by the CBO, as required. Accordingly, the BCRA needed 60 yes votes to overcome any Democrat filibuster.

As it turned out, nine Republicans — some moderate, some staunchly conservative — joined 46 Democrats and two independents in opposing the bill.

Senate Republicans plan to introduce and vote on other proposals this week that would either repeal the ACA and immediately replace it, or else repeal it, but delay its demise for 2 years while they come up with a replacement.

Follow Robert Lowes on Twitter @LowesRobert