Republicans in the U.S. Senate voted to open debate on repealing and replacing the Affordable Care Act (ACA), with 50 senators voting in favor of what’s called a motion to proceed, or MTP, opening the door to the chamber offering numerous amendments to craft some sort of repeal bill. The first option put forward—the Better Care Reconciliation Act (BCRA)—failed to pass as expected.

The MTP passed on a 51-50 vote, with Vice President Mike Pence breaking the tie. Republican Sens. Susan Collins of Maine and Lisa Murkowski of Alaska joined all Democrats in opposition. Other senators who had been opposed to earlier bills sided with the rest of the caucus to open debate.

“I remain committed to reforming our health care system while also addressing the concerns I have voiced for months,” Sen. Shelley Moore Capito, R-West Virginia, one of those swing votes, said in a statement.

The vote was technically for proceeding to a vote on the House-passed American Health Care Act, but the Senate can and will change the entirety of the bill through amendments, with a series of procedural votes expected. One of the final “yes” votes was cast by returning Sen. John McCain, R-Arizona, who was expected to have a lengthy absence after being diagnosed with a brain tumor. After the vote, he proceeded to chastise the Senate’s process for crafting its repeal-and-replace legislation, urging a “return to regular order.”

“All we've managed to do is make more popular a policy that wasn't very popular when we started trying to get rid of it,” he said on the Senate floor. “I voted for the motion to proceed to allow debate to continue and amendments to be offered. I will not vote for the bill as it is today. It's a shell of a bill right now.”

Despite that declaration, McCain did vote for the BCRA as-is just a few hours later.

This version of the bill contained two amendments, including the one favored by Sen. Ted Cruz, R-Texas, allowing insurers to sell plans not compliant with ACA regulations on required benefits and community rating, which have yet to be scored by the Congressional Budget Office (CBO). This meant the bill would need 60 votes to pass, an impossible hurdle with all Democrats voting against it.

The final vote count was 43-57 with nine Republicans joining Democrats in opposition: Collins, Murkowski, Mike Lee of Utah, Bob Corker of Tennessee, Lindsey Graham of South Carolina, Rand Paul of Kentucky, Dean Heller on Nevada, Tom Cotton of Arkansas and Jerry Moran of Kansas.

“This bill missed the mark for Kansans, failed to adequately repeal Obamacare and did not address the rising costs of healthcare. Healthcare is too important to Kansans, our families and future generations of Americans to get wrong,” Sen. Moran said in a statement.

The next vote is expected to be on the 2015 repeal-only bill which had passed both houses of Congress when it was assured to be vetoed by then-President Barack Obama. This legislation, which would repeal much of the ACA while giving Republicans a two-year window to craft a replacement, would result in 32 million fewer people being insured by 2026, according to the CBO.

A new idea gaining traction among Republicans is a “skinny repeal” bill. This legislation would eliminate three of the more unpopular parts of the ACA: the individual mandate penalizing people who choose not to buy insurance, the employer mandate requiring companies with at least 50 full-time-equivalent employees to provide coverage and the medical device tax.

This option, while leaving Medicaid expansion untouched, would cause premiums to increase by 20 percent and increase the number of uninsured by 15 million people by 2026, according to a CBO analysis from Dec. 2016. It could lead to a “death spiral” in the individual market, as healthier, younger customers the ACA markets have struggled to attract would now be free of the financial penalty for choosing to be uninsured.