Mitch McConnell likes to say that finding 50 Republican votes to pass healthcare reform is like solving a Rubik’s cube. As he pushes his party toward a vote expected early next week, the Senate majority leader is still furiously twisting the puzzle.



Republican senators left Washington on Thursday confused about what to expect and frustrated that they did not know what they would be asked to vote on. John Cornyn, the number two Senate Republican from Texas, said knowing the final shape of the healthcare bill in advance was a “luxury we don’t have”.

Another blow landed, meanwhile, when the Senate parliamentarian, the chief adviser on the rules of the chamber, indicated that several of the provisions of the bill would need to meet a 60-vote threshold to pass. Republicans were planning to use a process known as budget reconciliation, which requires a simple majority of 51 votes.

That process, however, is limited to matters concerning taxes and the deficit, thereby making efforts to defund the women’s healthcare provider Planned Parenthood, for example, ineligible for such treatment.

A 60-vote threshold would require at least some Democrats – who see any attempt to undermine Barack Obama’s Affordable Care Act (ACA) as a nonstarter – to join Republicans. Republicans will therefore be forced to abandon some of the language within their bill, rendering its passage even more unlikely.

After a six-month debate in Congress and seven years of promising voters that they would repeal the ACA, popularly known as Obamacare, Republicans are therefore being asked to choose between two unpalatable options: a discarded and likely discredited plan to replace the 2010 healthcare law and a repeal-only measure.

A new analysis by the nonpartisan Congressional Budget Office (CBO) found that the latest draft of the Republican bill would leave 22 million more people uninsured compared to current law by 2026. If Republicans choose to repeal major provisions of the law without immediately replacing it, the CBO estimates that 32 million people will lose out in the same time.

Republican leadership is frantically trying to wrangle support to open debate on repeal. That would allow senators to offer countless amendments in a chaotic process that might still end in failure.

It’s beginning to feel like there’s a lack coherency in what we’re doing Senator Bob Corker

“You can’t debate something that you don’t initiate the debate on,” Cornyn said. “Everybody can offer endless amendments so if anybody’s got a better idea they can offer that and get a vote on it. In the end, 50 people are going to decide whether we’re going to have an outcome or not.”

Some argue that it’s harmless to consider a range of options, one of which might bridge the gulf between moderates and conservatives. Others are wary of having to cast a number of contentious votes that could haunt tough reelection battles.

Democrats will almost certainly portray a vote by their opponents to advance the bill as a vote in favor of the legislation, irrespective of whether it ultimately succeeds. There is also pressure looming from the right, as conservative groups that want to see the Affordable Care Act repealed threaten to score how Republicans vote on the procedural motion.

That saga had appeared to come to a close at the beginning of the week, when Mike Lee of Utah and Jerry Moran of Kansas announced their opposition to the latest plan. They joined Rand Paul of Kentucky and Susan Collins of Maine as no votes, leaving leadership at least two shy of the 50 votes necessary to advance the bill.

McConnell announced his intention to hold a vote on a measure that would repeal the healthcare law without a replacement. Although the repeal-only approach would not go into effect for two years, thus buying Republicans time to craft an alternative, that path was rejected by three members of McConnell’s conference.

Trump, who tweeted his support for repeal only, reversed course on Wednesday. During a lunch at the White House, the president instructed Republicans to find workable solution. The intervention sparked a flurry of activity, including a late-night meeting that left Republicans feeling optimistic … but without a concrete plan.

During the meeting, Republican senators received upsetting news: John McCain of Arizona had been diagnosed with brain cancer.

It remains unclear where Republicans will land before leaving Washington for the already postponed August recess. Bob Corker of Tennessee said frantic behind-the-scenes negotiations aimed at marshalling support for a bill to replace the ACA were starting to resemble haggling with vendors at a “Persian bazaar”.

“It’s beginning to feel like there’s a lack coherency in what we’re doing and it’s almost becoming a bidding process – spend $50bn here, let’s throw $100bn there,” the Tennessee senator told reporters.

Collins, a centrist, expressed frustration. “I don’t even know what we’re proceeding to,” she told reporters on Thursday. “I don’t know whether we’re proceeding to the House bill, a new version of the Senate bill, the old version of the Senate bill, the 2015 repeal and hope that we come up with something in two years bill. I truly don’t.”

As Republicans watched yet another strategy go up in flames, Democrats challenged their opponents to abandon their crusade against the ACA and instead work across the aisle on improving the law.

Insurers have raised concerns over market uncertainty stemming from the ongoing debate, with some pulling out of the exchanges set up by the Obama-era law. Some directly attributed the decision to a lack of commitment from the federal government to paying for subsidies designed to lower costs for millions of Americans. The federal government spends roughly $7bn annually on so-called cost-sharing reductions, funding that Trump has on multiple occasions threatened to eliminate.

White House press secretary Sarah Huckabee Sanders told reporters the government would make the next payment, but noted it was “undetermined beyond that”.

A handful of Republicans have expressed support for passing a bill alongside Democrats that would serve as a temporary fix to stabilize the insurance markets. Tom Carper, a Democratic senator from Delaware, said he had been speaking to Republicans privately about working together to stabilize the insurance markets if a repeal vote fails.

“Republicans have to go forward and have their vote that they’re preparing early next week,” said Carper. “And after that I hope we’ll hit the pause.”

In a sign of growing impatience brewing within the party, some Republicans signaled they were willing to support almost any alternative to the existing healthcare law.

“I’m prepared to vote for a bill to repeal, I’m prepared to vote for a bill to repeal and replace,” Florida senator Marco Rubio told Fox News on Friday, while underscoring the importance of reaching a deal “in a timely fashion”.

Rubio said he was “obviously interested” in the language of the Republican bill, but emphasized the need for his party to make good on its longstanding promise to dismantle Obamacare.

“I think people have a right to ask themselves,” Rubio said, “What’s the point in having Republicans if they’re not going to do what they said when they ran for office?”

That seemed to be a sentiment shared by the president, who on Saturday morning tweeted, indefatigably and apparently oblivious to the previous night’s reminder of Senate rules: “The Republican senators must step up to the plate and, after 7 years, vote to Repeal and Replace …

“Obamacare is dead and the Democrats are obstructionists, no ideas or votes, only obstruction. It is solely up to the 52 Republican Senators!”