Members of the Senate blocked a fat Affordable Care Act (ACA) change proposal package Tuesday and are now getting ready later today on a skinny package.

Republicans in Senate are now trying to change the ACA by debating, amending and, possibly, passing their own version of H.R. 1628, a House bill that would repeal many parts of the Affordable Care Act and change others.

Senate procedures

Republicans hold 52 seats in the Senate. Under Senate rules, Republicans need 60 votes to get an ordinary bill through the Senate, and just 51 votes to get a budget measure through.

Because of that system, Republicans are trying to use a budget bill to change the ACA.

The Senate had to vote simply to start floor debate on the idea of changing the Affordable Care Act. Members of the Senate deadlocked 50-50 on the motion to proceed to debate on H.R. 1628. Vice President Mike Pence, who officially presides over the Senate, cast a vote to break the tie.

S.A. 267: A proposed ACA change framework

Most of the bills and amendments now under serious consideration in the Senate would simply change the ACA, not repeal it.

Senate Majority Leader Mitch McConnell has introduced S.A. 267, the Obamacare Repeal Reconciliation Act of 2017 proposal, to serve as a framework for ferrying ACA change proposals through the Senate.

S.A. 267 would replace the text of the House version of H.R. 1628, the American Health Care Act bill. The proposal would eliminate the ACA individual coverage mandate penalty, the ACA employer coverage offer mandate penalty, the ACA public exchange program subsidies, and other ACA taxes and penalties. S.A. 267 would, for example, repeal the net investment tax on high earners for taxable years beginning after Dec. 31, 2016. It would eliminate the ACA Medicare surtax for tax years starting after Dec. 31, 2017.

Proposed amendments

The Senate is now considering a series of proposed amendments that could bolt on to the S.A. 267 framework.

The Senate debated, and blocked, one amendment, S.A. 270, the Better Care Reconciliation Act amendment, Tuesday.

S.A. 270 was a fat package of proposals includes many Republican ideas for improving the current health care system that have come up for debate in recent weeks.

One section of S.A. 270 would, for example, replace the current ACA insurance market stabilization programs with grants for states. A second section would create multi-state association health plans for small employers, and a third would encourage states to provide deregulated, unsubsidized individual health coverage for ordinary consumers outside the public exchange system.

Sen. Ted Cruz, R-Texas, and Sen. Mike Lee, R-Utah, were two of the most visible supporters of the idea of promoting deregulation of the off-exchange individual health insurance market.

Members of the Senate defeated S.A. 270 by a vote of 43-57 Tuesday.

No Democrat voted for S.A. 270, and nine Republicans voted against it.

Today, the Senate is preparing to vote on S.A. 271, a short amendment proposed by Sen. Mike Enzi, R-Wyo.

The Enzi amendment is a "skinny" ACA change measure that would eliminate the ACA Medicaid expansion program, the ACA public exchange system, the ACA exchange plan subsidies, the ACA individual coverage ownership mandate, and the ACA employer coverage offer mandate. The amendment would leave the current ACA commercial health insurance rules, such as the requirement that insurers sell individual coverage without use of medical underwriting, in place.

The Senate could vote on S.A. 271 sometime after 3:30 p.m. EDT today.

The Senate may also consider at least one true Affordable Care Act repeal measure, proposed Senate Amendment 273.

S.A. 273, offered by Sen. Ron Johnson, R-Wis., would cause the two federal laws that created the ACA, the Patient Protect and Affordable Care Act of 2010 and the Health Care and Education Reconciliation Act of 2010, to sunset with respect to plan years beginning on or after Jan. 1, 2020.

Instant Insights /

Senate prepares to vote on skinny ACA change proposal

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