(Updated at 10:40 p.m. ET)
Senate Republicans' first vote to repeal and replace Obamacare came nowhere close to passing Tuesday night after hours of debate on their yearslong pledge to tear down the healthcare law.
Nine senators on the right and center rejected the first version of the Better Care Reconciliation Act brought to a vote after the chamber began debate on a path forward earlier that afternoon.
Tuesday evening's vote was the first of many expected in the next several days as senators shape a final bill on how to reform the individual insurance market and change federal Medicaid funding.
The Senate will vote on a proposal to repeal the Affordable Care Act without a set replacement Wednesday at noon.
Sens. Susan Collins (R-Maine) and Lisa Murkowski (R-Alaska) voted against starting debate on BCRA earlier Tuesday, leaving Vice President Mike Pence to deliver the tie-breaking vote on the procedural motion.
Sen. John McCain (R-Ariz.) made his first return to the chamber since being diagnosed with brain cancer in order to vote to start debate on the bill. He also spoke on the floor, condemning the Senate for acting "more partisan, more tribal than at any time I can remember."
"We Republicans have looked for a way to end and replace (the ACA) without paying a terrible political price," McCain said. "We haven't found it yet, and I'm not sure we will. All we've managed to do is make more popular a policy that wasn't very popular when we started trying to get rid of it."
Before the roll call began, about a dozen spectators including some in white coats in the visitors' galley started chanting, "Kill the bill, don't kill us."
Senate Majority Leader Mitch McConnell (R-Ky.) will have no time to savor this hard-won victory. He will still need to woo three or four conservative senators to support what they see as a new entitlement: providing financial help to buy private insurance. Conservatives want to make sure that some customers can buy cheaper insurance on the individual market.
Since Obamacare remade the individual market by opening it to all customers and standardizing benefits, premiums have risen by nearly 100%, a burden for those who earn too much to qualify for subsidies.
But there are even more Republican senators who want to preserve Medicaid expansion in their states—more people gained coverage through Medicaid than buy policies on the exchanges.
Any change McConnell makes to appeal to conservatives loses votes in the center.
"I will not vote for the bill as it is," McCain said on the floor, pausing between each word for emphasis, noting he would only vote for a bill that slows the phaseout of enhanced federal funding for Medicaid expansion states.
McCain and Sen. Shelley Moore Capito (R-W.V.), who repeatedly has voiced concern over the end of Medicaid expansion, both voted for the first version of BCRA.
To make it even more complicated, only provisions that reduce the budget deficit can be included in the bill, because only budget-related bills are allowed to proceed with a 51-vote majority rather than 60-vote majority. The parliamentarian has already signaled that she does not believe that the Republican replacement for the individual mandate meets that standard. Republicans intended to impose a six-month waiting period for those who chose not to buy ACA-compliant plans, even if they had some sort of insurance.
The parliamentarian has also nixed a simple-majority vote for any bill including conservatives' proposal to defund Planned Parenthood for one year, which could cause problems if the bill were to pass and return to the House of Representatives for a final OK.
Former Republican staffer Chris Jacobs, of the Juniper Group, wrote that Republicans should have rejected the motion to proceed, warning that what would follow would be "a policy morass that could make the confusing events of the past week look tame by comparison."
After debate, all senators, including Democrats, will be allowed to offer amendments in a process colloquially called a "vote-a-rama." There is no time limit on introducing amendments, and Sen. Chris Murphy (D-Conn.) has vowed to introduce 100.
But at the very end, McConnell can bring forward a substitution with new items that weren't part of the amendment process or the original bill. Senators would have virtually no time to evaluate it before voting.
McCain said it seems like the plan is to spring a bill on skeptical senators and tell them to vote for it because it's better than nothing.
"I don't think that's going to work in the end, and it probably shouldn't," he said.
Minority Leader Chuck Schumer (D-N.Y.) told reporters after the vote that McCain is one of "many, many Republicans who don't like this bill, who don't want to vote for it." He added: "We have some degree of hope they're not going to get this done."
American Hospital Association CEO Rick Pollack said the organization was disappointed in the Senate vote and hopes lawmakers will work in a bipartisan fashion as they debate the path forward.
"Our challenges are too great and our opportunities too promising to let political partisanship dictate the path forward for America's patients," he said. "Those of us on the front lines of healthcare know all too well the consequences repealing the ACA would have on patients."
Sen. Patty Murray (D-Wash.), the top Democrat on the Senate committee that handles health policy, implored her Republican colleagues to "stand with the patients and families you promised to protect."