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Running out of options to overhaul Obamacare, Senate Republicans ponder a 'skinny' repeal

Senate Republicans voted down July 26 a repeal of the Affordable Care Act.

Unable to agree on a path forward to repealing the Affordable Care Act, Senate Republicans are reluctantly coalescing around what may be the last idea standing: a dramatically scaled-down bill that would leave most of the 2010 law in place.

The so-called skinny repeal is still a work in progress, but one version being floated would repeal only three Obamacare provisions — a medical device tax and the mandates that individuals buy health insurance and that large employers offer it.

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That's far cry from the years-long GOP promise to gut the law, also known as Obamacare. But the face-saving strategy, which could come to a vote as soon as Thursday, would at least allow senators to say they acted on something.

It could also trigger a conference committee with House lawmakers to reconcile the Senate bill with the more sweeping House repeal legislation, giving lawmakers another shot at reaching agreement.

"I've got to think about moving things along to get to conference to hopefully get a good product," said Sen. Charles E. Grassley (R-Iowa), who viewed the skinny alternative as a step toward something more comprehensive.

On Wednesday, GOP senators spent another frustrating and fruitless day debating and rejecting possible approaches.

After voting down their leaders' most comprehensive overhaul plan a day earlier, Republicans rejected another long-standing GOP idea on Wednesday: to simply repeal most of Obamacare.

The amendment from Sen. Rand Paul (R-Ky.) mirrored a bill from conservatives that passed in 2015 but was vetoed by President Obama. Paul's measure would have repealed the Affordable Care Act by 2020, theoretically providing time to devise a replacement law.

President Trump has at various times pushed the repeal-only idea, which was seen as the most straightforward approach amid disagreement within the party.

But Paul's proposal failed to reach the 50 votes needed for passage, despite Republicans' 52-seat Senate majority. Seven Republicans joined all Democrats in the 55-45 no vote.

That followed the late Tuesday rejection of GOP leaders' Better Care Reconciliation Act, which had been bolstered with provisions to attract support from conservatives who want full repeal and centrists who worry about cuts to Medicaid.

Nine Republican senators voted against that idea.

"Clearly it has proven to be quite challenging to get 50 Republicans on board with one solution," said Sen. John Thune (R-S.D.). "It's been trying to move pieces around that would get everybody kind of comfortable and find a good landing spot. We just haven't quite gotten there yet."

Senators braced for an expected all-night session Thursday to consider about 100 amendments from Republicans and Democrats. None are likely to gain traction.

Even the skinny repeal is no sure thing, and leaders Wednesday were assessing what provisions could be cobbled together to win majority support.

A few GOP senators who have been hardest to satisfy voiced interest Wednesday in the scaled-down plan, including Sens. Rand Paul of Kentucky and Dean Heller of Nevada. Sens. Rob Portman of Ohio and Mike Lee of Utah also said they would review it.

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For some, even a limited repeal would provide GOP senators an opportunity to pass a bill, declare victory and move on to other issues like tax reform.

Others hope to continue the fight if the legislation moves to a conference to be reconciled with the House bill.

Several Republican senators seemed open to that route, hoping to adjust the final bill in the negotiations to come. But whatever is agreed to in conference would still have to be approved by both the House and Senate.

Paul took the opposite stand. He said he could consider a limited repeal, but was worried that once negotiations with the House began, the legislation would be changed in ways he would not support.

It is highly possible that the House and Senate will not be able to resolve their differences, since they remain far apart on their approaches.

Rep. Mark Meadows (R-N.C.), chairman of the House Freedom Caucus and a key broker of the House-passed bill, said the skinny version had "zero" chance in that chamber.

Even so, some predict that House Republicans may be pressured to approve whatever skinny version ultimately passes the Senate, even if it is less ambitious than what Republicans once envisioned.

Meanwhile, many outside groups have voiced concerns about elements of the skinny plan, particularly if it repeals the individual mandate.

Though that mandate is unpopular with consumers, removing it could cause chaos in the insurance markets.

Without some kind of penalty, many healthy Americans would not get insurance until they were sick. That would push up health insurance costs, causing what people in the business call a death spiral.

The nonpartisan Congressional Budget Office estimated two years ago that repealing the mandates would increase the ranks of the uninsured by as many as 15 million, mostly people voluntarily dropping their coverage. It also estimated that premiums would increase by 20%.

On Wednesday, the skinny plan drew criticism from several leading healthcare groups, including the American Medical Assn., the nation's largest physicians' organization and the Blue Cross Blue Shield Assn., a health insurance trade group.

"A system that allows people to purchase coverage only when they need it drives up costs for everyone," the insurance group warned in a statement.

Times staff writer Noam N. Levey contributed to this report.

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