* Senate Republicans unveiled a "skinny repeal," a narrow measure to roll back parts of the Affordable Care Act.
* Speaker Ryan tried to reassure senators balking at narrow bill, but he left the door open for "skinny" passage.
* The health insurance lobby came off the sidelines Thursday to warn Republicans against repealing the individual mandate.
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McConnell unveils narrow Obamacare repeal bill.
Senator Mitch McConnell, the majority leader, pulled in his sails on repealing the Affordable Care Act, and unveiled a more modest measure that would:
REPEAL THE INDIVIDUAL MANDATE, which says that most Americans have to have health insurance, or pay a penalty to the Internal Revenue Service.
REPEAL THE EMPLOYER MANDATE, which said that most large employers have to provide insurance for their workers.
PROVIDE FLEXIBILITY TO STATES, by granting waivers from state governments that do not wish to follow the Affordable Care Act's rules, such as holding that insurance must provide essential health benefits like emergency services, mental health coverage and prescription drugs.
INCREASE HEALTH SAVINGS ACCOUNT CONTRIBUTIONS.
REPEAL THE MEDICAL DEVICE TAX.
FUND COMMUNITY HEALTH CENTERS.
Ryan tries to calm Senate nerves.
With senators pleading for reassurance, Speaker Paul D. Ryan did his best.
"If moving forward requires a conference committee, that's something the House is willing to do. The reality, however, is that repealing and replacing Obamacare still ultimately requires the Senate to produce 51 votes for an actual plan."
He then said whatever compromise comes out of the House-Senate conference would have to pass the Senate first before the House picks it up.
That might not be all that reassuring. If the Senate failed to pass that conference agreement, the House could still pass the Senate passed "skinny repeal" and send it to President Trump for the signing ceremony he desperately wants.
Three Republicans: No 'yes' votes without assurances of a conference.
Senators Lindsey Graham of South Carolina, John McCain of Arizona and Ron Johnson of Wisconsin declared Thursday evening that they would not vote for a slimmed-down partial repeal of the Affordable Care Act that is being pushed by Senate leaders without ironclad guarantees that the House will negotiate a comprehensive measure.
The senators were unsparing in their criticism of the so-called skinny repeal, which would repeal the mandates that most individuals have health insurance and large employers cover their employees but leave most of the health law in place. Such a bill would crater the health insurance market and send premiums skyward, they said.
"The skinny bill as policy is a disaster," Mr. Graham said. "The skinny bill as a replacement for Obamacare is a fraud."
Senator Johnson said: "The skinny bill in the Senate doesn't come close to meeting our promises."
But they feared that House Republican leaders could just take the stripped-down bill, pass it and send it to President Trump.
"Right now, I am voting no," Mr. McCain said.
Mr. Graham was emphatic.
"I need assurances from the speaker of the House and his team that if I vote for the skinny bill, then it will not be the final product," Mr. Graham said. "I'm not going to vote for a pig in a poke."
Mr. Ryan's assurances may just win the night. For all his bluster, Mr. Graham said he would trust the speaker.
Sen. Johnson also looked like a yes.
But Mr. McCain was holding out.
Senate Republicans trim sails on 'Repeal and Replace.'
The turmoil came as Senate Republicans, unable to reach consensus on broad legislation to repeal and replace the Affordable Care Act, looked instead at chipping away at it.
Besides the mandates, Senator David Perdue, Republican of Georgia, said the other item under discussion for the so-called Skinny Repeal is rolling back a tax on medical devices imposed by the health law.
But to avoid a 60-vote threshold for passage, the bill must meet specific deficit reduction targets. It's still not clear how those targets will be reached.
Then there's the question of what would come next. Republican leaders are assuring senators that the narrow repeal would be merely a vehicle to begin negotiations with House Republicans on a broader compromise to repeal and replace the Affordable Care Act. But some senators worry that they are being asked to vote for legislation they don't like on a promise that it won't become law - but they have no guarantee that the House won't take it up and pass it.
This might not have helped.
As Republican senators seek assurances that the bill they are being asked to vote on won't become law, the House majority leader, Kevin McCarthy of California, may have sent shivers down a spine or two in the upper chamber with this announcement.
"While last votes are currently scheduled to take place tomorrow, Members are advised that - pending Senate action on health care - the House schedule is subject to change. All Members should remain flexible in their travel plans over the next few days. Further information regarding potential additional items will be relayed as soon as possible."
That doesn't sound like a man preparing for lengthy House-Senate negotiations on a comprehensive health care bill. So maybe the "skinny repeal" could become law after all?
Parliamentarian takes another scalp.
Senate Republicans also would have liked the "skinny repeal" to include a measure that would make it much easier for states to waive federal requirements that health insurance plans provide consumers with a minimum set of benefits like maternity care and prescription drugs.
Then the Senate parliamentarian stepped in. The parliamentarian, Elizabeth MacDonough, objected on Thursday to the waiver provision, saying it appeared to violate Senate rules being used to speed passage of the bill to repeal much of the Affordable Care Act.
Republicans want to make it easier for states to get waivers for two reasons: State officials can regulate insurance better than federal officials, they say, and the federal standards established by the Affordable Care Act have driven up insurance costs.
But Republicans are learning the limits of the fast-track rules they are using. The Senate is considering the repeal bill under special procedures that preclude a Democratic filibuster, but the procedures also limit what can be included in the bill.
"The function of reconciliation is to adjust federal spending and revenue, not to enact major changes in social policy," said Senator Bernie Sanders, independent of Vermont. "The parliamentarian's latest decision reveals once again that Republicans have abused the reconciliation process in an attempt to radically change one-sixth of the American economy by repealing the Affordable Care Act."
The Senate bill would give states sweeping new authority to opt out of federal insurance standards established by the Affordable Care Act. It builds on a section of the law that allows states to obtain waivers for innovative health programs. But it would relax many of the requirements for such waivers that Democrats put into the law, signed by President Barack Obama in 2010.
Insurers come off sidelines with warning.
The health insurance lobby, America's Health Insurance Plans, came off the sidelines on Thursday to warn Senate leaders against repealing the Affordable Care Act's mandate that most Americans have insurance without approving some mechanism to pressure people to maintain their coverage.
"We would oppose an approach that eliminates the individual coverage requirement, does not offer continuous coverage solutions, and does not include measures to immediately stabilize the individual market," the group wrote.
AHIP played a major role in getting the Affordable Care Act passed in 2010 but has been reluctant to intervene in the fight over its repeal. On Wednesday, the Blue Cross Blue Shield Association, a narrower insurance lobby, weighed in with a similar warning.
Both groups were pulled into the fray by expectations that the Senate could end up voting in the early morning hours of Friday on a narrow bill that repeals a few important parts of the Affordable Care Act but leaves much of the law in place. Two of the pieces that would be repealed are the mandates that individuals have health insurance and that large employers cover their employees. The Senate had intended to repeal those mandates but create a new rule that anyone who allows coverage to lapse would have to wait six months before getting a new policy.
That lock out period was supposed to be enough to convince people not to simply wait until they were sick to buy insurance, a prospect that could send insurance markets into a tailspin, since only sick people would have insurance.
But it looks certain that any bill that can emerge from the Senate would not have the lock out provision, a deep concern to insurers who say that without it, insurance premiums would soar.
The American Medical Association piles on.
The American Medical Association, by far the largest physicians' advocacy group, has stood firmly against each of the bills to repeal the Affordable Care Act. Now the A.M.A. has come out against the "skinny repeal."
"There has been considerable speculation regarding a so-called 'skinny package' that would primarily eliminate penalties related to the individual and employer mandates and provide tax cuts to device manufactures and the health insurance industry. Eliminating the mandate to obtain coverage only exacerbates the affordability problem that critics say they want to address. Instead, it leads to adverse selection that would increase premiums and destabilize the individual market.
"We again urge the Senate to engage in a bipartisan process - through regular order - to address the shortcomings of the Affordable Care Act and achieve the goal of providing access to quality, affordable health care coverage to more Americans."
Oh, and so does AARP.
Protesters make their voices known.
Across the Capitol on Thursday, supporters of the Affordable Care Act tried to reach out to senators, sometimes through mass protests, sometimes through their stories.
"I had epilepsy as a kid. I would not have been able to be covered under what you're proposing," one man told Senator Richard Shelby, Republican of Alabama.
The senator replied: "I think we need to have - not just for you but for any group that is underserved medically - we ought to protect them."
Vigils broke out throughout the Capitol and around lawmakers' offices.
Protesters in the Senate gallery chanting "kill the bill" disrupted proceedings on Tuesday just before the Senate voted, 51-50, to begin the health care debate. Democrats, including Senator Cory Booker of New Jersey, spoke to crowds on the steps of the building. Hundreds of protesters flooded the lawns outside the Capitol.
"The message was: we are not backing down," Nora Franco, campaign organizer at Planned Parenthood, said in the Capitol. She added, "Now is not the time to throw in the towel. Now is the time to literally be harassing your senators."
Seven years ago, similar scenes unfolded before the votes on the Affordable Care Act, but then, the passion came from the opponents. Those voices now are little in evidence.
Has Alaska's delegation crossed Trump?
President Trump went after Senator Lisa Murkowski of Alaska, who was one of only two Republicans to vote against starting debate on health care this week, with a Twitter post on Wednesday.
But that might not be the end of it.
Ryan Zinke, the Interior secretary, called both Ms. Murkowski and Alaska's other senator, Dan Sullivan, "letting them know the vote had put Alaska's future with the administration in jeopardy," The Alaska Dispatch News reported. Mr. Sullivan, also a Republican, voted in favor of beginning debate.
"I'm not going to go into the details, but I fear that the strong economic growth, pro-energy, pro-mining, pro-jobs and personnel from Alaska who are part of those policies are going to stop," Mr. Sullivan said, according to the newspaper.
But the leverage goes both ways.
Ms. Murkowski is the chairwoman of the Senate Energy and Natural Resources Committee, which has oversight of the Interior Department. She is also the chairwoman of the Senate Appropriations subcommittee with jurisdiction over the department.
She likely can do more to Mr. Zinke than he can do to her.
Tracked down by reporters on Capitol Hill, Mr. Sullivan called for the administration and Alaska's small but powerful congressional delegation to "get back to cooperation."
No word yet from Ms. Murkowski.
Where did the Senate leave off on Wednesday?
Wednesday's big vote was on a measure to repeal major parts of the existing health law - but without swapping in something new.
Republicans have struggled to agree on the contents of a replacement for the law, so a "clean repeal" bill seemed like a good alternative to some of them.
But the measure was soundly rejected. Seven Republicans - including Senator Lamar Alexander of Tennessee, the chairman of the Senate health committee - joined Democrats in voting against it.
The repeal-only measure was expected to fail. But the episode demonstrated the problem facing Republican leaders: They don't have enough votes to pass a broad replacement of the health law. They also don't have the votes to simply repeal major parts of it.
What happens on Thursday?
Senate Republicans have been trying to push through a repeal by using special budget rules that limit debate to 20 hours. That time is expected to be exhausted on Thursday.
After it expires, the Senate will move into what is known as a "vote-a-rama" - a marathon series of votes on amendments.
Typically, Democrats would be expected to offer a barrage of amendments. But on Wednesday night, the minority leader, Chuck Schumer of New York, said Democrats would not offer any amendments until Mr. McConnell revealed the final bill he wants the Senate to consider.
"We ought to see it soon, in broad daylight, not at the 11th hour," Mr. Schumer said.
The vote-a-rama could begin late in the day on Thursday. If Democrats do offer a blizzard of amendments, it could stretch overnight. But it remains unclear when, exactly, Mr. McConnell plans to reveal his legislation.
Republicans seem increasingly likely to try to pass a slimmed-down bill that would repeal only a small number of the existing health law's provisions. By passing a so-called "skinny" repeal bill, Senate Republicans would keep the repeal effort alive long enough to try to negotiate a broader compromise bill with the House of Representatives.