The “motion to proceed” – which marks the start of debate on bills in the Senate – reached a majority on the strength of “yes” votes from senators who previously voted “no,” including Rand Paul, Dean Heller and Shelley Moore Capito; John McCain’s quick return to Washington after a brain cancer diagnosis; and a rare tie-breaking vote from Vice President Pence.

While this is a major step in the legislative process in the Senate, it’s important to remember that today’s vote is procedural, not substantive. No bill has passed. All that has happened is that the Senate will begin formal debate.

Majority Leader Mitch McConnell depended on a couple of factors to help get the motion passed. First, members are more likely to support their parties on procedural votes than votes directly attached to whether a bill should pass. Second, this particular procedural vote has almost no substance; nobody knows what the Senate bill will look like, so it’s unclear what exactly the Senate just agreed to debate. Since the health care bill is massively unpopular, this lack of substance probably helped get marginal senators on board.

So what bills could McConnell now bring up?

One is the bill the Senate was working on before it all but died when four GOP senators – Mike Lee, Jerry Moran, Susan Collins and Rand Paul – announced they would vote against it.

A second is a “repeal and delay” option, which would repeal Obamacare in full, but on a two-year delay. This would give Congress more time to come to an agreement on what a replacement should look like.

Unless a number of senators reverse their public opposition, neither of these two bills is likely to pass.

The third option is a “skinny” bill with a small number of relatively popular provisions. One possibility would repeal Obamacare’s individual and employer mandates, and the medical device tax, but leave the rest of Obamacare intact. This has a better chance of passing. It’s also primarily intended to simply get the Senate to conference committee, where senators and House members could continue negotiations on what the final bill should look like.

Who will lead the Senate health care debate?

Senate Republicans voted by the narrowest of margins – 51-50 – to begin debate to repeal and replace the Affordable Care Act. Several days ago even this procedural victory appeared unlikely.

McConnell scheduled today’s vote even though several polls show the bill’s low public approval. With the help of President Donald Trump, McConnell pressured just enough senators to vote in favor of the motion – including Dean Heller and Rand Paul – who previously said they had concerns with Republican reform ideas.

Although McConnell and Trump successfully used their positions to pressure critics such as Ron Johnson of Wisconsin, one of the most vocal critics of the process used in the Senate, it is unlikely the tactics used to squeeze 50 Republican senators to vote to allow debate will translate into a Republican bill that repeals and replaces Obamacare.

The likely leaders in the next phase of the Republican attempts to reform health care will come from different parts of the caucus. Their arguments in the upcoming debates will be forceful and not amenable to the pressures of McConnell or Trump.

Susan Collins of Maine, one of two Republicans who voted against the motion to debate, leads the group of moderate Republicans and has been clearest about the need for starting over on reform.

McCain made an emotional return to the Senate floor to cast his vote to proceed with debate, even while criticizing the Republicans’ bill and the process used by McConnell. McCain represents the mainstream Republicans who want to follow a more traditional legislative process.


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Rand Paul of Kentucky, speaking for the libertarian wing, argues that nothing short of a complete repeal of the ACA with no reform that offers government subsidies is the best solution.

The Republican caucus remains divided about the way forward on health care reform. However, with a weakened majority leader and an unpopular president, it will be interesting to see who emerges as a leader in the next few weeks.

What about the president’s agenda?

So what does this vote portend for Trump’s policy agenda on health care and other issues?

That the House and Senate started with health care reform says something about their policy goals. They could have highlighted an effort to work with Democrats and started with Trump’s proposal to spend US$1 trillion to update and improve America’s infrastructure. They could have brought the Republican caucus together and begun work on tax reform, a priority for Trump. There may be good reasons to start with health care, including a procedural desire to use the reconciliation process and the need to rely on savings from health care reform to justify widespread tax cuts. But the issue has demonstrated the deep ideological, geographic and policy differences within the party. Putting those divisions front and center at this early stage engenders an image of chaos and could exacerbate later efforts to find common ground on other issues.

Like all presidents, Trump spent his campaign laying out a series of policy commitments. Unlike most presidents who have had experience negotiating the fine points of policymaking, Trump is relying on congressional leaders to fill in the blanks and make his policy commitments real. Unified government generally yields more “landmark” legislation, but the current health care debate suggests that Trump will have a hard time leading his party forward on immigration reform, infrastructure spending, financial deregulation and tax cuts.

Trump seems ambivalent about the details of this policy debate. While campaign rhetoric to “repeal and replace” may be popular among Republican voters, actual reform is fraught with risks to Republican lawmakers, including the unpopularity of Republican alternatives. Republican legislators see a mandate to move forward decisively on this issue, but the president has not proven to be a consistent leader in this effort. To the extent that the president’s agenda will be achieved, it will be because Republican leaders in Congress share his goals and are willing to hash out the details among their members.