Lazaro Gamio / Axios

The current version of the Senate health care bill is dead, following last night's opposition from Sens. Mike Lee and Jerry Moran — and Majority Leader Mitch McConnell's subsequent admission that the Senate's repeal-and-replace bill "will not be successful." He said the Senate will instead vote on straight repeal with a two-year delay.

It'll be a tough vote for McConnell's caucus, but holding it is probably the only way he can declare health care dead for good and move on.

  • Most of the Senate GOP caucus is already on the record supporting full repeal.
  • It's still likely to fail this time — and probably by a pretty significant margin, given that it's now obvious the Republicans won't be able to agree on a replacement at the end of the two-year delay.
  • (Technically, the vote that fails might be a procedural vote to begin this debate, rather than a vote on the repeal bill itself. Either way, repeal wouldn't happen.)
  • But Trump wants to try it, as he tweeted last night: "Republicans should just REPEAL failing ObamaCare now & work on a new Healthcare Plan that will start from a clean slate. Dems will join in!"

What killed the bill: The biggest, most consistent obstacle was that the complaints within the GOP caucus were diverse, and a big part of that caucus was not especially invested in reconciling them.

  • As one senior GOP aide put it to Axios' Caitlin Owens last night, before McConnell's announcement: "How many more changes could possibly be made at this point. We're talking about people on the absolute ends of our spectrum. Every time you move toward one you move away from the other."
  • Lee wanted a new version of Sen. Ted Cruz's consumer-choice amendment — which allowed insurance companies selling ACA-compliant plans to also sell non-compliant plans — with separate risk pools for each set of policies.
  • Moran and Sen. Ron Johnson complained mostly about the process, or the fact that the bill wasn't full repeal. They're correct that it wasn't full repeal. A longer process almost certainly wouldn't get it much closer to that goal. Or any other goal.
  • Who knows whether there was a move to the right that would have actually emboldened the moderates — other than Sen. Susan Collins — to stake out a firm position against any version of this bill. But as a matter of principle, the further it moved to the right, the harder it was going to be for McConnell to lock down Dean Heller & Company.

Who's breathing a sigh of relief, and who's breathing into a paper bag:Pressure's off:The Senate's moderates, who can now safely announce their opposition to the bill without being the ones who sent it over the edge (and thus earning Trump's ire).The House Freedom Caucus: If anything had passed the Senate, the Freedom Caucus would have faced a very unpleasant choice (swallow the best deal possible, or hold the line on conservative principles). They — like Lee — will now get to maintain their ideological purity.Pressure's on:The moderates: This repeal-only bill would be much more disruptive in the individual market and Medicaid expansion, but wouldn't include the steep additional Medicaid cuts they found so objectionable in the Senate bill. Can they live with that? What if killing it means they'd have to step up and ... actually kill it?Tax reform: Repealing the ACA has been Republicans' bedrock campaign promise since 2010. To win total control of the government and fail to deliver is a stunning setback, and one that will reverberate into other legislative goals. If tax reform fails, too, it's going to be awfully hard for even McConnell and House Speaker Paul Ryan — never mind Trump — to deliver on much of their agenda before 2020.Cruz: The man who once made it his business to outflank almost the entire Republican party from the right decided to make a play for pragmatism — and found himself outflanked from the right.Democrats: They've been eager to concede the ACA has some problems — which is undeniably true — and suggest bipartisan negotiations to fix those problems. We'll see whether Trump and McConnell have any interest in that (McConnell has at least said he might), but it may well be time to walk the walk on fixing the ACA.Health and Human Services secretary Tom Price: He's been beating up on the ACA nonstop, in an effort to help get this bill passed — but It's still his job to implement the law he so despises.

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