Jonathan Cohn - The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage

John McCain stood on the Senate floor, an outstretched arm signaling for the clerks attention, as his colleagues and a nation watched to see what he would do.

It was about an hour and a half past midnight on Friday, July 28, 2017the culmination of a debate that had begun some six months before, when Donald Trump had become president. Republicans were finally in a position to repeal the Affordable Care Act, the 2010 law that had transformed American health care.

Obamacare represented everything conservatives hated about big government. They saw it as a sprawling amalgam of taxes, spending, and regulation that interfered with the workings of the free market and forcibly redistributed money from one group in society to another. But in the years since the laws enactment, repeal had become more than another agenda item. It had turned into the partys defining cause, the rallying cry that brought its different factions together and animated its most passionate supporters.

And now it was on the verge of happening. The House had already passed a repeal bill of its own. If the Senate did the same, it would only be a matter of time before the two chambers worked out a compromise and sent legislation to the White House for presidential signature.

Trump was plainly eager to secure his own place in the history books and, perhaps more importantly, to scratch out Obamasso much so that it wasnt clear whether he grasped, or cared, about repeals impact. But that impact promised to be enormous.

More than twenty million people relied on the Affordable Care Act for their health coverage. The number of Americans without insurance had plummeted to less than 10 percent of the population, the lowest rate ever recorded. And the lives of real people were changing for the better. More were seeing the doctor and getting the tests they needed. Fewer were going bankrupt because of hospital bills. They were hotel housekeepers and cancer survivors, retail workers and parents of children with rare diseasesall of them with security they had never known before, security that was suddenly in jeopardy.

Still, even with the law in place, universal health care remained an aspiration. Millions had no insurance, and millions more still struggled with medical bills. Some had cheaper insurance before the Affordable Care Act took effect, only to see carriers cancel those plansand they remembered, bitterly, Obamas promise that they would be able to keep their old coverage if they liked it. Their anger at Obama and the Democrats was one reason that Republicans had gained control of Congress and taken back the White House, putting repeal within reach.

Republicans had moved swiftly, using a special parliamentary procedure that allowed the Senate to pass legislation with just fifty votes, instead of the customary sixty. Whip counts showed that forty-nine of the chambers fifty-two Republicans were already on board. But two relatively moderate Republicans, Susan Collins of Maine and Lisa Murkowski of Alaska, were voting no. Too many of their constituents would suffer, they said. McCains would be the decisive vote.

His instincts on domestic policy were mostly conservative, making him skeptical of the taxes and regulations that the law had fostered, and he sounded like his more strident colleagues when he said the Affordable Care Act was a disaster that was failing his constituents. Arizonas experience with the law had been among the rockiest, with premiums skyrocketing and insurers leaving the state because they were losing so much money. Those problems were the focus of McCains very first 2016 campaign ad, which trumpeted that John McCain is leading the fight to stop Obamacare.

But McCain had been making Republican leaders nervous all week, ever since his dramatic flight back from Arizona, where he was undergoing treatment for the brain tumor that would soon take his life. A war hero and former presidential candidate, McCain was notoriously unpredictable and had a history of bucking the party leadership. He was one of the few remaining institutionalists in the Senate, somebody who took words like deliberation and bipartisanship seriously. Among his proudest accomplishments was a major reform of campaign finance laws he had cosponsored with Russ Feingold, a liberal Democrat from Wisconsin.

Repeal, by contrast, was a purely partisan project, one that GOP leaders were trying to ram through the chamber as quickly as possible. The usual committees werent holding hearings, and members were being asked to vote before they even understood the basics of what they were considering. McCain had made his most explicit warning a few days earlier as debate began. Standing in the well of the Senate, a long scar from the recent medical work visible across his lower temple, McCain vowed, I will not vote for the bill as it is today.

Most Republican leaders found it difficult to believe McCain would fly back from Arizona, in the middle of life-sustaining cancer treatment, to cast a vote that would alienate so many of his colleagues and supportersto say nothing of rescuing a program signed into law by the man who once vanquished him in a presidential election. On Wednesday, the day before the final vote, he told administration officials he was a likely yes on repeal. But he had been having misgivings for weeks. Just before returning to Washington from Arizona, he had confided by phone to his old friend, former senator Joe Lieberman of Connecticut, that he was thinking seriously of voting no.

In the evening, as the moment approached, Vice President Mike Pence, on hand as the administrations chief lobbyist and potential tie-breaking vote in the Senate, pulled McCain aside for a conversation. Pence left with a conspicuously grim look on his face. A few minutes later, McCain was standing on the floor and joking with Democrats while Mitch McConnell, leader of the Senate Republicans, huddled with several of his lieutenants a few feet away. Trump called by phone, and McCain listened, according to multiple accounts, without saying much.

The GOP leaders were still standing there when the roll call got underway. McCain, who had left the floor, walked back through the chamber doors and stopped in front of the podium. He was unable to lift his arms above his shoulders, a result of torture during the five years he spent as a prisoner of war in Vietnam. All he could do was to hold his right hand outward, stiffly, while he waited for the clerks attention. For a second, he looked like a Roman emperor waiting to rule on a gladiatoruntil the clerk looked up, and McCain turned his thumb down in a quick, jerky move. No, he said.

One Democratic senator gasped audibly, another pumped her fist in the air. Way in the back, beneath the overhang of the visitors gallery, two more Democratic senators cheered until minority leader Chuck Schumer frantically waved at them to stop.

At the front of the chamber, McConnell stood motionless, hands across his chest while he stared down at his feet. McCain walked away, taking his usual seat a few rows up on the Republican side of the chamber. Not once did he look in McConnells direction.