THE PROGNOSIS

Republicans' seven-year quest to wipe out President Obama's Affordable Care Act came to a crashing halt around 1:30 this morning, when Sen. John McCain (R-Ariz.) shockingly bucked his party and voted against a scaled-down repeal bill that emerged as the Senate's last-ditch effort. It's now clear that replacing Obamacare -- or even repealing small parts of it -- may be forever a pipe dream for President Trump and the GOP, whose deep divisions over the U.S. health-care system proved unbridgeable in the end.

Gasps broke out around the Senate chamber early this morning as McCain walked to the dais and uttered "no" on the "skinny repeal" bill. Two other Republicans -- Sens. Susan Collins of Maine and Lisa Murkowski of Alaska -- had already opposed it, making McCain the third GOP no vote and the senator to ultimately sink the measure. It was a surreal scene; until the end, McCain wasn't among the senators expected to defect. Earlier this week, McCain made a quick return visit to Capitol Hill after surgery related to his recent diagnosis of brain cancer to help Republicans start health-care debate, for which Trump had praised him warmly. This seems oh-so-long ago, already:

While the health-care debate will never really be over -- and lawmakers are still under pressure to respond to some Obamacare marketplace ills -- Republicans appear to have landed at a dead end on their top legislative priority six months into Trump's presidency. 

The House is soon departing for the long August recess and the Senate will follow in another week or two. The aim was to start work on a tax rewrite, another key GOP priority, once members return in September. One thing seems apparent: Republican leaders are unlikely to have any more appetite for prolonging the sour health-care debate they've tried to press for the last few months, judging from Senate Majority Leader Mitch McConnell's (R-Ky.) eulogy-style speech on the floor last night, right after the vote failed:

"This is a disappointment, this is a disappointment indeed," McConnell said. "I regret our efforts were simply not enough this time."

"What we tried to accomplish for the American people was the right thing for the country and our only regret tonight is that we didn't achieve what we had hoped to accomplish," he added. "It’s time to move on."

But if McConnell's chief aim was to show he'd tried his darndest to pass an Obamacare repeal bill, that is something the leader appears to have accomplished. The week started out painfully and turned excruciating, as Senate Republicans took up and then rejected multiple iterations of ACA rollback plans. First, they barely managed to start debate. Then they failed to pass a repeal-replace bill that was McConnell's brainchild. Then, they failed to pass a repeal-only bill. Just when McConnell thought he had scraped the votes together for his "skinny repeal" measure, McCain revolted.

While viewed as the only bill that could possibly unite the GOP's hard-line conservatives and pragmatic moderates, that final "skinny" bill faced strong resistance from all corners, similar to its beefier siblings. Insurers hated it because it repealed the law's individual mandate to buy coverage while still requiring them to offer generous benefits and accept all comers regardless of their health status. Conservatives didn't like the fact it repealed only small parts of Obamacare and would drive up premiums. Moderates charged that "skinny repeal" wouldn't improve, and could even worsen, the marketplaces, where premiums are rising and insurers are withdrawing.

That's where McCain landed, in the end. "Skinny repeal" didn't fix Obamacare, he tweeted shortly after the vote:

McCain had also repeatedly criticized McConnell for skipping public hearings and input from Democrats while crafting health-care legislation. Republicans shouldn't make the same mistakes as Democrats in 2010 when crafting and passing the ACA without any GOP support, he said.

“We should not make the mistakes of the past that has led to Obamacare’s collapse," McCain said. "We must now return to the correct way of legislating and send the bill back to committee, hold hearings, receive input from both sides of aisle, heed the recommendations of nation’s governors, and produce a bill that finally delivers affordable health care for the American people."

(Check out my colleague Paul Kane's amazingly prescient take last week on McCain and what he learned from the late Sen. Ted Kennedy (D-Mass.)

The failure is a huge political blow to Trump, who had promised during his campaign to sign a repeal bill on "Day One" of his presidency. The president had been heaping pressure and blame on Republicans over the past several weeks, intensifying his rhetoric over the past few days. Trump tweeted this about 45 minutes after "skinny repeal" failed:

Besides repealing the individual mandate, "skinny repeal" would have also suspended for eight years the ACA's employer mandate to offer coverage and repealed just one of its taxes, the medical device tax. Additionally, it would have raised the contribution limit for tax-free health savings accounts, extended some more latitude through waivers in how states could run their marketplaces and blocked Medicaid funds from Planned Parenthood clinics for one year.

But its repeal of the individual mandate would have had the biggest effect on insurance coverage. The Congressional Budget Office estimated it would result in 15 million fewer Americans insured within a few years and a 20 percent average increase in premiums.

Republicans weren't ignorant of those outcomes. That's why the whole effort nearly folded even before the final vote, when McCain, Lindsay Graham of South Carolina and Ron Johnson of Wisconsin refused early Thursday evening to vote for the measure without a promise that the House wouldn't pass it. House Speaker Paul D. Ryan ultimately won Graham and Johson over, after issuing a measured statement expressing openness to a House-Senate conference where the bill could be rewritten. But McCain wouldn't budge.

“If moving forward requires a conference committee, that is something the House is willing to do,” Ryan said. “The House remains committed to finding a solution and working with our Senate colleagues, but the burden remains on the Senate to demonstrate that it is capable of passing something that keeps our promise.”

Of course, Ryan no longer has to follow through on the that promise since the Senate has failed to pass a health-care bill at all.

AHH, OOF and OUCH

AHH: Last night's scene on the Senate floor was the most dramatic The Health 202 has ever seen. The Senate started voting at midnight on sending the "skinny repeal" back to committee, offered by Democrats. The plan was to immediately turn to an up-or-down vote on "skinny repeal" after that, but McConnell delayed and delayed, clearly short of the 50 votes he needed. The Post's Ben Terris paints the scene for us in this must-read:

"Journalists had fanned out around the Capitol, searching for the Arizona senator, a man they believed controlled the fate of the so-called 'skinny repeal' bill. The fact that Papa John’s pizza had been delivered to his Russell building office was a good sign he was in there somewhere, but the cleaning crew that kept popping in and out was a sign that maybe he wasn’t," Ben writes. "The clock struck midnight, and out he came. The hero or the villain, depending on which side you were on, and neither side knew which yet."

“It’s very hard to do the right thing,” McCain said into a bright red phone pressed to his ear. And then he gave some hints of his plan to jump ship:

Freelance reporter Matt Laslo:

HuffPost editor Igor Bobic:

It slowly became clear that the partial repeal bill would fail, judging from the body language in the chamber and the interactions between lawmakers on both sides of the aisle. The Post's Mike DeBonis observed cheerful Democrats surrounding McCain:

Democratic Sens. Amy Klobuchar of Minnesota and Diane Feinstein of California embraced McCain. Per CNN's MJ Lee: 

USA Today's Eliza Collins:

At another point, McCain patted the hand of his GOP colleague Sen. Orrin G. Hatch of Utah. From Bloomberg's Sahil Kapur: 

Just before the vote started, there was an interaction between McCain and Democratic leader Charles E. Schumer:

McConnell's body language read NOT HAPPY with McCain, per Mother Jones's Clara Jeffery: 

Once McConnell started the voting on "skinny repeal.", things moved pretty quickly. Here's the climactic moment when McCain voted "no:"

Schumer had apparently been working McCain for days. The Hill's Peter Sullivan:

Many re-upped this tweet from Obama speechwriter Cody Keenan from earlier this week:

OOF: Let's not forget it wasn't just McCain who blocked the repeal bill -- Collins and Murkowski did, too. Everyone had expected Collins to defect, but you could see GOP leaders working Murkowski on the floor:

HuffPost's Matt Fuller: 

MSNBC's Joy Reid: 

At first, Schumer only praised McCain:

But Democrat Amy Klobucher reminded him not to forget Murkowski/Collins. The Guardian's Lauren Gambino: 

OUCH: Senate Republicans failed to pass their health-care bill on the same day the Senate passed Medicare and Medicaid 52 years ago, several onlookers pointed out:

 

Emma Sandoe, a former flack at the Department of Health and Human Services under Obama and a self-described Medicaid lover:

Sen. Bob Casey (D-Pa.):

TRUMP TEMPERATURE

--Vice President Pence, who was in and out of the Senate chamber throughout the night, gave perhaps the best hint the whole thing was about to go down in flames. When the voting started, he wasn't presiding at the dais, where he'd need to be to cast a tie-breaking vote.

Politico's Seung Min Kim:

HuffPost's Matt Fuller reported that the White House called Pence while he was in the chamber: 

And CNN's Phil Mattingly said Trump called McCain before the vote to no avail: 

Health and Human Services Secretary Tom Price kind of ignored the failure in a statement. Instead he said his team "has taken numerous steps to provide relief to Americans who are reeling from the status quo, and this effort will continue." Full statement, per Vox's Sarah Kliff:

HEALTH ON THE HILL

--What's next for Republicans and health care? I laid out a list of issues they're going to have to deal with in the coming months, from whether to fund extra Obamacare cost-sharing subsidies to how to convince more insurers to participate in the marketplaces to whether to enforce the individual mandate. 

In the meantime, Democrats, other supporters of the ACA and basically the entire health-care industry is waking up this morning unbelievably relieved:

Former top Obama adviser David Axelrod: 

Former McCain chief strategist John Weaver: 

House Democratic Leader Nancy Pelosi:

Protesters gathered outside the Senate following the vote, from Politico's John Bresnahan: 

The conservative world ain't so happy. Heritage, per Sarah Kliff:

Some helpful perspective from Politico's Dan Diamond:

--Of several amendments the Senate voted on yesterday, members did approve 52-48 a measure offered by Nevada Republican Dean Heller to repeal the "Cadillac tax." The 40 percent excise tax on high-cost health plans -- designed to discourage employers from offering extremely cushy benefits that can drive up health spending -- was included in the ACA. But it had previously been delayed by Congress and was scheduled to take effect in 2020. Of course, it's moot now that the underlying bill has failed.

 

From Heller:

--Earlier in the day, the Senate rejected a single-payer amendment introduced by Republican Sen. Steve Daines of Montana, which was designed to test vulnerable Democrats on whether they would vote for the controversial idea. Indeed, four red-state Democrats -- Sens. Heidi Heitkamp of North Dakota, Joe Manchin III of West Virginia, Sen. Joe Donnelly of Indiana and Jon Tester of Montana -- and an independent, Angus King of Maine, joined Republicans to oppose it. The rest of the Democrats voted "present" on the amendment, which failed 0-57. My colleague Dave Weigel had reported Wednesday night that Democrats had planned all along to reject the amendment, calling it a "sham." 

"I suspect that what Sen. Daines is doing is nothing more than an old political trick, trying to embarrass Democrats," Sanders said on the Senate floor yesterday.

"But I do hope, by the way, at some point within this debate, if we can — if not, certainly in the near future — to in fact be introducing a Medicare-for-all, single-payer program," Sanders added. "It will be somewhat different than my friend John Conyers Jr.' bill in the House, but what it will do is say that in America, if you are rich or if you are poor, if you are a man, woman, and child, yes, you are entitled to health care as a human right and not a privilege."

Mic's Emily Singer: 

A few more interesting reads:

MEDICAL MISSIVES
The court-mandated deadline to agree on Charlie Gard's hospice care has passed.
Lindsey Bever and Cleve R. Wootson Jr.
The war in Congress over repealing and replacing the Affordable Care Act has brought anxiety to the people whose health insurance is at risk.
The New York Times
Dr. Sanjay Mishra, the husband of CMS Administrator Seema Verma, is part of a group practice in Indiana that does not accept Medicaid payments.
Kaiser Health News
DAYBOOK

Coming Up

  • A health-care rally is planned for Saturday in Washington, D.C. 
  • Brookings Institution is holding an event on "Procedure and politics in the 115th Congress" on August 2.  
SUGAR RUSH

How the Obamacare repeal failed, in two minutes:

Watch a reporter inadvertently drop a notebook on a senator during votes: 

 

So-called "baby boxes" for newborns to sleep in were first introduced in Finland in the 1930s. The Finnish tradition has recently caught on in the United States:

And in case you missed the story on White House Communications Director Anthony Scaramucci's profanity-laced interview in the New Yorker... Stephen Colbert's take on the interview: