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

Republicans in Senate are now trying to change the ACA bydebating, amending and, possibly, passing their own version of H.R.1628, a House bill that would repeal many parts of the AffordableCare 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 theSenate, and just 51 votes to get a budget measure through.

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

The Senate had to vote simply to start floor debate on the ideaof changing the Affordable Care Act. Members of the Senatedeadlocked 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 considerationin 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 serveas a framework for ferrying ACA change proposals through theSenate.

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

Proposed amendments

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

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

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

One section of S.A. 270 would, for example, replace the currentACA insurance market stabilization programs with grants for states.A second section would create multi-state association health plansfor small employers, and a third would encourage states to providederegulated, unsubsidized individual health coverage for ordinaryconsumers outside the public exchange system.

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

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

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

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

The Enzi amendment is a "skinny" ACA change measure that wouldeliminate the ACA Medicaid expansion program, the ACA publicexchange system, the ACA exchange plan subsidies, the ACAindividual coverage ownership mandate, and the ACA employercoverage offer mandate. The amendment would leave the current ACAcommercial health insurance rules, such as the requirement thatinsurers sell individual coverage without use of medicalunderwriting, in place.

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

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

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