The Early-Morning Thumbs-Down That Saved the Affordable Care Act

It was after one in the morning on July 28, 2017, and the Senate chamber was full in the way it almost never is. Senators who normally vote and leave were sitting at their desks. The bill on the floor was a stripped-down measure that its own supporters called "skinny repeal," and several of them had said openly that they did not want it to become law; they wanted it to pass so the House and Senate could negotiate something else. John McCain of Arizona, who had been diagnosed with brain cancer only days earlier and had flown back to Washington from treatment, walked to the front of the chamber, caught the clerk's eye, and held out his arm. Then he turned his thumb down. There were audible gasps. The bill failed, 49 to 51. Seven years after the Affordable Care Act passed, the most serious attempt to undo it was over.

In short: Republicans promised to repeal the ACA from 2010 through 2016, then failed when they finally had the power, because no replacement could keep millions of people covered and because three Republican senators voted no. The episode showed that once a program covers people, taking it away is far harder than promising to.

Seven years of a promise

The repeal promise started almost as soon as the law did. After Republicans took the House in the 2010 elections, the chamber voted to repeal, defund or weaken the ACA dozens of times. Those votes were mostly symbolic; the Senate was controlled by Democrats until 2015, and President Obama would have vetoed anything that reached him. In January 2016, with a Republican Senate, Congress did send Obama a bill that would have repealed major parts of the law through budget reconciliation. He vetoed it.

Then Donald Trump won the 2016 election, and Republicans held both chambers. The promise was now a test. Trump had said during the campaign that the replacement would cover everyone and cost less. Congressional leaders spoke of moving quickly, some suggesting repeal could happen in the first weeks.

The House goes first

The House leadership, under Speaker Paul Ryan, wrote the American Health Care Act. It would have ended the ACA's penalty for going without coverage, replaced its income-based subsidies with flatter tax credits based mostly on age, and, most significantly, cut federal Medicaid spending deeply by ending the extra funding for the expansion and capping the rest of the program.

The Congressional Budget Office estimated that the bill would leave many millions more people uninsured within a decade compared with the ACA. The first attempt at a House vote, in March 2017, was pulled when leaders could not find enough support. After changes that let states seek waivers from some ACA protections, the House passed the bill on May 4, 2017, by 217 to 213. Trump celebrated in the Rose Garden.

The Senate made clear it would write its own bill.

The Senate's three tries in one week

Majority Leader Mitch McConnell drafted a Senate version, the Better Care Reconciliation Act, mostly in private. Like the House bill, it made deep cuts to Medicaid over time. Because it was moving through budget reconciliation, it needed only a simple majority, and with 52 Republicans, McConnell could lose two votes and still win with Vice President Mike Pence breaking a tie.

That math is the whole story of July 2017. Two Republican senators, Susan Collins of Maine and Lisa Murkowski of Alaska, signalled early that they were troubled by the Medicaid cuts and by the effect on their states. That left McConnell with no room for a third.

On July 25, the Senate voted on whether to even begin debate. McCain flew back for that vote, and his arrival helped carry the motion; Pence broke a 50-50 tie. McCain then gave a speech on the floor. He criticized the secretive, partisan process, urged the Senate to return to regular order with hearings and amendments, and said he would not vote for the bill as it then stood. He voted to proceed anyway, and many listeners took the speech as a sign of conscience without consequence.

Over the next three days, the Senate voted on several versions. The full Better Care Reconciliation Act failed. A repeal-only bill, which would have scrapped major parts of the ACA with a two-year delay to find a replacement, also failed, with several Republicans voting against it. That left McConnell with a final option.

What skinny repeal actually did

The Health Care Freedom Act, the skinny repeal, was a much narrower bill. It would have eliminated the penalty for individuals going without insurance and the requirement that larger employers offer coverage, along with a few other changes. It left the Medicaid expansion alone.

The bill had an unusual selling point: some of the senators being asked to vote for it said they did not want it to become law. Several, including Lindsey Graham of South Carolina, held a news conference beforehand demanding assurances that the House would not simply pass the skinny bill and send it to Trump. Their goal was to get something, anything, through the Senate so that a conference committee could write a final bill. Speaker Ryan offered a statement saying the House was willing to go to conference, but the assurances were not ironclad.

That set the stage for a vote that was partly about health policy and partly about how the Senate should work. Collins and Murkowski voted no. Leaders, the President and the Vice President spent the evening pressing McCain. Shortly before he voted, he spent time talking with Democratic senators, and Pence was seen speaking with him on the floor. Then came the gesture.

Afterwards, McCain released a statement explaining that skinny repeal offered no replacement, that it would have increased premiums and that the process had been the wrong one. He called again for bipartisan work through committees.

Why the repeal push failed

It is tempting to make this story about one man's dramatic moment. The deeper reasons were in place before he walked to the well.

First, the ACA was no longer an abstraction. By 2017, around twenty million people had gained coverage through its marketplaces and Medicaid expansion. Thirty-one states and the District of Columbia had expanded Medicaid, including states with Republican governors who had done it on purpose. Governors from both parties, including the Republican governors of Ohio and Nevada, both expansion states, lobbied their senators hard.

Second, the protections for people with pre-existing conditions had become extremely popular, and every replacement plan either weakened them or made them harder to keep affordable. Voters who had never thought about the ACA started turning up at town halls because they had a child with a heart defect or a spouse in cancer treatment.

Third, the replacements did not do what the campaign had promised. Every serious estimate showed more people uninsured, not fewer. The CBO's numbers became headlines in every state.

And fourth, there was an organized public. Groups of patients, people with disabilities, nurses and doctors pushed back in the halls of Congress. People with disabilities staged protests, including sit-ins in Senate office buildings, and were removed by police from McConnell's office hallway. Those images mattered.

The other side's case

Supporters of repeal had a fair case worth stating. Premiums on the individual marketplaces had risen sharply in many states, especially in 2017 and 2018. In many rural counties only one insurer was offering plans, leaving buyers with no choice. People who earned too much for subsidies were paying full price for plans with high deductibles. Many conservatives also believed, on principle, that the federal government should not require individuals to buy insurance.

Those problems were real, and some were serious. My answer is that the bills on offer did not fix them. They addressed the cost for some healthier and younger buyers mostly by cutting Medicaid for poorer and sicker ones. A bipartisan bill to stabilize the marketplaces, worked on by Senators Lamar Alexander and Patty Murray later in 2017, tried to address premium problems without repeal, but it never became law.

What happened after the thumbs-down

Repeal did not completely die. Later in 2017, Senators Lindsey Graham and Bill Cassidy proposed another version, which turned Medicaid expansion and marketplace money into block grants for states. It never got a vote. Then, in December 2017, the tax law reduced the penalty for going without insurance to zero, starting in 2019. A group of states sued, arguing that without the penalty the whole law was unconstitutional; in 2021 the Supreme Court dismissed that case, holding that the challengers lacked standing.

McCain died in August 2018. His vote is now part of the law's history, and his call for regular order is still quoted by members of both parties.

For progressives, the useful lesson of July 2017 is not that a hero arrived at the last minute. It is that the hero had cover: governors, hospitals, patient groups, nurses and constituents had made it politically survivable to vote no. Without the pressure built over the spring, the outcome could easily have been different.

The part of the bill that mattered most

Most coverage of the repeal fight focused on the individual mandate, the requirement to buy insurance. The provisions that would have changed the most lives were about Medicaid, and they are easy to miss because they work slowly.

Since 1965, Medicaid has been an open-ended partnership. The federal government pays a fixed percentage of whatever a state spends on eligible people and services, so if more people enroll during a recession or a new treatment becomes standard, federal money rises with the cost. The House and Senate bills of 2017 would have replaced that arrangement with a per-person cap. Washington would have paid each state a set amount per enrollee, growing each year by a formula. Over time, according to the budget office, that formula would have grown more slowly than actual health costs, leaving states to make up the difference, cut benefits, lower payments to providers or cover fewer people.

The bills also would have ended the enhanced federal funding for adults covered through the ACA's expansion, phasing it down over several years. For states that had expanded, this was a direct hit to their budgets.

That is why the fight was never only between Democrats and Republicans in Washington. Republican governors, state Medicaid directors, children's hospitals, rural hospitals and nursing homes all read the formulas and saw what they meant. Rural hospitals in particular depend heavily on Medicaid, and many of their administrators said that the cuts could force closures.

Spring at the town halls

The other half of the story happened far from the Capitol. In February and March 2017, members of Congress home for recess walked into town-hall meetings and found rooms full of constituents asking about health care. Many were not activists. They were parents of children with complex medical needs, people who had bought insurance on the marketplace for the first time, cancer survivors and people who had gained Medicaid through the expansion.

Videos of those meetings spread widely. Some members stopped holding public town halls. Others came out of them changed. And the stories travelled up: senators cited constituents by first name on the floor, describing what a lost card or a cut would mean for a particular family.

That pressure is why Collins and Murkowski felt secure voting no, and why McCain could do it without his vote looking like an act of personal revenge. Public opinion polls in 2017 showed the ACA more popular than it had ever been, largely because people now feared losing it.

McCain's own state

One detail makes McCain's vote easier to understand. Arizona had expanded Medicaid in 2013 under Governor Jan Brewer, a conservative Republican who had pushed the expansion through her legislature over objections from many in her own party. By 2017, several hundred thousand Arizonans were covered through that expansion, and the state's hospitals depended on it.

Brewer's argument at the time was practical rather than ideological: Arizona's taxpayers were already paying for the expansion through federal taxes, and refusing it would send that money to other states while local hospitals absorbed the cost of treating uninsured patients. McCain was not voting in a vacuum. He represented a state whose own Republican leaders had chosen the program he was being asked to unwind, and whose voters would feel the change in hospital waiting rooms and county clinics.

What you can do

The 2017 fight was won by people who called, visited, protested and told their stories. The next one will be too.

• Call the people who represent you. The representatives lookup uses your address to find your House member, senators and state legislators, with their phone numbers, contact forms and how they voted lately. Short, personal and specific beats long and general.
• Watch the Senate's math. The Congress votes page tracks what the House and Senate are voting on. In close votes, a handful of members decide everything, and knowing who they are tells you where pressure matters.
• Back the people who organize. Disability rights groups, patient advocates and nurses' unions led much of the 2017 pushback. Find them in the organizations directory, which lists nonprofits by cause in every state.
• Stay current on coverage fights. The health care topic page collects reporting on Medicaid, the marketplaces and the bills that change them.
• Say thank you across party lines. When a member of the other party votes to protect coverage, tell them you noticed. It makes the next hard vote a little easier.