Senate Republicans failed to secure enough votes Tuesday night to advance legislation that would repeal and replace the Affordable Care Act, with Nevada Sen. Dean Heller joining eight of his GOP colleagues and all Democrats in voting against the motion.

The vote came hours after Heller and other wavering Republicans set aside their lingering concerns with the proposals currently on the table to repeal the Affordable Care Act and voted by the thinnest of margins to allow debate on the health care legislation to proceed.

“I will vote to move forward and give us a chance to address the unworkable aspects of the law that have left many Nevadans — particularly those living in rural areas — with dwindling or no choices,” Heller said in a statement just minutes before the razor-thin vote. "Obamacare isn’t the answer, but doing nothing to try to solve the problems it has created isn’t the answer either.”

The iteration of the bill the Senate voted on Tuesday night — which failed 47-53 after needing 60 votes to move forward — included many of the original elements of the Senate’s repeal-and-replace bill in addition to an amendment from Texas Sen. Ted Cruz. The amendment allows insurance companies to offer higher deductible “Freedom Plans” as long as they offered at least one ACA-compliant plan.

Cruz argued that people who can’t afford “Cadillac” health plans are being penalized for their inability to afford the better coverage. Oregon Democratic Sen. Jeff Merkley countered that such packages were “fake plans.”

The measure also included a proposal from Ohio Sen. Rob Portman to add an additional $100 billion to help cover out-of-pocket costs for some of the current Medicaid patients who would lose coverage due to the bill’s cuts to the government-funded program.

Heller said before the procedural vote to start debate earlier on Tuesday that he wouldn’t vote in favor of a health care bill that doesn’t improve Nevada’s situation. The Republican senator declared his staunch opposition the original version of the Senate’s repeal-and-replace bill in June, saying then that he wouldn’t even vote to allow the Senate to debate the legislation.

He expressed more optimism about a health care overhaul in his statement.

“Whether it’s my ideas to protect Nevadans who depend on Medicaid or the Graham-Cassidy proposal that empowers states and repeals the individual and employer mandates, there are commonsense solutions that could improve our health care system and today’s vote gives us the opportunity to fight for them,” he said in a statement. “If the final product isn’t improved for the state of Nevada, then I will not vote for it; if it is improved, I will support it."

The motion to begin the health care debate passed in a 51-50 vote, with only Republican Sens. Susan Collins of Maine and Lisa Murkowski of Alaska joining Democrats in opposition and Vice President Mike Pence casting the tie-breaking vote. Sens. Ron Johnson of Wisconsin and John McCain of Arizona cast the final two Republican votes in support of moving forward with debate on the health care legislation.

As voting was about to begin, protesters broke the decorum of the Senate chambers with loud chants of “Kill the bill!” and “Shame!”

Tuesday was just the first in what is expected to be a days-long process that includes 20 hours of debate split evenly between Democrats and Republicans. On Wednesday, they’re expected to vote on Kentucky Sen. Rand Paul’s proposal to repeal and not replace the ACA.

Any legislation approved by the Senate would need to go back to the House for approval in a conference committee, where differences between the houses are reconciled and other changes can be made. Heller told NBC News that Senate leaders want the whole voting process wrapped up by Friday.

Heller and a handful of his Republican colleagues had remained undecided as late as Monday on how they would vote for the so-called motion to proceed, with lingering concerns over whether the ultimate goal was to repeal and replace or just repeal the federal health care law, and how doing so would boot millions of Americans off of Medicaid.

Nevada Gov. Brian Sandoval, a staunch opponent of attempts to roll back the expansion of Medicaid allowed under the Affordable Care Act who has worked with the senator to determine how the various versions of the bill would affect the state, said in a statement that he would continue to work with Heller.

"My healthcare conversations have been focused on policy, not procedure," he said in a statement. "My policy position has not changed. I will continue to do all I can to protect the thousands of Nevadans whose lives are healthier and happier as a result of the expansion of Medicaid. My health care team which includes staff and cabinet experts, have and will continue to review proposals offered in the Senate and discuss the potential impacts on Nevada with Senator Heller and his staff."

Democrats, including Nevada Sen. Catherine Cortez Masto who voted against the motion to proceed, said even a preliminary vote in favor of beginning debate was problematic.

A vote to bring #Trumpcare to the floor is a vote to take away healthcare from hundreds of thousands of Nevadans and millions of Americans.

— Senator Cortez Masto (@SenCortezMasto) July 25, 2017

Paul, who had held out his vote in the hopes of gaining more leverage and support for a “clean” repeal of the health care law, said Monday that he would vote to support the motion to begin debate.

Heller came out strongly against the original version of Senate Republicans’ repeal and replace legislation in June, saying that it would strip health care away from millions of Americans without the guarantee of lower premiums.

But he has repeatedly avoided taking a position on the other proposals that have been brought to the table since then. His spokeswoman didn’t immediately respond to an inquiry Tuesday on why Heller supports a motion to proceed now but opposed it earlier.

In an email to supporters Tuesday afternoon, Heller said that he was working with colleagues to improve the health care system, including transferring power the the states and repealing individual and employer health insurance mandates. He said his final vote would depend on whether the health care legislation is better for Nevada than it is now.

Senate Republicans needed the support of at least 50 members of their caucus for debate on the legislation to move forward, meaning they could afford to lose no more than two members to prevail on the motion. In a dramatic move, McCain returned to Washington to vote yes after being recently diagnosed with brain cancer, then delivered an impassioned first speech urging the Senate to take action but also to return to normal Senate procedure.

For weeks, Heller had found himself in the middle of a game of tug-of-war with Sandoval, who staunchly opposes any legislation that would cut Nevada’s Medicaid program, and Republican leadership and President Donald Trump who are promoting it. At a lunch meeting last week, Trump chided Heller for wavering over the repeal-and-replace legislation.

“Look, he wants to remain a senator, doesn’t he? And I think the people of your state, which I know very well, I think they’re gonna appreciate what you hopefully will do,” Trump said. “Any senator who votes against starting debate is really telling America that you’re fine with Obamacare. But being fine with Obamacare isn’t enough for another reason. Because it’s gone. It’s failed. It’s not gonna be around.”

Despite voting to repeal the ACA in 2015, Heller was one of the first Republican senators to come out strongly against his party’s repeal-and-replace proposal, the Better Care Reconciliation Act. He said in June that he could not vote to start debate on a bill that would strip Medicaid away from hundreds of thousands of Nevadans, threaten access to health care and cause millions of Americans to lose insurance.

“Barring significant changes from the Congressional Budget Office, this bill will mean a loss of coverage for millions of Americans and many Nevadans,” Heller said at a June press conference, standing next to Sandoval. “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 used the repeal of the health care law as a major cudgel in his 2012 race against former Democratic Rep. Shelley Berkley.

Sandoval was the first Republican governor to expand Medicaid under the Affordable Care Act, which has led to an additional 210,000 Nevadans being covered by the government-funded program. The state has projected that rolling back Medicaid funding for the expansion population would leave a $420 million hole in the state’s budget, one that the state likely will not be able to afford to fill.

Democratic Rep. Jacky Rosen, who announced plans to challenge Heller last month, said on Twitter that it was a “heartless, reckless vote to take health care away from tens of thousands of Nevadans.”

This is a heartless, reckless vote to take health care away from tens of thousands of Nevadans. Let's repeal & replace @DeanHeller in 2018. https://t.co/bHutqVZNHw

— Jacky Rosen (@RosenforNevada) July 25, 2017

A full repeal of the ACA without a replacement is estimated to leave an additional 32 million Americans uninsured and double premiums. Senate Republicans’ latest draft of their repeal-and-replace bill is estimated to leave 22 million Americans uninsured by 2026 while reducing the federal deficit by $420 billion.

Considered the most vulnerable Republican senator up for re-election in 2018, Heller has faced immense political pressure over the health care vote in recent weeks. A pro-Trump political nonprofit planned a $1 million ad blitz against him after he announced his initial opposition to the health care bill, and some Republicans at home aren’t too happy with him either.