âItâs hard to see how tinkering is going to satisfy my personal concerns,â Senator Susan Collins, Republican of Maine, told reporters.
Negotiations on Tuesday that leaders hoped would move senators toward yes only exposed the fissures in the Republican Party. Conservatives were demanding that states be allowed to waive the Affordable Care Actâs prohibition on insurance companies charging sick people more for coverage and are asking for a more expansive waiver system for state regulators. They also wanted more money for tax-free health savings accounts to help people pay for private insurance.
Senators from states that expanded the Medicaid program â and Senator Susan Collins â would not brook many of those changes, especially the measure to severely undermine protections for people with pre-existing medical conditions. They wanted more money for mental health benefits for people addicted to opioids and money for states to cover people left behind by the rollback of the Medicaid program in both the House and Senate versions.
Three Republican senators â Ms. Collins, Rand Paul of Kentucky and Ron Johnson of Wisconsin â had announced they would vote against the motion to begin debate that had been scheduled to hit the Senate floor on Wednesday, joining Senator Dean Heller of Nevada, who made the same pledge on Friday.
A bevy of other senators from both flanks of the party seemed headed in the same direction if they did not see changes made to the Senate health care bill, leaving the measure in deep peril, since Republicans can only lose two votes from their own party.
The release of a Congressional Budget Office evaluation on Monday did little to help leaders roll up votes from either side of the fence. The budget office said the Senate bill would leave 22 million more uninsured after 10 years, while sending out-of-pocket medical expenses skyrocketing for the working poor and those nearing retirement.
The budget office did not provide conservatives with support for their demands either. The state waivers already in the Senate bill âwould probably cause market instability in some areasâ and âwould have little effect on the number of people insuredâ by 2026, the analysis concluded. Adding still more waivers, including one that could allow insurers to price the sick out of the health care market, could deprive even more people of health care.
Even before Mr. McConnellâs decision, White House officials had braced for the likelihood that the procedural vote would fail and that they would have to revisit the measure after the Fourth of July recess â when they hoped to be able to woo Mr. Johnson, who has been a surprisingly fierce critic of the bill from the right. The senator has repeatedly warned that this week is too soon to vote on the health care measure, as Republican senate leaders have insisted they need to do.
Vice President Mike Pence, attended the Senate Republican lunch on Tuesday and then broke off for private meetings with Mr. Heller, a seemingly firm ânoâ and the first moderate Republican to break with Mr. McConnell over the bill, and Rob Portman of Ohio, who is feeling pressure from his stateâs governor, John R. Kasich, to oppose the bill and defend Ohioâs Medicaid expansion.
Mr. Portman was the subject of a spirited evaluation of his open criticism of the bill by Mr. McConnell, who was frustrated with the expansion-state senators who showed their hand early to other wavering colleagues, dooming the bill for now. Mr. McConnell was unhappy that Mr. Portman seemed to be abandoning his previous stance on fiscal rectitude by opposing Medicaid cuts in the bill.
But the Ohio senator was getting it from both sides. Mr. Kasich appeared in Washington on Tuesday to sharply criticize the Senate bill. The governor said he was deeply concerned about millions of people losing coverage under the bill.
âWho would lose this coverage?â Mr. Kasich said. âThe mentally ill, the drug addicted, the chronically ill. I believe these are people that need to have coverage.â
At the same news conference, Coloradoâs Democratic governor, John W. Hickenlooper, said his stateâs Republican senator, Cory Gardner, âunderstands the hardships and the difficulties in rural life.â
âThis bill would punish people in rural Colorado,â Mr. Hickenlooper said, raising the pressure.
Doctors, hospitals and other health care provider groups came out strongly against the Senate bill, as did patient advocacy groups like the American Heart Association. But business groups were ramping up their support. In a letter on Tuesday, the U.S. Chamber of Commerce endorsed the Senate bill and urged senators to vote for it.
The Senate bill âwill repeal the most egregious taxes and mandatesâ of the Affordable Care Act, allowing employers to create more jobs, said Jack Howard, a senior vice president of the group. The bill, he noted, would repeal a tax on medical devices and eliminate penalties on large employers that do not offer coverage to employees.
A separate letter expressing general support for the Senateâs efforts was sent by a coalition of 28 business and employer groups including the National Association of Home Builders, the National Restaurant Association and the National Retail Federation.
But Senate conservatives found themselves squeezed between business sentiment and their conservative base. Club for Growth, an ardently conservative political action committee, came out strongly against the Senate measure on Tuesday.
âThe Club for Growth and the American people took Republicans in Congress at their word when they promised to repeal every word â âroot and branchâ â of Obamacare and replace it with a patient-centered approach to health care,â the groupâs president, David McIntosh, said in a statement. âOnly in Washington does repeal translate to restore. Because thatâs exactly what the Senate GOP healthcare bill does: it restores Obamacare.â
Even the Trump administration is divided over what comes next, especially on the payment of subsidies to health insurance companies to compensate for reducing out-of-pocket costs for low-income people.
Mr. Trump has threatened to withhold the monthly payments as a way to induce Democrats to bargain with him over the future of the Affordable Care Act. Administration officials said Mr. Trump did not want to make the payments if the Senate did not pass a health care bill this week. But they said Tom Price, the secretary of health and human services, had urged the White House not to cut off the payments abruptly.
A federal judge has ruled that the payments are illegal because Congress never appropriated money for them, but that ruling is being appealed. Any interruption of the payments could have a dire destabilizing effect on markets, insurers say. Blue Cross Blue Shield of North Carolina recently blamed the Trump administrationâs mixed signals on the subsidy for most of its proposed 23 percent spike in premiums next year.
Sean Spicer, the White House press secretary, defended the administrationâs position at his briefing on Friday.
âIf the president were to hypothetically say that heâs going to make the payments in perpetuity or for a year, I think that continues to prop up a failed system,â Mr. Spicer said. âIt continues to do wrong by the American taxpayer. And it also doesnât lend itself to the expediency that I think we want to â help get a new health care system in place.â