After three days of debate and several fruitless votes on amendments, the Senate Republicans were unable to obtain enough support to pass their so-called "skinny" repeal of the Affordable Care Act.

Sen. John McCain, who recently returned from medical leave in Arizona to exhort his fellow senators to work together on reforming the healthcare system, was the deciding vote. He joined fellow GOP senators Susan Collins (ME) and Lisa Murkowski (AL) in voting against the bill.

With the GOP only holding a 52-seat majority in the chamber, these three votes were enough to ensure the demise of the Healthcare Freedom Act, the legislation introduced at the last minute by GOP leadership.

McCain had opposed the content of the "skinny" bill and said earlier on Thursday that he would only be willing to vote for it if he had a rock-solid assurance from House leadership that they would not immediately attempt to vote on the Senate bill. Instead, he and some other Republicans wanted a guarantee that the House would enter into a conference committee to work out a more amenable piece of repeal legislation.

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Speaker of the House Paul Ryan made a vague assurances, but would not guarantee, a conference committee on the bill. While Ryan's statement was sufficient for some on-the-fence Republicans, it was apparently not enough to get McCain out of the "no" column.

He ultimately signaled his disapproval with a thumbs-down gesture when his name was called. When the Senate clerk listed the "no" votes, there was an audible gasp in the Senate chamber when McCain was included in that group.

"Our efforts were not enough this time," said Majority Leader Mitch McConnell after the vote, which ultimately went 51-49 against passing the repeal bill.

"We are not celebrating," said Minority Leader Chuck Schumer. "Obamacare was hardly perfect. It did a lot of good things, but it needs improvement."

At around 2:30 a.m. ET, President Trump used his preferred mode of communication to express his displeasure with the vote, blaming "3 Republicans and 48 Democrats" for the legislative failure and once again calling for lawmakers to "let ObamaCare implode, then deal."

What Was in The Bill

Many people are probably waking up this morning not even knowing the name, let alone the substance, of the Healthcare Freedom Act.

The Senate Budget Committee released the bill [PDF] via Twitter shortly after 10 p.m. ET on Thursday night. We presume they were waiting to see who was evicted from Big Brother. (Spoiler: It was Ramses.)

The 8-page bill proposed the following:

  • Negate the "individual mandate"—the requirement that all people must have some form of insurance or pay a penalty—by reducing the penalty for not having insurance to $0. This would have been effective immediately and retroactive to the beginning of 2016.
  • Negate the "employer mandate"—the requirement that businesses of a certain size must provide full-time employees with qualifying coverage—by reducing the penalty for not having insurance to $0. This would have been effective immediately and retroactive to the beginning of 2016, but would have returned in 2025.
  • Delay the tax on medical device manufacturers through 2020.
  • Allow for increased maximums on Health Savings Accounts, starting in 2018.
  • Deny federal funds to Planned Parenthood (or any similar program, but the definition is so specific that it's really just Planned Parenthood) for one year.
  • Shut down all funding to the Prevention and Public Health Fund, which provides funding to a variety of public health concerns, like Alzheimer's research, diabetes prevention, heart disease prevention, anti-smoking initiatives, immunization, scientific support for state and local officials to detect and respond to outbreaks, and much more. This fund is about 15% of the entire budget for the Centers for Disease Control and Prevention. Funding would end starting in 2018, with no replacement offered.
  • Allow states to seek "innovation" waivers. These waivers would give states the option of allowing insurers to not comply with several aspects of Obamcare, including the requirement that all plans must cover certain "Essential Health Benefits." Once granted, these waivers can not be rescinded.
  • Provide additional funding for the Community Health Center Fund for 2017. This money would have come from the funds that would have been taken from Planned Parenthood.