After working furiously to whip up support for the Healthcare Freedom Act of 2017, which would go after several of the health law’s mandates but keep much of it intact, McCain, Maine’s Susan Collins, and Alaska’s Lisa Murkowski ultimately defied their party leadership to vote “no.” The latter two have been strongly opposed to nearly all of the Republican Senate’s recent health bills—but McCain’s decision was a nail-biter.

Click here to subscribe to Brainstorm Health Daily, our brand new newsletter about health innovations.

Just several days ago, McCain had returned to Washington following a recent brain cancer diagnosis to vote yes on a procedural motion that allowed the Senate to consider the various pieces of Obamacare legislation it’s taken up this week. Many read that as a sign that he would ultimately support one of the bills, perhaps a pared-back version of Obamacare repeal, or that enough GOP Senators would eventually get on board to cobble together the requisite 50 votes.

But it appears that, ultimately, the unconventional process that led to the legislations’ consideration—the bills were essentially written on the fly, and the “skinny” repeal was being worked on into Thursday night—galvanized his opposition. McCain gave a rousing speech to his Senate colleagues after Monday’s procedural vote urging the Senate to get back to a more regular order of legislating and governance.

One particularly striking part of McConnell’s and his lieutenants’ strategy is that GOP leadership began openly telling its members that the “skinny” repeal would never become the law of the land. Rather, it was meant to be a gateway into a “conference committee” with the House of Representatives with which a far broader, far-reaching health care deal could be struck. House Speaker Paul Ryan appeared to win over several last-minute holdouts in the Senate who wanted assurances that such a conference committee would be initiated if the Senate passed its bill.

The defeat presents a major setback to McConnell. Vice President Mike Pence actually arrived at the Senate chamber earlier in the evening, ostensibly to cast a successful tie-breaking vote after expected defections from Collins and Murkowski. Instead, he was forced to leave after trying, along with other GOP Senators, to convince McCain to change his mind (he did not).

After the bill’s failure, McConnell essentially returned a version of Obamacare repeal back to the Senate schedule. But at this point, it appears that any path forward on health care will likely have to involve a more conventional committee process and some collaboration with Democrats. For now, the Senate GOP’s repeal efforts are dead.

3 Republicans and 48 Democrats let the American people down. As I said from the beginning, let ObamaCare implode, then deal. Watch!

— Donald J. Trump (@realDonaldTrump) July 28, 2017

Shortly after the vote, President Trump tweeted “3 Republicans and 48 Democrats let the American people down. As I said from the beginning, let ObamaCare implode, then deal. Watch!”