This was ostensibly a vote on a motion to waive the Senate's budget rules with respect to an amendment by Sen. Pat Roberts (R-KS) that would have prohibited cuts in Medicare payments to critical access hospitals (CAHs). CAHs are located in rural areas where many residents lack access to hospitals. The measure Roberts sought to amend was a “companion bill” making a number of changes to health care reform legislation already signed into law by President Obama. The underlying context was that Republicans were trying to attach amendments to the companion bill in order to send it back the House, where it had passed by a narrow margin. CNN reported that Republicans had chosen to offer a slew of amendments in order to “undermine the measure,” while the Associated Press characterized the amendments as “a final drive to thwart President Barack Obama's health care remake.”

Specifically, the amendment would have barred the Independent Payment Advisory Board from cutting payments to CAHs. The health care reform bill signed into law by President Obama created this independent board to make cuts in Medicare spending (although Congress could act to block the cuts).  The Roberts amendment would have barred the board from targeting CAHs for these cuts. Roberts urged support for his amendment: "…This amendment protects the rural health care delivery system by exempting critical access hospitals from dangerous payment cuts by the Independent Payment Advisory Board. This board is an unelected and unaccountable body, nefarious to be sure, with unprecedented power to set payment rates and make other Medicare policy changes."

The Senate's budget rules prohibit amendments from being adopted to a bill considered under the reconciliation process (such as the companion bill) if those amendments are not strictly relevant to budgetary matters. Sen. Max Baucus (D-MT) indicated he supported the substance of the amendment, but claimed it violated Senate budget rules: "I agree--Kansas, Montana, anywhere--critical access hospitals should be treated the same way as other hospitals. And when we get to that point, I say to my good friend from Kansas, I will work with him, and I know he will with me, so we can exempt critical access hospitals from this commission." Roberts made a motion to waive the Senate budget rules. Motions to waive the budget rules require 60 votes for passage.

After the House and Senate both passed their respective health care reform bills, the two chambers had intended to reconcile those two bills into a final package. After the House and Senate passed that final package, it would have been sent to President Obama, who would have signed it into law. Sen. Scott Brown (R-MA), however, won a special election to replace the late Sen. Ted Kennedy (D-MA) before the final health care bill could be brought up for a vote. Brown's victory gave Republicans 41 votes in the Senate, leaving Democrats with 59 members – one vote short of the 60 votes they needed to defeat a unanimous Republican filibuster against the final health care bill. 

In order to pass comprehensive health care legislation without a 60-vote majority in the Senate, Democratic leaders devised a plan in which the House would pass the Senate health care bill (H.R. 3590), thereby enabling the president to sign it into law. The House would then pass a separate companion bill (H.R. 4872) to make changes to the Senate health measure under a process known as "budget reconciliation." Bills considered under budget reconciliation cannot be filibustered under Senate rules. This process allowed the House to make changes to Senate-passed health care legislation without sending the entire health bill back to the Senate, where it could have been filibustered indefinitely.   The companion bill incorporated changes to the Senate health care legislation desired by House Democrats. The House passed the companion measure, and sent it to the Senate, where Democratic leaders hoped to defeat all amendments -- thereby avoiding a second vote in the House on a substantively changed bill; a vote that Democrats might have lost given the already tight margin when it was voted on the previous week.

The Senate rejected the motion to waive its budget rules by a vote of 42-54. All 39 Republicans present and 3 Democrats voted "yea."  54 Democrats voted "nay." As a result, the Senate effectively rejected an amendment Democratic leaders feared could have torpedoed the entire companion health care measure and would have prohibited cuts in Medicare payments to critical access hospitals.