US senators have rejected a bill to make fundamental changes to the "Obamacare" healthcare system in a move described as a "stinging blow" to President Donald Trump.
Republican John McCain, Susan Collins and Lisa Murkowski crossed party lines and joined Democrats to defeat the slimmed-down repeal bill in a 51-49 vote.
The loss derails the Republicans' seven-year campaign to dismantle former president Barack Obama's signature law, "dealing a huge political setback to President Trump", the New York Times says.
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Trump is now without a major legislative win after six months in office, even though his party controls the White House, Senate and House of Representatives.
His complaints that senators had "not done their job in ending the Obamacare nightmare" received short shrift from McCain.
"Whether or not we are of the same party, we are not the President's subordinates. We are his equal," he said.
The outspoken senator felt so strongly about the issue that he returned to cast his vote merely days after being diagnosed with a brain tumour.
In what The Hill described as "doubling down on his past call to 'let ObamaCare implode'", Trump tweeted after the vote. "3 Republicans and 48 Democrats let the American people down. As I said from the beginning, let Obamacare implode, then deal. Watch!"
Republican attempts to replace Obamacare fail
18 July
The US Senate will vote on a "clean repeal" of Obamacare with no bill to replace it, following an announcement by two more Republicans that they could not back the healthcare proposal currently making its way through the legislature.
Mike Lee of Utah and Jerry Moran of Kansas said last night the Better Care Reconciliation Act - dubbed "Trumpcare" - was too timid.
"In addition to not repealing all of the Obamacare taxes," Lee told CNN, "it doesn't go far enough in lowering premiums for middle class families. Nor does it create enough free space from the most costly Obamacare regulations."
With moderate Susan Collins of Maine and libertarian Rand Paul of Kentucky previously stating they would oppose the bill, for different reasons, the GOP is without the majority required to pass Trumpcare.
"Regretfully, it is now apparent that the effort to repeal and immediately replace the failure of Obamacare will not be successful," Senate majority leader Mitch McConnell said.
He added he would push for a repeal of Obamacare - more correctly known as the Affordable Care Act - with a two-year delay to implementation, leaving lawmakers time to construct a new version of the legislation while fulfilling Donald Trump's campaign pledge.
Democrats are united in their opposition to the bill. Chuck Schumer, the party's leader in the Senate, said the effort to replace the existing act was effectively dead.
"Republican leaders and the White House were left with just a few options: try to rewrite the plan, engage in a bipartisan effort to address the flaws recognised by both parties or abandon it altogether and focus on other key issues, such as tax reform," the BBC says.
Bad medicine: Is Trumpcare in jeopardy?
5 July
During his election campaign, Donald Trump vowed to repeal Barack Obama's healthcare reforms in favour of an alternative that would offer the advantages of Obamacare while allegedly lowering premiums.
However, in a sign of troubles to come, an early draft of his proposal, now a bill called the Better Care Reconciliation Act (BCRA), squeaked through the House of Representatives in May by just four votes, with 20 Republicans crossing the aisle to join unanimous Democrat opposition.
Two months on, the so-called "Trumpcare" has yet to appear before the Senate as hard-right and centrist Republicans are stuck in an unshakeable gridlock over what form it should take.
Their lack of enthusiasm is shared by the electorate. A USA Today poll found only 12 per cent supported the bill, while a little more than half said Congress should either leave Obama's bill, the Affordable Care Act, alone or concentrate on fixing its problems while keeping its framework intact.
So how Trumpcare differ from Obamacare - and why can't the Republicans agree on it?
Trumpcare vs Obamacare
The Republican vision for healthcare differs substantially from the Affordable Care Act. With some exemptions, Obama made mandatory to purchase healthcare coverage on the grounds that premiums would soar if previously uninsured patients flooded the market without healthy people to balance them out.
The mandate remains one of the most bitterly resented aspects of Obamacare, decried by many as unconstitutional and even un-American.
BCRA would lift this, leaving people free to take their chances without health insurance.
The ACA also made it mandatory for all insurance plans to offer a minimum ten benefits deemed "essential". These include maternity and neonatal care, mental health services and coverage for prescription drugs.
Under BCRA, from 2020, individual states would be able to determine what constitute "essential benefits".
By far the most controversial aspect of the Republican healthcare plan is its changes to Medicaid, the government programme that provides basic healthcare to people on low incomes who cannot afford insurance.
Currently, the federal government reimburses each state for the money it spends on Medicaid, with no upper limit. The BCRA would introduce a per-capita limit on how much federal funding the states receive.
In addition, critics warn that a seemingly minor change to the formula used to raise per-capita spend in line with inflation will mean deep long-term cuts to funding in real terms.
A version of the bill from the House of Representatives - which even Trump described as "mean" and in need of "more heart" - would have gone even further, allowing states to impose work provisions on Medicaid recipients. BCRA dropped this proposal.
Why hasn't Trumpcare passed?
Trump has blamed recalcitrant Democrats for the delay in implementing one of his key campaign pledges. However, with Republicans unable to agree on a final draft, the bill has yet to actually face opposition scrutiny on the Senate floor.
Last week, the non-partisan Congressional Budget Office released figures estimating BCRA would leave 22 million more Americans uninsured by 2026.
It also claimed the plan would result in a 35 per cent reduction in Medicaid funding over the next 20 years.
By 2035, it "might be unable to fulfill its core obligations, even when it’s needed most", says The Atlantic.These claims are unsettling for Republicans representing districts where large swathes of the electorate rely on Medicaid.Skittish about backing proposals that could hammer them at the polls in 2018, several senators have said more must be done to protect their low-income constituents before they can vote yes.
The problem with pushing for ideological purity, says CNN, is that although many voters were attracted by the Republican vision of "root and branch" dismantling of the Affordable Care Act in principle, "there are provisions in Obamacare that are overwhelmingly popular".
Two of the most popular - banning insurers from denying coverage or charging more for pre-existing conditions and allowing dependents to stay on their parents' health insurance plan until age 26 - have been carried over to the Republican plan.
However, conceding any more ground risks alienating the ultra-conservative wing of the party, who are determined to eradicate every trace of Obama's reforms.
"Eventually you cross a line where saying that you've repealed and replaced Obamacare will be hard to say with a straight face," said South Carolina Senator Lindsey Graham.
Congressmen such as Rand Paul of Kentucky and Mike Lee of Utah say the current proposals retain too many provisions from Obamacare and that they will balk if the trend continues.
Senate Majority Leader Mitch McConnell needs at least 50 of the 52 Republican senators' votes, but with holdouts from both the moderate and the hardcore wing of the party, finding the "Goldilocks zone" has so far proved impossible.
Deal or no deal?
Last Friday, with time running out to broker a deal to satisfy both groups before the 4 July holiday weekend, Trump urged senators to repeal the Affordable Care Act as soon as possible and then work out the details of the replacement bill afterwards.
Several Republican senators publicly applauded the idea of splitting the repeal and replace process into two more manageable chunks - but even agreeing on a bill to roll back Obamacare is proving a headache.
By Sunday, White House director of legislative affairs Marc Short told Fox News Sunday that Republican senators were "close" to agreeing on a repeal bill, Politico reports.
However, Rand Paul, appearing on the same show, gave a very different impression.
"I don't think we're getting anywhere with the bill we have," Paul said. "We're at an impasse."
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