In the early hours of Thursday morning, Senate Republicans voted along party lines to begin the process of Obamacare repeal.
That much has been well-reported, but readers could be forgiven for not knowing quite where it leaves things now. So here's the short answer: more or less where they were on Wednesday.
Now here's the long answer:
Thursday morning's vote, while nonbinding, was a procedural first step on what will likely be a long road to repeal of the Affordable Care Act.
Thanks to the filibuster, Congressional Republicans have few options for repealing Obamacare, none of them easy and all a mess. The most straightforward would be to do away with the filibuster altogether, eliminating the last roadblock between Republicans and virtually absolute control over the government.
While some in Congress have been making noises in this direction, so far party leadership appears unwilling to go down this path (presumably given how heavily the party leans on this procedural rule when it occupies the minority).
The alternative, then, is budget reconciliation. This parliamentary procedure allows purely fiscal legislation to pass on a simple majority vote and is intended to make budgeting easier. Democrats used this same rule to make changes to the ACA after its original passage.
To pass a reconciliation bill, Congress has to first issue what are called "reconciliation instructions." This procedural step is a formal request that various committees draft the necessary language for a bill, which can then come up for a vote.
On Thursday the Senate passed its reconciliation instructions, and the House is expected to follow suit on Friday.
"The best way to think of this is as a sort of long, multistep process from here to repeal," said Molley Reynolds of the Brookings Institute. "This was just step one."
"There's a lot of questions about the timeline, about when that repeal language would be developed in the House and Senate," she added. "When they would bring it to the floor, when the consideration of repeal language would happen in relation to the development of replace language. That's where we get into a lot of uncertainty."
The instructions voted on this week set January 27 as the deadline for committees to come up with specific language for repeal; however, there is no current consensus around what that should look like.
Absent this consensus, the speed with which Thursday's vote happened relied on an existing but incomplete 2017 fiscal year budget resolution written last year. In order to expedite an ordinarily lengthy process, Congressional leaders simply borrowed this work, added language to defund the Affordable Care Act and pushed for passage.
"They picked up that unfinished budget legislation," Reynolds said, "and put in some instructions to the effect of repealing the Affordable Care Act."
From a procedural standpoint, then, this week's voting is a necessary step towards repeal through reconciliation but not a binding one. At its discretion Congress could follow up with inaction.
And many observers do expect a long wait between reconciliation instructions and any concrete legislation.
"Senate Republicans have set the ball rolling on the path toward repeal," Reynolds said. "House Republicans will take step two, and after that, we'll be in a little bit of a holding pattern."
Observers expect Congress to slow down while it considers the limits of reconciliation. Although the rule lets Republicans overcome a sizable Democratic minority in the Senate, a reconciliation bill can only address fiscal matters. This is a concern for two reasons:
First, it limits any possible Republican replacement plan. Although some politicians, including President-Elect Donald Trump, want to repeal the ACA while simultaneously passing its Republican counterpart, it would be almost impossible to pass health care reform and call it completely financial.
If the party relies on reconciliation, any replacement plan is realistically off the table.
That has caused some concern even on the Right.
"There are some Republicans, from both [ideological] ends who are apprehensive about voting to start the repeal process without knowledge of what a replace plan would look like," Reynolds said. "The concern from the moderate Republicans is of the same flavor that you've heard from some senate Republicans: There are parts of the law that people like; we like the fact that there are more people who have health insurance thanks to the law...we are concerned about the consequences of repealing the law without knowing what a replacement would look like."
Meanwhile, she added, hard-Right Conservatives worry that without a replacement, Congress will vote to repeal the ACA on a delayed schedule -- and then keep kicking that can down the road.
From a political and procedural standpoint, then, this has the potential to create problems. Although many members of the Republican caucus want to implement some, as yet unclear, replacement plan, they simply can't do that through reconciliation.
Reconciliation will also create the problem of piecemeal repeal. Since lawmakers are restricted to financial legislation only, they can't actually repeal the entirety of the Affordable Care Act. They're limited to yanking out its financial provisions without undoing the law's market regulation.
This could have potentially catastrophic effects on the marketplace, perhaps most urgently the introduction of death spirals.
The ACA grants subsidies for individuals to buy insurance, and imposes penalties if they do not. This offsets the law's ban on health insurance companies considering pre-existing conditions when evaluating an insurance application. Together this is known as the "three legged stool," with the individual mandate meant to ensure that health care consumers don't simply wait until they get sick before purchasing insurance.
Through reconciliation Congress can repeal the subsidies and penalties that make up the individual mandate, doing away with the only unpopular component of the ACA. (It has long been an anomaly that, despite the law's political toxicity, most Americans actually approve of everything the legislation does except for the mandate.)
Reconciliation cannot undo market regulation, however, and as a result, companies would be stuck with guaranteed issuance but no individual mandate. According to an Urban Institute study, this would cost insurers approximately $3 billion and increase the uninsured population by roughly 4.3 million people… in the first year.
Further, per the study, "the number of uninsured people would rise from 28.9 million to 58.7 million in 2019" with "very large increases in demand for uncompensated care on state and local governments and providers." This would put "states, localities and providers of care at risk for an extra $1.1 trillion in uncompensated care over ten years."
This is not necessarily the only outcome. Republicans could pass a different form of tax through reconciliation, replacing one mandate with another. They could follow "repeal and delay," and try to pressure Senate Democrats to help undo the rest.
Over the past decade Americans (and even some members of Congress) have become increasingly aware of the many obscure rules by which the House and Senate function. That's only going to continue as procedure takes center stage in the repeal of the Affordable Care Act.
Thursday's vote was the first step, but there's a long road ahead.