The 3 Republican women who doomed a Senate repeal of the health law

WASHINGTON — It was men who started it. It may be women who finished it.

The Senate effort to repeal the Affordable Care Act, a process that began with 13 Republican men drafting a plan behind closed doors, collapsed Tuesday, as three Republicans said they would not support an ultimately futile attempt to simply roll back the current health care law without a replacement.

Though all three are women, their objections have little to do with their sex and more to do with the legislation's cuts to Medicaid. In a twist, that aligns them with President Donald Trump's campaign promise not to touch Medicaid, which helps low-income people, pregnant women and people with disabilities, among others, as well as those eligible under the Affordable Care Act's expansion of the program in 31 states and the District of Columbia.

Who are these senators, and why did they break with their party's leaders?

Sen. Shelley Moore Capito of West Virginia

Capito became the first woman elected to the Senate in her state's history in 2014, after serving 14 years in the House of Representatives. Since then, she has proved open to working with Democrats, particularly when it comes to addressing the acute opioid problem in West Virginia, which has the nation's highest rate of overdose deaths.

The opioid epidemic led to her misgivings with her party's effort to repeal the Affordable Care Act. West Virginia expanded Medicaid under President Barack Obama's health care law, a decision that increased the number of her constituents with health insurance.

Capito expressed reservations in recent months about Republican proposals, calling for a plan that would at least draw out the rollback of federal payments made to states under the health care law over several years. But on Tuesday, she said every Senate proposal had failed to address her concerns. "I did not come to Washington to hurt people," she said in a statement.

Sen. Lisa Murkowski of Alaska

Murkowski has been a more centrist voice among Republicans during her more than 14 years in the Senate, demonstrating a similar willingness to defy her party for the sake of her state. In February, she was one of two Republicans to vote against the confirmation of Betsy DeVos as Trump's education secretary — basing her decision in part on her concern that DeVos' affinity for vouchers would do little for Alaska, where many schools are too far apart for a viable school choice program.

[Alaska Sens. Murkowski and Sullivan hope for a path forward on failed health care bill]

Though she pointed to skyrocketing premiums and dwindling options, Murkowski was unconvinced that Alaska's problems — particularly its high health care costs — would have been helped by the original Republican plan to repeal and replace the law. Like West Virginia, the state expanded Medicaid, which covers about a quarter of its residents, and earlier this year Murkowski said that as long as the Alaska Legislature wanted to keep that expansion, she would not vote to repeal it.

Murkowski said Tuesday that she would oppose the repeal-only effort. "Repealing the ACA without a clear path forward just creates confusion and greater uncertainty," she said in a statement.

Sen. Susan Collins of Maine

The most moderate Republican in the Senate, Collins has proved one of her party's sturdiest obstacles to repealing the Affordable Care Act. But unlike Sen. Rand Paul of Kentucky — who opposed previous proposals for not repealing enough of the law — she cautioned against repealing too much of it.

As was the case for Capito and Murkowski, Collins opposed her party's proposals to make deep cuts to Medicaid, criticizing the effects on the "most vulnerable." While Maine did not expand Medicaid, the health care law's subsidies increased the number of individual policyholders in the state to 80,000 from 30,000. And the proposals were projected to increase rates in particular for older Americans, a particular problem for Maine, where the median age of 43 is the oldest in the country.

Collins has called for Republicans to work with Democrats to fix the current health care law — and on Tuesday, her decision to oppose the repeal effort may have helped ensure that would be her party's only remaining option.