Dive Brief:

• The Senate on Tuesday approved a procedural vote to continue debating healthcare legislation to repeal part or all of the Affordable Care Act (ACA). The vote was 51-50 with Vice President Mike Pence breaking the tie.
• Senate Republicans now have a few options for what they will vote on next. One is the Better Care and Reconciliations Act (BCRA), which does not have enough support without some changes. Another is full repeal of the ACA, which is also unlikely to pass on its own.
• Another plan that has surfaced relatively recently is known as “skinny repeal.” This would most likely involve repealing the ACA's individual and employers mandates and some industry taxes like the one on medical devices, but a full plan hasn't been released. 

Dive Insight:

The no vote on the BCRA was expected, but the number of Republicans voting against the measure — nine — is a bad sign for party leaders. They can’t get legislation through the Senate if more than two in their ranks are opposed.

The skinny repeal plan appears to be gaining the most traction. This would have a negative, destabilizing impact on the individual market, which insurers are already wary of. A repeal of the individual mandate alone would lead to 15 million fewer people with coverage and premium increases of about 20%, according to a report from the Congressional Budget Office.

Health politics wonks are speculating McConnell’s latest goal is to get a bill approved that repeals at least some of the ACA. Then, lawmakers in the House and Senate would work together to draft a new bill. This would be an opportunity to include large Medicaid cuts and more ACA rollbacks.

Assessing a "skinny repeal" bill is important, but what's really important is what might come out of a House-Senate conference committee.

— Larry Levitt (@larry_levitt) July 25, 2017

Also still on the table is an amendment that would allow insurers to offer plans that do not meet ACA requirements as long as they offer at least one plan that does. According to an analysis from the consulting firm Avalere, this would lead to premium increases of 40% in the next five years for plans that are compliant and more than 4 million fewer people with individual insurance plans.

Another provision that could be added is a $200 billion fund to help supplement private coverage for people who lose their insurance when Medicaid expansion is ended. Judith Colomon, vice president for health policy as the Center for Budget and Policy Priorities, wrote the money wouldn’t be nearly enough to offset other Medicaid cuts and wouldn't help with other issues like increasing deductibles. “No one should be fooled: The reported $200 billion can’t fix the basic problems with this bill,” she wrote.

A major hurdle still remains for any plan — all the provisions have to meet strict requirements for the bill to pass through the budget reconciliation process, which is the only way the GOP could get it through. The Senate parliamentarian has already said parts of BCRA won't qualify, including a six-month lockout against people who have not maintained continuous coverage and removing essential health benefits for state Medicaid plans.

The Senate procedures following Tuesday’s approval of the motion to proceed get pretty complex. The first step is 20 hours of debate, but after that the process can continue with what is called a vote-a-rama. Democrats may try to draw out this part by offering hundreds of amendments. Republicans, however, are likely to find their own procedural maneuvers to counter and continue moving forward. Lawmakers in the House and Senate would then start the conference process.