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We are dealing with one-sixth of the economy, said Senator Chris Van Hollen, a Maryland Democrat who has worked on many budget blueprints. We are dealing with something that impacts the lives of millions of Americans. Its a totally inappropriate use of the budget reconciliation process.

On Tuesday night, the Republicans broadest plan to repeal and replace the Affordable Care Act was defeated after Democrats protested that the Congressional Budget Office had not formally assessed the measure; therefore consideration violated budget rules.

Key provisions on abortion and Planned Parenthood funding and efforts to persuade people to maintain insurance coverage could also slip away because they violate the rules that Republicans chose to operate under.

The expedited procedures were first used in 1980. Since then, Congress has completed action on 24 budget reconciliation bills. Twenty became law. Four were vetoed.

Reconciliation is probably the most potent budget enforcement tool available to Congress for a large portion of the budget, the Congressional Research Service, a nonpartisan arm of Congress, has said.

Democrats used the reconciliation process to adopt a very small piece of Obamacare in a separate bill enacted one week after President Barack Obama signed the original 905-page measure in March 2010.

Reconciliation has never, ever been abused to the extent that it is today, Representative Paul D. Ryan of Wisconsin, then the senior Republican on the House Budget Committee, said at the time. The goal of the fast-track procedure, he said then, was to control the government, not expand it.

To be sure, Democrats used procedural shortcuts to clean up the Affordable Care Act in 2010. But those changes are dwarfed by the repeal bill being debated in the Senate this week and by the one passed by the House in May.

The nonpartisan Congressional Budget Office says those bills would erase the gains in insurance coverage made in the seven years since the Affordable Care Act was adopted.

The Senate parliamentarian has challenged at least 11 provisions of the Republican health care bill, including one that would prevent consumers from using tax credits to help pay for insurance that includes coverage for abortions.

And so far, Republicans have not pushed back. Ms. MacDonough grew up in the Washington area and graduated from George Washington University. She knows the guts of the Senate firsthand. She served as a legislative reference assistant in the Senate Library and as an assistant executive clerk for the Senate, keeping track of treaties and nominations. She was also an assistant editor of the Congressional Record.

Seeking wider opportunities, she obtained a law degree from Vermont Law School in 1998.

She worked for the Justice Department, then took a job as an assistant Senate parliamentarian in 1999 and became the first woman to head the office in 2012.

J. Keith Kennedy, who worked for Republican senators for 28 years, said: Elizabeth diligently worked her way up through the ranks. Shes a very smart woman, has a wonderful sense of humor, enjoys life.

Being caught in the political crossfire between Republicans and Democrats is an occupational hazard that Ms. MacDonough has so far managed to avoid.

She is performing a very important institutional duty, is under enormous pressure and is handling it very well, Mr. Kennedy said.

Muftiah M. McCartin, who worked in the office of the House parliamentarian from 1976 to 2005, said Ms. MacDonough is stellar, 100 percent professional.

Under the procedure that Republicans are using to speed passage of their health care bill, senators can object to a provision if its budgetary effects are merely incidental to some policy goal.

There was talk in recent days that Republicans could try to overturn key decisions of the parliamentarian, through a strong-armed majority vote the same way Senate Democrats ended the filibuster for most judges and presidential appointees, and Republicans then ended it for Supreme Court justices.

But at least for now, Ms. MacDonoughs judgments have not been overturned or overruled.

The merely incidental test is inherently subjective, Ms. McCartin said. But Elizabeth has fidelity to Senate precedents and to advice given over the years by the Senate parliamentarians office. Thats what shes striving for: consistency.

A version of this article appears in print on July 27, 2017, on Page A17 of the New York edition with the headline: Republican Gamble on Fast-Track Rules for Health Care Hits Wall.

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Republican Gamble on Fast-Track Rules for Health Care Hits Wall - New York Times