How has the health care debate unfolded this year?

The Senate voted 51-50 on Tuesday afternoon on a motion to proceed to a health care bill to repeal and replace the Affordable Care Act, with Vice President Pence casting the tie-breaking vote.

For seven years, repealing the health care law has been one of the central organizing principles of the GOP -- but they've found it difficult to deliver on it now that they're actually in power. With the vote on Tuesday narrowly passing, the Senate began debate on a bill to replace the ACA that passed the House in March, voting on a series of amendments to that legislation. 

How did we get to this moment?

Here's a timeline of health care reform efforts during the President Trump's time in office and during the 115th Congress:

January 20

Mr. Trump signed an executive order on his first day in office aimed at tackling Obamacare's individual mandate. The individual mandate requires Americans to buy health insurance or pay a penalty.

February 5

Mr. Trump gave his administration an extended timeline to repeal and replace Obamacare. When asked if repeal legislation would pass in 2017, Mr. Trump said in an interview with Fox News, "Yes, in the process and maybe it'll take till sometime into next year but we're certainly going to be in the process."

February 20

House Republicans praised their outline to repeal and replace Obamacare, as GOP leaders distributed talking points to their colleagues which said their plan "ensures more choices, lower costs and greater control over your health care."

February 26

House Republicans circulated a draft of their health care bill, which Democratic lawmakers were quick to criticize.

Senate Minority Leader Chuck Schumer, D-New York, said the plan was "a recipe for disaster," while House Minority Nancy Pelosi, D-California, noted that the Republican draft would result in millions of Americans losing coverage.  

Some of the key provisions in the House Republican bill included the end of Medicaid's expansion, the elimination of taxes on the wealthy and the creation of tax credits up to $4,000.

March 17

House Majority Leader Kevin McCarthy, R-California, announced a vote on a Republican sponsored bill to repeal and replace Obamacare will be held the following week.

March 23

House Republicans postponed a vote on the American Health Care Act as they didn't have enough support for the bill to pass.

The postponed vote also came in the wake of the Congressional Budget Office (CBO) releasing a score on the bill. Their findings estimated that 14 more people would be uninsured by 2018 and 24 more million people uninsured by 2026 under the new plan compared to the current law.

Coupled with the CBO score was the release of a Quinnipiac University poll that highlighted the unfavorable ratings of the House Republican bill. The poll showed that only 17 percent of American voters approve of the AHCA.

During the evening, White House OMB Director Mick Mulvaney indicated to House GOP members that Mr. Trump was finished negotiating on the bill. The President requested a vote on May 24th so that the administration could move onto other items on Mr. Trump's agenda.

March 24

House Speaker Paul Ryan officially cancelled the vote on the ACHA as it didn't have enough support from House GOP members. During his press conference, Ryan said House Republicans "came up short" and noted that Obamacare will remain in the "foreseeable future."

After Speaker Ryan pulled the bill from the floor, Mr. Trump said Republicans came "very, very close" to passing the bill. He added that it is time to "let Obamacare explode."

Mr. Trump also pressured the House Freedom Caucus to vote for the legislation. "The irony is that the Freedom Caucus, which is very pro-life and against Planned Parenthood, allows P.P. to continue if they stop this plan!" Mr. Trump tweeted.Mr. Trump also pressured the House Freedom Caucus to vote for the legislation. "The irony is that the Freedom Caucus, which is very pro-life and against Planned Parenthood, allows P.P. to continue if they stop this plan!" Mr. Trump tweeted.

April 4

The White House proposed a new health care plan to repeal and replace Obamacare as Vice President Pence, White House Chief of Staff Reince Priebus and Budget Director Mick Mulvaney met with House GOP members.

After meeting with the House Republican conference, Speaker Ryan told reporters there is no legislative text yet and they are in the "concept stages" of the bill. 

April 26

After not supporting the first version of the American Health Care Act in March, the House Freedom Caucus supported a new version of the bill that included an amendment from Rep. Tom MacArthur, R-New Jersey, that would allow states to apply for waivers from some parts of Obamacare, including the law's definition of essential health benefits and its rules regarding pre-existing conditions. States who wish to obtain a waiver under the proposal would be required to set up a high-risk pool to cover sicker people who might otherwise be unable to purchase insurance, but there were questions about whether the high-risk pools would provide sufficient coverage. 

The House Freedom Caucus had been criticized by President Trump for not supporting the original version of the bill. The caucus, a group of roughly three dozen House conservatives, argued that the AHCA wasn't a full repeal of Obamacare. Mr. Trump expressed his frustration with the caucus when he tweeted, "The Freedom Caucus will hurt the entire Republican agenda if they don't get on the team, & fast. We must fight them, & Dems, in 2018!"

April 30

In an interview with CBS News "Face the Nation," Mr. Trump insisted that pre-existing conditions were covered in the new version of the AHCA. He added that the bill evolved from the original version that failed a month earlier.

"This bill is much different than it was a little while ago, okay?" he said in the "Face the Nation" interview.

May 4

The House passed the updated version of the AHCA with a final vote count of 217-213. The bill passed with 20 Republicans voting against the bill and without any support from Democrats.  

The bill includes revamped tax credits, while eliminating Obamacare's individual mandate that requires people to purchase health insurance. The bill would also freeze Medicaid expansion under Obamacare and allow states to receive Medicaid funding as a block grant.

The challenge then moved to the Senate and Republican Senator Lindsey Graham tweeted that Senators should proceed with caution. 

May 31

The Kaiser Family Foundation released a poll on the favorability ratings of the ACHA. According to the poll, 55 percent Americans viewed the AHCA as "unfavorable," while 31 percent of Americans favored the bill.

June 22

Senate Republicans released their "discussion draft" of their health care bill, which would repeal and replace Obamacare, after weeks of secrecy. The 142 page bill, known as the Better Care Reconciliation Act (BCRA), was supposedly crafted by 13 Senate Republican men in a closed door process.  But even some members of that group complained they had no idea what was in the bill, and that it was being written by Majority Leader McConnell's staff. 

The Senate is using the budget reconciliation process to get the bill through, which means that Republicans need a simple majority--50 votes plus a tie breaking vote from the Vice President, instead of  60 votes to get the bill through the legislative process. The Senate currently has 52 Republicans and 48 Democrats.

The bill would cut Medicaid expansions under Obamacare and eliminate the Obamacare individual mandate. Senate Majority Leader Mitch McConnell announced the Senate would vote on the measure before the July 4 recess.

June 26

The CBO released their score on the Senate health care bill, which indicated that 22 million more Americans would be uninsured over ten years under the new plan.

This score was similar to the CBO's score of the AHCA, which estimated that 23 more million Americans would be uninsured under that plan.

The dismal forecast was enough for Sen. Susan Collins of Maine and Sen. Mike Lee of Utah to announce their opposition.   Sen. Rand Paul of Kentucky, Sen. Ted Cruz of Texas had already voiced their opposition.

June 27

A day after the CBO score was released on their health care bill, McConnell informed Senate Republicans that a vote on their bill would be postponed until after July 4 recess. McConnell said Republicans lack the votes to pass the legislation as it currently stood.

"We're still working toward getting at least 50 people in a comfortable place," McConnell said.

June 30

As Senate Republicans were scrambling to garner votes to pass their bill, Mr. Trump added to the health care debate by tweeting, "If Republican Senators are unable to pass what they are working on now, they should immediately REPEAL, and then REPLACE at a later date!"

July 4

Some Republican senators who headed home for the July 4 recess were confronted by constituents opposed to the repeal effort. After on event in Kansas, conservative Sen. Jerry Moran said, "I think at this point, it's time to figure out how … to get rid of the bad things and improve on the things that need to be improved," according to Politico.

In Iowa, GOP Sen. Joni Ernst declined to take a stand in support of the Republican bill during her own town hall meeting. "I am not going to say whether I would or would not support that bill, because I am offering up my own ideas, my own suggestions, and I'd like to see them included in the bill," the Iowa senator said, according to the Des Moines Register. "We'll continue with those discussions."

July 13

The Senate released a new draft of the BCRA, which included an amendment proposed by Republican Senator Ted Cruz, in their latest effort to repeal and replace Obamacare.

Sen. Cruz's amendment would allow insurers to sell cheaper bare-bones plans if they offer a plan that complies with Obamacare standards. The modified version also would keep three Obamacare taxes on the wealthy and have an increase of $45 billion dollars to combat the opioid crisis.

The bill needed 51 votes, including a tie breaking vote from Vice President Pence, on a motion to proceed, which would bring the bill to floor.

Sen. Collins and Sen. Paul announced they would vote against the motion to proceed on this version of the bill, which meant that Senate Republicans could not afford to lose another vote, assuming that no Democrats would vote for the bill to advance.

July 17

Republican Senators Mike Lee and Jerry Moran announced their opposition to the BCRA, joining Sen. Collins and Sen. Paul. 

The four senators expressed they were a 'no' vote on the motion to proceed, which meant McConnell would be unable to even begin work on the amendment process.

McConnell released a statement expressing his disappointment with the Senate being unable to pass a repeal and replace bill. McConnell's statement also indicated that the Senate will vote on the House bill passed in May. The first amendment on the House bill would be to replace the House bill with a bill from 2015, which would repeal Obamacare and give lawmakers two years to devise a replacement. The 2015 bill passed the Senate two years ago.

July 18

Sen. Collins, Sen. Lisa Murkowski of Alaska and Sen. Shelley Moore Capito of West Virginia announced their opposition to repealing Obamacare without a replacement. Their announcement to vote 'no' on the motion to proceed complicates McConnell's proposal to hold a vote on repeal only legislation.

At a White House event with military officers, Mr. Trump said to "let Obamacare fail."

When discussing the collapse of Obamacare,  Mr. Trump added, "I can tell you that the Republicans are not going to own it. We'll let Obamacare fail and then the Democrats are going to come to us and they're going to say how do we fix it?"

July 19

Mr. Trump hosted a White House lunch with Senate GOP members to make another pitch to repeal and replace Obamacare.

"For seven years, you had an easy route," Mr. Trump said to Senate GOP members. "I don't think we should leave town unless we have a plan."

Mr. Trump's push for a repeal and replacement plan during the lunch comes a day after he said to "let Obamacare fail."

Later in the day, the CBO released its score on the Obamacare Repeal Reconciliation Act of 2017, which is the repeal only bill McConnell said the Senate will vote on after the second version of the BCRA failed to gain enough support. The score displayed that 32 million more people would be uninsured under this plan by 2026 compared to current law.

July 20

The CBO released its score of the second version of the BCRA that included the amendment proposed by Sen. Cruz. The score forecasted that 22 million more Americans would be uninsured by 2026 under the new plan compared to Obamacare.

July 21

The Senate parliamentarian determined that certain provisions in the BCRA violate the "Byrd Rule," which means that these provisions would require a 60-vote point of order, rather than the simple majority granted through the budget reconciliation process.

The Senate Budget Committee released the provisions that violate the "Byrd Rule" that would need a 60-vote point of order. Some of the provisions include defunding Planned Parenthood and funding for cost-sharing subsidies.

July 24

Mr. Trump delivered remarks a day before a vote is expected on the motion to proceed to a Senate health care bill.

He urged Senate Republicans to "keep their promise" to repeal and replace Obamacare after seven years of campaigning on this issue and unifying behind this promise.

"We, as a party, must fulfill that promise to repeal and replace, what they've been saying for the past 7 years," Mr. Trump said.

In the morning, Mr. Trump said Senate Republicans have another opportunity to repeal and replace Obamacare when he tweeted, "Republicans have a last chance to do the right thing on Repeal & Replace after years of talking & campaigning on it."

July 25

The Senate voted 51-50 with Vice President casting the tie-breaking vote on the motion to proceed to debating the AHCA, which is the bill the House passed in May.

Sen. Collins and Sen. Murkowski were the only Senate Republicans who voted 'no' on the motion to proceed. All Senate Democrats opposed the procedural vote. Sen. Dean Heller of Nevada, Sen. Capito and Sen. Paul voted 'yes' on the motion to proceed.

After being diagnosed with glioblastoma, a form of brain cancer, last week, Sen. John McCain of Arizona returned to the Senate to vote 'yes' on the motion to proceed. He was welcomed by applause and a standing ovation from Senate members from both parties. 

Later this evening, the Senate voted on a motion to advance the BCRA, the Senate GOP's health care plan. The vote failed with a final vote count of 43-57. The Senate needed 60 votes to advance the proposal, instead of 51 votes. The plan needed 60 votes because it included Sen. Cruz's proposal and a proposal from Sen. Rob Portman of Ohio that wasn't scored by the CBO.

According to a McConnell aide, Sen. Portman's proposal would help transition low-income people from Medicaid to private insurance plans.

Nine Senate Republicans voted against the measure. They include: Sen. Collins, Sen. Graham, Sen. Heller, Sen. Lee, Sen. Moran, Sen. Murkowski, Sen. Paul, Sen. Bob Corker of Tennessee and Sen. Tom Cotton of Arkansas.

July 26

The Senate failed to pass Sen. Mike Enzi of Wyoming and Sen. Paul's amendment of a clean Obamacare repeal. Their amendment was the 2015 Obamacare repeal with a two year implementation period to devise a replacement.

The Senate voted 45-55 with seven Senate Republicans voting against the measure. The Republican Senate defectors were: Sen. Heller, Sen. Capito, Sen. Collins, Sen. McCain, Sen. Portman, Sen. Murkowski and Sen. Lamar Alexander of Texas. All of the senators, with the exception of Collins, supported the measure in 2015.

After the clean repeal vote failed, the Senate held three more votes. Democratic Senator Joe Donnelly of Indiana put forth a motion to send to the bill back to committees. The Donnelly motion failed with a 48-52 vote.

The Senate also voted on Sen. Heller's amendment, which pushed for senators to commit to Medicaid funding. Nevada was the first state to expand its Medicaid program under Obamacare. Sen. Heller's amendment need a waiver from the Budget Act to advance. The Senate rejected Sen. Heller's amendment to get a waiver with a 10-90 vote.

The final vote in the Senate Wednesday was on a proposal from Democratic Sen. Bob Casey of Pennsylvania. The proposal aimed at sending the bill back to the Senate Finance Committee and would ensure that people with disabilities would not lose access to their Medicaid coverage. This motion failed 48-51.

Throughout the day, Senate Republican leaders were drafting a "skinny repeal" of Obamacare. The draft hasn't been released yet, but it would most likely eliminate the individual and employer mandate and a medical device tax imposed by Obamacare.

On the Senate floor in the evening, Sen. Minority Leader Schumer said Democrats will not offer amendments to the bill and urged Sen. Majority Leader McConnell to be more transparent in the legislative process.

Once news of a "skinny repeal" broke, 10 governors – five Republicans and five Democrats – quickly signaled their opposition to the new proposal in a letter to Senate leadership.

In:
• Patient Protection and Affordable Care Act
• Donald Trump
• U.S. House of Representatives
• Health Care