President Trump pushes Senate Republicans to get something done on health care. But it’s not at all clear that they can.

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The Senate is expected to vote Tuesday on whether to advance health care legislation to the Senate floor. That would open up debate on an Obamacare repeal and/or replacement plan.

At a White House event Monday, President Trump highlighted what he called the “failures” of the Affordable Care Act, also known as Obamacare, and called on senators to pass a bill that both repeals and replaces the ACA. Last week, Trump urged an approach that would repeal the law over two years, giving lawmakers more time to craft new health care legislation. Several days later at a lunch with lawmakers, he advocated repeal and replace.

But it’s still not clear what the Senate will be voting on. There are multiple bills in play.

The Senate hopes it can muster the 51 votes needed to pass a bill, but some Republicans are wavering, both in the center and on the right.

NPR’s health and politics teams have been doing our best to shed some light on what’s a very confusing situation, even by health policy standards.

What are they voting on?

There are at least four bills that could advance to the Senate floor. Here’s our summary, with a chart comparing House and Senate bills to the Affordable Care Act, and links to stories that dive into the implications of the legislation.

Who wins? Who loses?

We worked with NPR member station reporters and editors to create an interactive Q&A on how key elements of the bills would affect people in different states.

What if the Senate parliamentarian says ‘nope’?

Another potential wrinkle came up late Friday. Julie Rovner with Kaiser Health News reports that the Senate rule-keeper has advised that some key parts of some of the bills could need 60 votes to proceed. They include defunding Planned Parenthood and incentives to have people keep health insurance. Getting 60 votes would require Democratic support, which they won’t get.

And if Obamacare remains the law of the land?

For now, the Affordable Care Act is still the law, and insurers are trying to plan for next year. That’s proving to be difficult and might drive up costs for consumers.

Congressional action could have an enormous impact on people’s health insurance. But the U.S. Department of Health and Human Services has some wide berth in interpreting the law and could make a lot of changes without congressional action. Here are some key actions and regulations that could affect the exchanges and Medicaid (and more).

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Gina Mazany grew up in Anchorage, Alaska. And that’s where she had her first fight.

“It was right after I turned 18,” she recalls.

A local bar had a boxing ring, and Mazany decided to give it a shot. Her opponent was an older woman with a “mom haircut.”

“She beat the crap out of me,” Mazany says. “Like she didn’t knock me out, she didn’t finish me. But she just knocked me around for three rounds. And I remember, later that night I was very, very nauseous. I was throwing up that night.”

It was her first concussion.

Thanks to research on boxers and football players, both athletes and the public are becoming more aware of the dangers of sports-related head injuries. Yet there is little data on participants like Mazany. That’s because, unlike the vast majority of athletes studied, she is a woman.

“We classically have always known the male response to brain injury,” says Mark Burns, at Georgetown University. But there have been remarkably few studies of females. The bias runs throughout the scientific literature, even in studies of mice.

“Male mice have been used historically in research and not really been compared to female mice,” he says.

That’s changing now. The National Institutes of Health recently began to require scientists to include female animals.

Burns’ lab has begun using both sexes in research on head injuries. And they’re finding some differences. This summer, Burns published a study in the journal Glia that looked at mice with severe brain injuries. He says the brains of male mice showed a massive immune response within a day, but the female response was much slower — up to seven days.

There have been hints of differences in people as well. Just this year, a study of college athletes found that women more likely than men to get concussions.

But to find out more, scientists want to study fighters like Mazany. She is 28 now and lives in Las Vegas. She’s a professional mixed martial arts fighter who competes in Ultimate Fighting Championship events.

Her nickname is “Danger.” Mazany has begun worrying about her brain.

“One day I want to get married and have a family. And I want to be able to take care of my babies and like all that kind of stuff,” she says. “So I’m not going to get the s*** kicked out of me for nothing, if that makes sense.”

So Mazany volunteered to be part of a study of fighters at the Cleveland Clinic Lou Ruvo Center for Brain Health, in Vegas. For six years now, professional fighters have been coming to the center for brain scans and blood work. They also complete tests of mental functions.

On the day of Mazany’s annual checkup, she is subjected to a battery of tests that assess her balance, reaction time, memory, and thinking.

After about 40 minutes, Mazany meets with Dr. Charles Bernick, the scientist in charge of the fighters study. They move to a quiet room. Bernick scans a chart. It shows Mazany’s test results over the past few years.

“Well you’re pretty stable,” Bernick says. There’s no obvious sign of trouble from her fighting career, at least not yet.

Bernick says the study of fighters like Mazany now includes nearly 700 men and about 60 women.

“So, [the women are] still a minority, because they are a minority in the sport,” he says. “But I think it’s a very important group to evaluate because we really don’t know if there are differences between men and women.”

Bernick does believe that there’s now enough evidence to suggest real differences between the ways men and women respond to head injuries.

“Women may be more likely to suffer concussion. Their symptoms may linger longer,” he says. “The question is: Is that because women are just more likely to report injuries, or is there a biological higher vulnerability.“

Researchers have suggested some reasons women might be more vulnerable. They tend to have weaker neck muscles. So a head impact might shake the brain more violently. And hormonal differences might affect the brain’s response to an impact or injury.

Bernick says the fighters’ study offers a way to directly compare men and women who compete in combat sports where a concussion is often the goal.

He says the study has already shown that brain scans and other tests can show who’s been getting hit a lot.

“You can detect changes in brain structure even over a year’s period,” he says. “The question really is in the long run, are those changes predictors of somebody who is going to have a neurodegenerative disease later in life.”

Bernick says an answer is still years away.

In the meantime, Gina Mazany is trying to stay safe while also staying competitive.

During her training sessions at the Xtreme Couture mixed martial arts center, Mazany tries not to give anyone a head injury, though things can happen during sparring: “I have knocked out another girl in my gym on accident,” she says. “Sorry, Hannah.”

But Mazany says these days, most fighters know what they’re doing is risky.

“My theory to it all is yeah, there’s brain damage. Yeah, this sport is not safe. I don’t care who you are, it’s not safe,” she says. “But a lot of things that we do aren’t safe.”

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Aaron Albaugh peers out from under the brim of his cowboy hat, surveying the acres of hay fields in front of him. The fourth-generation rancher is raising about 450 cattle this year, in this remote corner of Lassen County, California.

His closest neighbor lives a half mile away. “And that’s my brother,” Albaugh says.

“If I want to go see a movie, it’s 70 miles, round-trip,” he adds. “If I want to go bowling, that’s 100 miles, round-trip.”

Living a half day’s drive from civilization, you learn to do without, he explains. If your refrigerator breaks, you put your food on ice until the weekend when you can go buy a new one. With health care, it’s the same thing.

“Put a Band-Aid on it,” Albaugh says. “I was raised: ‘You don’t need to cry’ and ‘Suck it up, buttercup.’ That’s the way I still live, and I try to treat my kids the same way.”

When people are already used to doing without health coverage, it’s particularly annoying to have the government say you have to buy it, say Albaugh and many of his neighbors in Lassen, Modoc and Shasta Counties.

While Obamacare is largely viewed as a success in California – the state marketplace, Covered California, is one of the most financially stable in the country – it has not worked as well for folks in this rural, northeast corner of the state.

There are two insurers selling plans in each county here, but residents say that has not created enough competition to bring down prices. Plus, many doctors these residents are used to seeing don’t take the marketplace plans.

“Being told you have to have insurance you can’t afford, and then that doesn’t cover what you need? You are stuck,” says Modoc County resident Althia Cline, who decided to forego coverage – and a surgery she needs to help with her asthma.

Just like the movie theater and the bowling alley, most medical specialists are miles away. In Modoc County, there’s no hospital or birthing center where a woman can have a baby. Tessa Anklin, who lives in Canby, Calif., gave birth to her son and daughter over the border in Oregon, an hour and a half away from home.

Anklin makes about $33,000 a year as a dental receptionist. Her husband does seasonal work baling hay and herding cattle at local ranches. While their kids are covered by Medi-Cal, neither parent gets health insurance through work, and before the Affordable Care Act passed, Anklin and her husband did without coverage for a while.

Two years ago, they bought a plan through Covered California. Their monthly premium was just $2 a month after the ACA subsidy, but their deductible was $10,000.

“We paid for all of our medical services and our prescriptions,” she says. “We had no help until we reached the $10,000 deductible. So really, we had nothing.”

Then, last year, their monthly premium jumped to $600. The plan was the same, Anklin says, and their household income was the same. And they still faced the same hour and a half drive to see doctors they almost never needed.*

Anklin thought of all the other ways she could spend that money.

“It makes the car payment. Almost your mortgage payment. Groceries for at least four months,” she says. “That’s a big difference, when you think about how little you actually use the health coverage.”

That’s the reason she decided to cancel her health plan this year and go without insurance. But she’ll still have to pay a penalty when the next tax season comes around.

“It basically penalizes us one way or the other because we can’t afford the coverage,” she says. “So, that’s kind of difficult — to be that middle-class person.”

Anklin says she’d be happy to see Republicans get rid of Obamacare.

“To me, it’s no good, if you have to force people to pay yet another something out of their paycheck,” she says, “when they’re already trying to survive with what they have. It should be an option.”

But the Republican repeal and replace plan wouldn’t make things much better for Anklin and her neighbors. Average premiums in California would double under the GOP plan, according to a recent analysis from the Kaiser Family Foundation. Anklin could end up paying more than $2,000 a month for coverage, according to Kaiser’s county-by-county projections.

That’s not what she had in mind as a fix.

“I’d love that insurance could be more affordable for families that need it, for families that work hard for it,” Anklin says.

With the Republican bill now in flux, Democrats have been more willing to admit to Obamacare’s flaws. The Dems agree that the rising costs of marketplace plans are the chief complaint they hear about, too.

Democrats have also said if the Republican bill fails, they’d be willing to work together on solutions, but it’s not clear the parties could agree on one that would help people like Anklin.

If they can’t, Anklin says she has no choice but to continue to go without coverage. Financially, it makes sense in the short term, but she still worries about an unforeseen surgery, serious illness or accident.

“If I ever have a problem,” she says, “I know I will be paying for the rest of my life.”

*Premiums in this part of California went up an average of 10.6 percent in 2016, according to Covered California’s rate booklet, and most premium increases are matched with an increase in subsidy. So the most likely explanation for why Anklin’s premium jumped this much is that she lost her subsidy. This can happen if customers, intentionally or unintentionally, do not check a box on their application form that allows the federal government to verify their income, or, if customers do not file tax returns.

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We examine what options Senate Republicans have left if they want to repeal and replace the Affordable Care Act. The country’s oldest civil rights organization, the NAACP, is looking for a new leader.

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On Thursday, the Senate unleashed yet another iteration of its effort to repeal and replace the Affordable Care Act, and with it came another analysis from the non-partisan Congressional Budget Office. If your head is spinning, you’ve got plenty of company, us here at Shots included.

Here are the key versions of repeal and/or replace legislation so far this year:

The American Health Care Act, the House bill passed on May 4. The Senate chose to write its own bill rather than amend this House version.

Better Care Reconciliation Act (BRCA), the Senate bill:

• The original: Introduced June 22. It differs from the House bill in key ways, see the chart below.
• Revision #1: Introduced July 13. Added a provision called the Cruz amendment, widely disliked by industry and consumers, but appealing to conservatives. The version also added money for opioid treatment, a provision to give Alaska more federal funding and other, smaller changes.
• Revision #2: Introduced July 20. Cruz amendment is gone, keeps some taxes the original bill repealed, other smaller changes

The Obamacare Repeal Reconciliation Act, ORRA, a repeal-only bill modeled on the 2015 bill that made it to President Obama’s desk, which he vetoed.

And here’s what’s next: Senate leaders say they want to start debate on a bill next week, but it is not clear which legislation will end up on the Senate floor.

The two most likely options for consideration right now are the latest BCRA and the ORRA. Both pieces of legislation have met opposition, but Senate Majority Leader Mitch McConnell is trying to persuade those holdouts to change their mind and vote to bring legislation to the floor. His argument is that they need to begin debating and amending a bill in order to pass a repeal and/or replacement for the ACA. (Note: Republicans have held no hearings on the bills, where a lot of debate would have already occurred).

Holdouts could stay opposed and efforts to move a bill to the floor could continue to go nowhere.

But if one of those bills does make it to the floor, there is no way to predict what the final bill will look like.

Any senator can offer amendments, and this is where the Cruz amendment could return, as could any other amendments on anything. It’s called a vote-a-rama.

And a few other proposals may come up: On Jan. 23, Sens. Susan Collins, R-Maine, and Bill Cassidy, R-La., introduced a bill that lets states keep the ACA if they would like to. On July 13, Cassidy and Sen. Lindsey Graham, R-S.C., announced an amendment that would give states a block grant to decide how to spend vis-à-vis the Affordable Care Act. It does not include any changes to Medicaid.

The vote-a-rama usually ends with an amendment by the leader that cleans it all up and kicks out any offending provisions added during vote-a-rama.

Skeptical lawmakers may not want to go this route, because could it easily end with them getting pressured to vote for a bill unlike anything they’ve yet considered, and one they may not be happy with.

Additional reporting by Susan Davis and Tamara Keith.

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Some Senate Republicans have suggested they will work with Democrats to craft legislation on health care after their party failed repeatedly to pass a bill on their own. But that is also an uncertain path.

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