Senate takes first step toward repeal of Obamacare

At about 1:30 a.m. on Thursday, Republicans moved one step closer to repealing a law they have railed against since the moment it was passed nearly seven years ago.

By a final vote of 51-48, the Senate approved a budget resolution that sets the stage for broad swaths of the Affordable Care Act to be repealed through a process known as budget reconciliation. The resolution now goes to the House, where leaders are hoping to approve it by the end of the week.

The powerful tool sets up a fast track for repealing large parts of Barack Obama's major domestic achievement; the best guess is that the Senate is still several weeks away from largely repealing Obamacare. But as the process continues, large questions still loom over how — and when – Republicans will replace the health care law.

An expedited repeal, starting with a vote-a-rama The vote took place during a session known as a "vote-a-rama." These all-night vote-fests happen surrounding budget resolutions, which allow senators to propose unlimited amendments, as the New York Times' Thomas Kaplan explained this week.

The passage of the resolution kicks off the budget reconciliation process. That process is special because a reconciliation measure cannot be filibustered, meaning it allows the Senate to pass a bill with a simple majority (as opposed to needing 60 votes to overcome a filibuster). That's good for Republicans, who hold 52 of the Senate's 100 seats.

Once the House approves the measure, which could happen as soon as Friday, committees from both chambers will meet to create instructions telling the budget committee what repeal should look like. Once repeal legislation is drafted, both houses can pass it with a simple majority, and then it would go to President Trump for signature.

Should that repeal legislation pass both houses and be signed by a President Trump, it would cut out important provisions of Obamacare, but would still not repeal the entire law.

Budget reconciliation only allows Congress to repeal parts of the bill — more specifically, the parts that deal with how much the government spends or taxes people. That means this process can't repeal, for example, the parts of the bill that allow young adults to stay on their parents' insurance or the rules saying companies couldn't deny coverage for people with pre-existing conditions.

But those are the parts of the law that end up costing a lot of money, while the parts that can be repealed through budget reconciliation — like the mandate that people have coverage (which is enforced through a tax), billions of dollars in Medicaid funds and subsidies for private coverage — bring money into the system to help balance out the cost equation.

Democrats try to send their own messages

Democrats went into Wednesday night with a messaging plan: Use vote-a-rama to get Republicans on the record about what may come next. That plan consisted of proposing amendment after amendment to force Republicans to vote on Medicaid expansion, funding for rural hospitals, women's access to health care and other popular programs.

Democrats know this is a train they can't stop. As the night drew to a close, all they could do was stage a protest.

Senators aren't supposed to give speeches during a vote, but Sen. Tammy Duckworth, D-Ill., a disabled Iraq War veteran, ignored the rule.

As the presiding senator was gaveling for order, Duckworth said, "For all those with pre-existing conditions, I stand on prosthetic legs to vote no!"

The gaveling continued as Sen. Al Franken, D-Minn., said, "I vote no on behalf of the more than 2.3 million Minnesotans who can no longer be discriminated against because of the ACA!"

What's next (and when)? That's complicated...

Republicans are united on wanting to repeal Obamacare. But they're more divided over the timeframe of that repeal, as well as what happens next.

At one point, it appeared likely that congressional Republicans would take a "repeal and delay" approach — that is, pass repeal legislation that would only be implemented far down the road, to allow time to craft a replacement for Obamacare. But now divisions are growing. House Speaker Paul Ryan this week said he would like a repeal and a replacement for Obamacare to come "concurrently." And in a Wednesday press conference, President-elect Donald Trump indicated that he would like the two to happen in quick succession, though he didn't provide much more clarity on that timeframe.

"It will be repeal and replace. It will be, essentially simultaneously," he said, later adding, "It will be various segments, you understand, but will most likely be on the same day or the same week — but probably the same day — could be a same hour."

Other Republicans, however, believe the process won't be so abbreviated.

"I don't see any possibility of our being able to come up with a comprehensive reform bill that would replace Obamacare by the end of this month," said Maine Republican Sen. Susan Collins.

Wisconsin Republican Sen. Ron Johnson also seemed to say on Tuesday that the process could take a while, involving multiple intermediate steps. As he told WBUR's Here and Now:

"If you had a bridge that's about ready to collapse, you know, the first thing you would do is you'd start working to repair that bridge," he said. "You aren't going to blow it up; I mean, at least people have a bridge to use. Repair that so people can use it while you start building other bridges."

Collins is one of five Republican senators who this week proposed that the resolution provide more time for committees to craft their instructions.

One big concern for Republicans here is repealing a law they detest without disrupting the lives of the roughly 20 million people insured because of that law, including 6.4 million Americans insured through ACA exchanges. Americans definitely want some sort of change — in an NPR-Ipsos poll released Thursday, 38 percent said the ACA should be "strengthened or expanded," and close behind, 31 percent said it should be repealed and replaced. Meanwhile, only 6 percent said it should be "left as-is" (the poll had a margin of error of plus or minus 3.5 percentage points). With reporting from Susan Davis. Copyright 2019 NPR. To see more, visit https://www.npr.org.