Nevada Sen. Dean Heller joined six of his Republican colleagues and all Democratic senators Wednesday to reject a bill to repeal the Affordable Care Act without a replacement plan, a reversal from his 2015 vote in favor a similar piece of legislation.

The Republican-controlled Senate rejected moving forward the repeal-only health care proposal, which the nonpartisan Congressional Budget Office estimated would result in 32 million people losing insurance, 45-55. The vote came on the heels of hours of debate and two votes to move health care legislation in the Senate forward, part of a 20-hour debate and vote schedule planned this week after senators narrowly voted to open up debate on the legislation on Tuesday.

The repeal measure, which needed a majority to pass, would have eliminated individual and employer mandates, marketplace subsidies, the exchanges and taxes on wealthy and the health-care industry in two years, while leaving protections for people with pre-existing conditions in place. It also included an amendment to ban people from using subsidies to buy plans that cover abortion.

While the bill was expected to fail, it’s part of a series of votes that are giving Republican leadership a better sense of where members stand and what kind of forthcoming bill might pass muster in the Senate. Leaders are trying to find a middle course that can garner a critical mass of Republican support and bridge the positions of the most ardent Obamacare opponents and moderates who fear widespread consequences of too broad a repeal.

Heller voted in favor of a similar clean repeal bill in 2015 when it was essentially guaranteed a veto by President Barack Obama. But he has been vocal in recent weeks about any legislation that makes cuts to the state’s Medicaid program, particularly taking funds made available to states under a Medicaid expansion option created by the Affordable Care Act.

Gov. Brian Sandoval was the first Republican governor to opt in to the expansion, under which 210,000 Nevadans are currently covered. Heller came out against the Senate Republicans’ original draft of their repeal-and-replace bill in June, saying he couldn’t vote for a bill that takes Medicaid away from hundreds of thousands of Nevadans, threaten access to care and result in millions of Americans losing insurance.

“I’m telling you right now I cannot support a piece of legislation that takes insurance away from tens of millions of Americans and hundreds of thousands of Nevadans,” Heller said at the time.

Senators also rejected a proposal to send the bill to committee with instructions to remove language related to Medicaid on a 48-52 vote, with Heller and all other Republicans voting against it.

President Donald Trump later tried to reel Heller in on health care. A pro-Trump PAC announced a seven-figure ad buy against him following his press conference pronouncement against Obamacare repeal, and the president lobbed a veiled threat at Heller while sitting next to him at a televised luncheon last week.

The Senate is now expected to move forward with what is being called a “skinny repeal” of the Affordable Care Act, something Heller told a Politico reporter Wednesday morning that he would likely support. The “skinny” plan is expected to repeal only three parts of the federal health care law, eliminating the so-called individual mandate that requires most Americans to have health insurance, the mandate that employers offer coverage workers if they have at least 50 full-time employees and a tax on medical devices.

Heller on skinny repeal: "we'll see at the end of the day what's in it, but overall I think I'd support it."

— Burgess Everett (@burgessev) July 26, 2017

The “skinny repeal” is the option of last resort by Senate Republicans to pass some version of a health care bill to send back to the House. The legislation would then likely end up in a conference committee, where lawmakers from both the House and the Senate would continue to work on a health care bill that enough members of their caucus would agree to.

But supporting such a measure would be politically difficult for Heller after Sandoval and nine other governors sent a letter to Majority Leader Mitch McConnell and Minority Leader Chuck Schumer declaring their opposition to a "skinny repeal." 

"The Senate should also reject efforts to amend the bill into a 'skinny repeal,' which is expected to accelerate health plans leaving the individual market, increase premiums, and result in fewer Americans having access to coverage," the governors wrote. "Instead, we ask senators to work with governors on solutions to problems we can all agree on: fixing our unstable insurance markets. Improvements should be based on a set of guiding principles, which include controlling costs and stabilizing the market, that will positively impact the coverage and care of millions of Americans, including many who are dealing with mental illness, chronic health problems, and drug addiction."

An analysis from the nonpartisan Congressional Budget Office released Wednesday evening projects that 16 million additional Americans would be uninsured by 2026, with 28 million uninsured Americans in 2017 to 44 million uninsured in 2026. The office has told Senate Democrats that the "skinny repeal" would result in premiums that are about 20 percent higher than under current law each year, according to a senior Senate Democratic aide.

“A system that allows people to purchase coverage only when they need it drives up costs for everyone,” Blue Cross Blue Shield Association said Wednesday.

Liberal think-tank Center for American Progress estimated that the so-called “skinny repeal” would lead to an average premium increase of $995 in Nevada, with benchmark premiums for 60-year-olds going up an average of $1,695 a year.

Critics have also raised concerns that the Medicaid cuts that aren’t in the skinny repeal bill the Senate might pass would return to the bill in the conference committee.

In the meantime, senators will continue the 20-hour debate period before entering a “vote-a-rama” period, where any number of germane amendments can be offered and voted on by the full Senate.

Heller joined nine of his other GOP colleagues and all Democratic senators Tuesday night to reject a measure that included many elements of the senate’s original repeal-and-replace bill in addition to an amendment proposed by Texas Sen. Ted Cruz that would have allowed insurance companies to offer higher deductible “Freedom Plans” that don’t comply with existing health care regulations as long as they offer at least one ACA-compliant plan. It also included an extra $100 billion to help out-of-pocket costs for current Medicaid patients who would lose coverage if cuts are made to the program.