Hours after the Republican-led U.S. Senate voted to begin debate on repealing former President Barack Obama's signature health care law, the chamber rejected a comprehensive bill aimed at that end.
Lawmakers Tuesday night voted 43-57 on a measure drafted by Senate Majority Leader Mitch McConnell that would have ended the expansion of Medicaid, the program that provides health insurance for poor Americans, cut subsidies to help low-income people buy private health insurance plans, and eliminated tax penalties on people who do not buy health insurance.
The measure also included an amendment by Texas Republican Ted Cruz that would let health insurers offer less generous plans than those required under the Affordable Care Act.
WATCH: Senators Welcome McCain for Vote
Tuesday night's vote is the first of many that will be taken this week in the Republican Party's years-long effort to repeal and replace the ACA, also known as Obamacare. The Senate's move to begin debate occurred after McConnell tried and failed over the past month to pass two different versions of the bill. But even that move nearly failed, as all Democrats and two Republican senators, Susan Collins and Lisa Murkowski, voting against the so-called motion to proceed, leaving the chamber deadlocked at 50-50.
It took Vice President Mike Pence, in his constitutional role as presiding officer of the Senate, to cast the tie-breaking vote.
A decisive vote was cast by Arizona Republican John McCain, who returned to Capital Hill just days after being diagnosed with brain cancer. McCain received a rousing ovation from his colleagues when he strode onto the Senate floor, and they broke into applause to cheer the sometimes stern message that he delivered.
McCain calls for bipartisanship
"I stand here today, looking a little the worse for wear," the Arizona Republican said, poking fun at his appearance post-surgery. He had a small scar above his left eye from the surgery, which removed a blood clot. Further tests revealed that he had a glioblastoma multiforme, one of the most aggressive forms of brain cancer.
McCain chided his colleagues for the lack of progress they have made in deciding what to do about the Affordable Care Act. He called on all senators to govern better by embracing compromise, bipartisanship and the Senate's traditional way of doing business.
WATCH: McCain: 'Let's Trust Each Other' in Health Care Debate
"Stop listening to the bombastic loudmouths on the radio, television and internet. To hell with them! They don't want anything done for the public good. Our incapacity is their livelihood,'' McCain said.
"Let's trust each other. ... We've been spinning our wheels on too many important issues because we keep trying to find a way to win without help from across the aisle," he said.
Despite the warm reception for McCain by senators of both parties, Democrats slammed the Republicans' tactics on the health care issue, in which a relatively small group meeting behind closed doors considered legislative drafts, with Democrats excluded.
Which version will they debate?
"I have never seen a process like this, where the senators are in the dark, and you're talking about a sixth of the American economy [the health care industry]," said Senator Ron Wyden, an Oregon Democrat. "All the [Republican] options provide for worse care for millions of Americans, more expensive care, and care with less coverage."
Republican Senate Majority Leader Mitch McConnell is leading the push to replace Obamacare, which has been in effect since 2010. Over the past month, however, the veteran senator from Kentucky has been forced to retreat when it became clear there were not enough votes to pass either of two different versions of the bill.
President Donald Trump was quick to praise Tuesday's vote. "Inaction is not an option," he said in a statement released by the White House. "And now the legislative process can move forward."
Republicans acknowledged, however, that beginning debate does not guarantee a bill's final passage.
"We have a distance to go to get where we need to be," said Senator Ted Cruz of Texas. "I will be happy when we get it done, accomplish what we set out to: honor our promise to repeal Obamacare and fundamentally expand consumer freedom and lower premiums for families who are struggling."
Details to determine final vote
Several moderate Republicans who had withheld their support for weeks ultimately voted "yes" Tuesday to open debate, but said they could well vote "no" on final passage unless changes are made to protect their poor and vulnerable constituents. Nine Republicans voted against the McConnell sponsored bill Tuesday night.
"If the final product isn't improved for the state of Nevada, then I will not vote for it; if it is improved, I will support it," Senator Dean Heller said in a statement.
It remained unclear which version of the legislation McConnell would put in play. Republicans have said a less comprehensive version of the latest Senate measure would have the best chance of gaining a majority vote to dismantle Obamacare. If the Senate approves a scaled-down version of the bill, a conference committee of the two houses of Congress will have to reconcile differences between the House and Senate versions.
In a series of tweets early Tuesday, Trump said Obamacare was "torturing" Americans.
Trump has repeatedly pressed the Republicans in Congress to set aside any misgivings and vote as a bloc to repeal Obamacare. A day earlier, he said the legislative process so far had been marked by "enough talk and no action."
'We are not the president's subordinates'
McCain said he would not vote for the current version of the bill that McConnell has been preparing. He advised his colleagues on the Senate floor Tuesday to consider the issue carefully: "Whether or not we are of the same party, we are not the president's subordinates. We are his equal!''
The nonpartisan Congressional Budget Office has projected the effects of various Republican health care plans. All would result in millions of Americans losing health insurance care coverage, but would yield budgetary savings.
Republicans are counting on those savings to help pay for tax cuts and their other legislative priorities. With the party controlling the White House and both houses of Congress, the health care vote is seen as a critical test of Republicans' ability to govern.
Recent public opinion surveys, however, show that Americans view the existing Affordable Care Act more favorably than any of the Republicans' proposals to replace it.
Democratic Senator Al Franken of Minnesota said the uncertainty about which bill the Republicans would bring to the floor was "deeply troubling."
"This is reckless. This is irresponsible," Franken said. "The American people deserve better."
Franken said the vote to proceed with debate "is a vote to move forward with conceivably any one of these bills, and all of these bills are terrible."
VOA's William Gallo contributed to this report.