After casting the deciding vote to begin debate in the Senate on the Republican effort to repeal and replace the Affordable Care Act, Sen. John McCain (R-Ariz.) brought the effort to an end when he voted against the so-called “skinny repeal” bill introduced by Senate Majority Leader Mitch McConnell (R-Ky.).

Sen. McCain crossed the aisle with Sen. Susan Collins (R-Maine) and Sen. Lisa Murkowski (R-Alaska) and voted with the 48 members of the chamber’s Democratic caucus to kill the bill. Republicans would have needed 50 votes to pass the measure, with Vice President Mike Pence on hand to cast a tie-breaking vote if necessary. With three senators voting against the measure, however, the 49 votes were not enough.

That bill was very limited in what it would do, including repealing the individual and employer mandates and the medical device tax, defunding Planned Parenthood, increasing contribution limits to health savings accounts, and providing flexibility to insurers to offer plans that did not cover all the essential health benefits as defined in the ACA.

In the early evening on July 27, however, Sen. McCain made it clear during a press conference that he would not vote for a skinny repeal. Other senators expressed concern over the skinny repeal but said they would vote for it if there were assurances that the House would actually go to conference committee (a procedure used when the House and Senate pass different versions of the same bill to allow a bipartisan group to find consensus and create a unified bill) and work out a final bill and not simply move the skinny repeal straight to the president’s desk.

Speaker of the House Paul Ryan (R-Wisc.) had issued a statement to that effect, but the House was laying a path to simply move any bill passed by the Senate, leaving it up in the air as to whether a conference committee would actually be created.

Despite a reported phone call from Speaker Ryan and conversations directly with Vice President Pence on the Senate floor, Sen. McCain ultimately could not be convinced to vote with the majority of Republicans.

“From the beginning, I have believed that Obamacare should be repealed and replaced with a solution that increases competition, lowers costs, and improves care for the American people,” Sen. McCain said in a statement issued July 28, following the early-morning vote. “The so-called ‘skinny repeal’ amendment the Senate voted on today would not accomplish those goals. While the amendment would have repealed some of Obamacare’s most burdensome regulations, it offered no replacement to actually reform our health care system and deliver affordable, quality health care to our citizens. The Speaker’s statement that the House would be ‘willing’ to go to conference does not ease my concern that this shell of a bill could be taken up and passed at any time.”

The vote brought to an end a few days of minimal activity. Every attempt by the GOP to pass some form of amendment to move the process forward – from the tweaked version of the Better Care Replacement Act to a straight repeal of the ACA – failed. Sen. Steve Daines (R-Mont.) even introduced a single-payer amendment, but that failed to get a single yes vote, with all 52 GOP members and five Democrats voting against it and the remaining 43 Democrats voting “present.”

Very few amendments were proposed, though one did get passed in the process that would have permanently repealed the so-called “Cadillac tax,” which levies a 40% tax on plans that exceed a certain value. That amendment passed along party lines by a 52-48 vote.

The future of the ACA and future reform efforts remain unclear at the moment. Following the vote, a defeated Majority Leader McConnell asked the minority party what plan they have to offer. Senate Minority Leader Charles E. Schumer (D-N.Y.) echoed Sen. McCain’s speech earlier in the week after the vote was cast to start the debate to return to regular and hammer out a bipartisan solution though the committee process.

Meanwhile, President Donald Trump advocated via Twitter to simply let the ACA continue to crumble and when it failed, then to work on a deal.

The American Medical Association called on Congress to continue its work on fixing the health care system. “While we are relieved that the Senate did not adopt legislation that would have harmed patients and critical safety net programs, the status quo is not acceptable,” AMA President David Barbe said in a statement. “We urge Congress to initiate a bipartisan effort to address shortcomings in the Affordable Care Act. The first priority should be to stabilize the individual marketplace to achieve the goal of providing access to quality, affordable health coverage for more Americans.”