Politics

Senate will now take on health bill, and outlook is far from certain

WASHINGTON — Senate Republicans, after a dramatic return by an ailing Senator John McCain, suffered a setback Tuesday night in their effort to repeal and replace the Affordable Care Act when they came up short of necessary votes in early maneuvering.

A plan to replace President Obama’s signature law stumbled during a vote, falling 57-43. It was a sign of the difficult road ahead for Republicans as they try to make good on a seven-year-old promise to ditch the federal health law.

Earlier in the day, majority leader Mitch McConnell muscled through an opening vote, 51-50, on a shell of a bill, with Vice President Mike Pence casting the tiebreaker to continue debate. That was enough to keep the repeal effort alive, but it began a confusing process of endless amendments, without any idea of what a final bill will look like, if the Senate can pass one at all.

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“Let the voting take us where it will,” McConnell said, exposing the massive uncertainty of the debate moving forward.

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His words summed up an extraordinary day on Capitol Hill. It included an anti-Republican protest in the Senate chambers that led to several arrests, a dramatic floor discussion between McConnell and a Republican holdout, and a passionate speech by McCain, who flew in from Arizona for the vote between treatments for brain cancer.

Brendan Lynch/Globe Staff

Senator John McCain said that he would not vote for the health care bill as it stood currently.

McCain denounced the secrecy in which McConnell and his leadership team drafted versions of a repeal bill, even as he enabled Tuesday’s unusual strategy by making the trip to cast his pivotal vote.

In his afternoon speech, McCain made a poignant pitch for bipartisanship and a call for the chamber in which he has served for three decades to recognize once more that compromise and comity can advance the interests and meet the needs of Americans.

“Stop listening to the bombastic loudmouths on the radio, television and the Internet,’’ he said. ‘‘To hell with them! They don’t want anything done for the public good. Our incapacity is their livelihood.’’

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Two Republican senators voted against the initial motion to proceed to debate, Susan Collins of Maine and Lisa Murkowski of Alaska, leaving Republicans with only the slimmest of margins.

But for a Senate that has struggled to make progress on a vow to repeal and replace Barack Obama’s signature Affordable Care Act, even advancing a dummy bill for debate counts as progress.

“I’m extremely happy that we got this vote,” President Trump said at a Rose Garden press conference with the prime minister of Lebanon. “This is the tough vote to get. Now we’re all going to sit together and we’re going to try and come up with something that’s really spectacular. We have a lot of options and a lot of great options.’’

But finding an option that can win support of 50 Republican senators has proved to be impossible thus far, and the hurdles remain significant.

On the Senate floor Tuesday, McConnell challenged his colleagues, saying they have a “duty to act.” He even held a awkward, visibly uncomfortable talk with a Republican holdout, Senator Ron Johnson from Wisconsin — who ended up casting the important 50th vote, even after McCain, setting up Pence’s tiebreaker.

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“With a surprise election comes a great opportunity to do things we never thought possible,” McConnell said on the Senate floor, referring to the unlikely Trump presidency and the campaign promise to repeal the federal health law.

There have been no public hearings in the Senate’s process to repeal-and-replace Obamacare. Even after their struggle with the replacement, Republicans are expected to introduce amendments to that bill, or merely replace, the law.

The nonpartisan Congressional Budget Office has said those options would leave 22 million or 32 million people uninsured respectively, as opposed to the current law. Republicans are also expected to consider amendments that would repeal discrete unpopular portions of Obamacare, such as the individual mandate or a medical device tax.

Senator Chris Murphy, a Connecticut Democrat, said his office has prepared more than 100 amendments. He said some of his Democratic colleagues have even more.

“When you break this down, it’s life or death,” Murphy said. “When you get rid of all the Senate jargon, lots of people will die if this bill becomes law. Millions of people will go bankrupt. And those are terms that anyone can understand.”

Massachusetts Senator Elizabeth Warren, a Democrat and a chief critic of Trump and McConnell, blasted Republicans for the nontransparent process. She charged that Republicans are taking the first steps to “destroy” the health care system.

“They have no idea what bill they’re going to be asked to vote on,” Warren said. “They don’t know exactly how many families it will kick to the curb . . . this isn’t just irresponsible. This isn’t just reckless. This isn’t just cruel. It’s immoral.”

But while McConnell’s strategy had the lasting impact, the day’s optics belong to McCain. The Arizona senator, who was diagnosed with brain cancer last week, triumphantly returned to Congress to help his party in a critical moment, entering the Senate chambers to a bipartisan standing ovation. A surgical scar partially framed his left eye.

After he flashed a “thumbs up” to approve of proceeding with the health care debate, he embraced McConnell and Democratic Leader Chuck Schumer.

“Let’s trust each other,” McCain said. “We’ve been spinning our wheels on too many important issues because we keep trying to find a way to win without help from across the aisle.”

McCain’s dramatic return strongly echoed the actions of Massachusetts Senator Edward M. Kennedy, who in the last year of his life made several trips to Washington as he suffered from the same form of brain cancer, although his mission was much different.

When an ailing Kennedy went to Washington in November 2008, he was advocating for universal health care, one of his life’s missions. “I’m looking forward to the session . . . I’m looking forward, particularly, to working with Barack Obama on health care,” Kennedy said then.

Kennedy died in 2009, before pivotal votes on the health care law, which passed in 2010. Still, he managed to cast deciding votes to protect Medicare payments to doctors in 2008, and he returned to Washington to cast an important vote to proceed on Obama’s stimulus package in February 2009, pushing it past a possible GOP filibuster.

It remains to be seen whether McCain’s choice to return will bolster his legislative reputation, in the same way it added to the Kennedy lore. McCain shocked observers Tuesday evening by voting to advance the repeal-and-replace bill, which he had previously said he didn’t support.

Earlier in the day, the unpopularity of that measure was on full display throughout the Capitol, including one protest which erupted just moments before McCain entered the Senate floor.

“Shame! Shame! Shame!” chanted protesters at one point. At another, they yelled “Kill the bill! Don’t kill us!”

The seated Republican lawmakers, who did not respond to the provocations, waited for the protesters to be escorted out before beginning to vote.

Astead W. Herndon can be reached at astead.herndon@globe.com. Follow him on Twitter @AsteadWH.