The curtain has closed on Act Two of the Senate's unfolding drama to pass a bill reshaping the Affordable Care Act, with abrupt and startling defections last night by two conservative senators, Mike Lee of Nevada and Jerry Moran of Kansas. But stay in your seats -- GOP leaders are working backstage on Act Three.

It appears the current version of the GOP's "Better Care Reconciliation Act" is dead for the time being, with three Republican senators now refusing to even bring it to the floor for debate: Sens. Susan Collins (Maine), Shelley Moore Capito (W.Va.) and Lisa Murkowski (Alaska).

“I did not come to Washington to hurt people,” Capito said on Twitter. this morning. She added, “I will only vote to proceed to repeal legislation if I am confident there is a replacement plan that addresses my concerns.”

Some conservatives are fine launching debate. But the additional changes Majority Leader Mitch McConnell (R-Ky.) added last week weren't enough to appease Lee and Moran, who issued critical statements last night saying the current bill still leaves too much of the law in place and doesn't do nearly enough to bring down health-care costs.

“In addition to not repealing all of the Obamacare taxes, it doesn’t go far enough in lowering premiums for middle class families; nor does it create enough free space from the most costly Obamacare regulations,” Lee said. Moran blasted the entire, closed-door approach toward writing the bill, calling for Republicans to "start fresh with an open legislative process."

Trump -- and some Republicans -- are likely to blame Demtwiocrats. But the truth is that replacing even parts of Obamacare is too wide a legislative chasm for the party's conservative and moderate wings to bridge. Republicans suffer from deep divides over how much to spend on Medicaid, how to approach the individual insurance market and how much of the ACA's elements to keep in place. For all their years of campaign vows to repeal and replace Obamacare, they never put in the hard work of crafting consensus legislation to replace it.

But McConnell is bound and determined to hold a vote on the measure -- even if it suffers an embarrassingly bad defeat (The Health 202 wrote about this a few weeks ago). Last night,  the majority leader said the Senate will still vote on starting debate on his bill "in the coming days." But once the bill is on the floor, the idea is to then replace it with another, repeal-only measure Congress passed back in 2015. President Obama vetoed that bill, but Republicans had passed it as a sort of exercise in how they would eliminate the ACA should they eventually win the White House.

McConnell's full statement, from my colleague Sean Sullivan:

President Trump and conservatives in the House are jumping on the repeal-only bandwagon fast. It's what many of them wanted all along, after all:

Trump tweeted this last night:

The president had more words this morning:

From House Freedom Caucus Chairman Mark Meadows, who leads an influential group of the most conservative House members:

From Rep. Jim Jordan (R-Ohio), a past Freedom Caucus chairman:

Passing a repeal-only bill represents a return to Republicans' original plan early this year. Ditching big parts of the ACA -- and replacing it later -- was their initial scheme as they considered how to fulfill their seven-year campaign promise to get rid of Obama's signature domestic achievement. They only decided to couple it with replacement elements when senators began expressing concerns about majorly disrupting the markets and leaving millions of Americans without health coverage.

Here's how the next few weeks are likely to play out. McConnell plans to hold a vote to start debate on the current health-care bill, essentially daring conservatives to vote against an Obamacare repeal bill. If that fails, McConnell can say he at least tried. If a majority of senators vote to start debate -- which would require two of the four defectors to come back on board -- the bill would then be replaced with the 2015 Obamacare repeal bill that nearly every Republican is on record voting to support. That bill would have gotten rid of Obamacare's individual and employer mandates, its taxes, its subsidies and its Medicaid expansion.

There's something interesting about that 2015 bill, though. It would actually repeal less of the ACA than McConnell's BCRA. Republicans also used the budget reconciliation process to pass that bill, so they'd only need 50 votes in the Senate and could bypass Democrats. Because of concerns that repealing the insurance regulations would run awry of rules governing a budget bill, Republicans didn't touch that part of the ACA in the measure.

Even so, every single Republican in the Senate at the time -- with the exception of one, Collins -- voted for the 2015 bill. McConnell is sure to remind them of that if he accomplishes the seemingly impossible by bringing it to the floor.

"Absolutely," Lee spokesman Conn Carroll told me this morning, after I asked whether Lee would vote for the prior bill.

McConnell doesn't really have any good outcomes at this point. He has bad options...and less-bad options, as my colleague Sean notes. If his bill officially tanks on the Senate floor, Republicans still face challenges in the Obamacare marketplaces for which they'll bear the blame if they don't respond. If they managed to pass the repeal-only bill, they'd cause major disruption in the insurance markets -- plus they'd still have to figure out a replacement within the next two years.

McConnell's long game is unclear at this point. Here's what we do know: Trying to ram a sweeping health-care bill through the legislative process with the help of Republicans who don't even agree in the first place on what the U.S. health-care system should look like isn't a winner. In fact, it's a recipe for disaster, as the majority leader has learned. Especially when you tack on deep cuts to Medicaid spending, which is something that doesn't play well with many voters or some Republican governors and senators.

From The Post's Robert Costa: 

Other reporters noted how broadly Moran criticized the Senate health-care bill. He wasn't just discontent with elements of it. The whole process of moving it through the Senate was flawed, Moran and other Republicans said:

From CNNs MJ Lee: 

From NBC News’ s Benjy Sarlin:

Benjy points out Moran was one of the only Republican senators to hold a town hall this month (where constituents slammed the health-care bill):

Sen. Lindsey Graham (R-S.C.), who has been critical of the entire process, echoed the thoughts:

The New York Times’s Nate Cohn points out that three conservative Republicans opposing the health-care bill (plus another one who has expressed doubts, Sen. Ron Johnson of Wisconsin) share a commonality: 


Democrats are probably opening bottles of champagne, judging from their tweets:

Rep. Colleen Hanabusa of Hawaii:

Sen. Tim Kaine of Virginia:

But some onlookers warned that the drama isn't over yet. There could be several more acts, depending on how badly Republicans want to say they slayed Obamacare.

Andy Slavitt, a former acting administrator for the Centers for Medicare and Medicaid Services in the Obama administration:

The Atlantic’s McKay Coppins:



AHH: Why did Republicans abandon their original plan to repeal Obamacare without replacing it? They realized it would cause massive and hugely damaging disruption in the health-care industry, even if the repeal is delayed for two years. The Post's Philip Bump explained last month how premiums would spike, insurers would bail, states would drop Medicaid coverage -- and there's no guarantee Republicans would develop a replacement soon enough.

"It’s not a safe bet that Congress would actually pass a bill to replace Obamacare after they light the fuse with a repeal bill...Congress tends to like to bump up against the hard deadlines it sets for itself, and there’s no reason to think that this time would be any different," Philip wrote. "In this case, though, much of the damage would probably already be done by the time the clock ran out."

OOF: Part of the reason Senate Republicans had such a hard time selling their politically unpopular health-care bill is because the Congressional Budget Office had projected it would result in 22 million fewer Americans being insured in a decade. But what about that repeal-only bill McConnell is now aiming for? It would cause 10 million more Americans -- for a total of 32 million people -- to lack coverage 10 years from now. Those coverage losses are grimmer than both the health-care bills the House and Senate introduced this year.

Yet this is what Trump is calling for, in his tweet last night:

--"Trump’s tweet is actually kind of useful," my colleague Greg Sargent writes. "It reveals once again that Republicans have been running a massive scam on Obamacare for years. They constantly fulminated for repeal, and voted repeatedly for it, in the full knowledge that President Barack Obama would veto it and that they would not face the consequences of their rhetoric and vote."

"The promise of unspecified replacements allowed Republicans to claim they would act to make sure millions didn’t lose coverage, without saying how," Greg continues. "But now that repeal could become a reality, they are no longer willing to vote for it, because they would be held accountable for those consequences. By calling for straight-up repeal right now, Trump has inadvertently called their bluff."

OUCH: Videos, photos and interviews obtained by the L.A. Times expose the shocking double life led by Carmen Puliafito, former dean of the University of Southern California's medical school. Puliafito is a renowned eye surgeon whose skill in the operating room was matched by a gift for attracting money and talent to the university -- yet there was another side to the Harvard-educated physician, the newspaper found.

"During his tenure as dean, Puliafito kept company with a circle of criminals and drug users who said he used methamphetamine and other drugs with them," the paper reports. "Puliafito, 66, and these much younger acquaintances captured their exploits in photos and videos...Shot in 2015 and 2016, they show Puliafito and the others partying in hotel rooms, cars, apartments and the dean’s office at USC."

"In one video, a tuxedo-clad Puliafito displays an orange pill on his tongue and says into the camera, 'Thought I’d take an ecstasy before the ball.' Then he swallows the pill. In another, Puliafito uses a butane torch to heat a large glass pipe outfitted for methamphetamine use. He inhales and then unleashes a thick plume of white smoke. Seated next to him on a sofa, a young woman smokes heroin from a piece of heated foil."

"As dean, Puliafito oversaw hundreds of medical students, thousands of professors and clinicians, and research grants totaling more than $200 million. He was a key fundraiser for USC, bringing in more than $1 billion in donations, by his estimation," the piece says.


--A fifth senator, Ron Johnson of Wisconsin, had already been back-pedaling on the Senate health-care bill even before the Moran/Lee defections. Johnson indicated last week that he would support starting debate on the revised legislation now that it includes an amendment from his conservative ally Sen. Ted Cruz to lower premiums for healthy people. But back in Wisconsin, Johnson told constituents he's worried that the legislation's steep Medicaid cuts might never go into effect -- a possibility McConnell has been raising with moderates to try to get their support.

"I am concerned about Leader McConnell's comments to apparently some of my Republican colleagues — 'Don't worry about some of the Medicaid reforms, those are scheduled so far in the future they'll never take effect,'" Johnson said to about two dozen Greater Green Bay Chamber members and other guests, according to the Press-Gazette. "I've got to confirm those comments ... I think those comments are going to really put the motion to proceed in jeopardy, whether it's on my part or others."

--Everything is still dependent on if and when Sen. John McCain (R-Ariz.) can make it back to D.C. for a health-care vote. McConnell was forced to postpone this week's intended vote, as McCain was recovering from an emergency surgery. McCain's vote would be essential for GOP leaders to have a chance of taking up a repeal-only bill.

Trump wished McCain a speedy recovery at a White House event yesterday, adding that Republicans need his help to get rid of Obamacare. "I can tell you, we hope John McCain gets better very soon, because we miss him," Trump said. "He’s a crusty voice in Washington, plus we need his vote...And he'll be back. And he will be back sooner than somebody else would be back. He'll be back soon.”

McCain's daughter, Meghan, tweeted that he was recovering well:

My colleague Kelsey Snell overheard a conversation between McCain and Sen. Graham:

McConnell's comments, per Sean:

Other reads from The Post and beyond:

Sen. Dean Heller of Nevada was one of few Republicans to come out against an earlier version of the GOP's health-care bill.
Ed O'Keefe and Amy B Wang
Trump goes light on details, assuming Americans will simply trust him.
Philip Bump
An estimated 700 to 900 women in the U.S. died from pregnancy-related causes in 2016. We have identified 120 of them so far.
Pro Publica
The Clinic is a global success story, but its host community remains mired in poverty.
What is "nucleoside bypass therapy," the treatment proposed for Charlie Gard, and how well has it worked in other patients? Here's what to know.
After fending off challenges to their tax-exempt status, the biggest hospitals boosted revenue while cutting charity care.


  • The Hill holds an event on mental health care with Virginia Gov. Terry McAuliffe (D) and Rep. Leonard Lance (R-N.J.).
  • The House Energy and Commerce Oversight and Investigations Subcommittee will hold a hearing on the 340B Drug Pricing Program.
  • The National Pharmaceutical Council holds a webinar on patients’ out-of-pocket costs.

Coming Up

  • The House Ways and Means Oversight Subcommittee holds a hearing on waste, fraud and abuse in Medicare on Wednesday.
  • The Manhattan Institute will hold an event on drug pricing featuring former Rep. Tom Coburn (R-Mich.) on Wednesday.
  • The National Press Foundation will hold an event on preventative health care on Wednesday.
  • The Hill is hosting an event on the prescription drug delivery system on Thursday.
  • The House Energy and Commerce Subcommittee on Health will hold a hearing on bipartisan legislation to improve Medicare on Thursday. 

What does Sen. McCain (R-Ariz.)'s absence mean for the future of the Senate health-care plan?

A neurologist explains a craniotomy procedure following Sen. John McCain's surgery:

Activists and doctors stage a "kill the bill" protest against the Republican plan on Capitol Hill: 

President Trump says we "hope John McCain gets better very soon:" 

President Trump sits in a fire truck on the White House lawn:

After Ann Coulter lashed out at Delta Air Lines on Twitter for asking her to switch seats, here’s a brief history of her controversial comments: