It's looking likely that GOP legislation to revamp Obamacare will undergo a pretty major weight loss program before all is said and done. Expectations are building that Senate leaders will ultimately present Republicans with a "skinny" bill after more aggressive  measures fail during some 20 hours of floor debate over the next few days. 

The way it's being presented to senators, this scaled-back version of an Obamacare rollback may ditch only a few components of the Affordable Care Act -- its individual and employer mandates, its medical device tax and its public health fund. That would fall far short of Senate Majority Leader Mitch McConnell's (R-Ky.) previous promises to repeal Obamacare "root and branch." 

So here's the big question: Would the Republican Party's right-wing support a bill that only erases a sliver of the ACA? After all, the whole reason Sens. Rand Paul of Kentucky, Ted Cruz of Texas, Ron Johnson of Wisconsin and Mike Lee of Utah opposed the first version of McConnell's repeal-and-replace bill (called the Better Care Reconciliation Act, or BCRA) was because they said it went too easy on Obamacare. Both Paul and Lee were among nine Republicans who voted last night against one version of that bill, which failed 57-43 (see how your senator voted here).

Still, neither Lee nor Paul's offices dismissed the idea when I asked whether they could get on board with a "skinny repeal" later on this week.

"Depends what is in it," Lee spokesman Conn Carroll told The Health 202. "Can't comment until we see legislation," Paul spokesman Sergio Gor said.

As for Cruz and Johnson -- who both voted for the failed BCRA last night after supporting a motion to open debate on the whole process -- they may now have political cover to embrace a very lean bill. That's because they're now on record supporting McConnell's bigger repeal-and-replace plan that included an amendment from Cruz. (The Cruz language allowed insurers to opt out of ACA regulations as long as they offered one plan that was compliant with Obamacare.) Cruz and Johnson could claim they at least voted to repeal most of Obamacare, even if it didn't fly with the rest of their party.

Regardless, "skinny repeal" may be the only measure Republicans can feasibly pass after trying and failing to unite conservatives and moderates around the bigger replacement plan that was BCRA. As the Senate undergoes endless debate that will culminate in a vote-a-rama,the word is that McConnell will next bring up a measure later this morning that erases big parts of the ACA, without replacing it. That is expected to fail, too.

Dramatically whittling down an Obamacare rollback to just a few of the law's most unpopular elements could help attract the votes of moderate Republicans, who never wanted to roll back its coverage expansions anyway. These members include Sens. Susan Collins of Maine, Lisa Murkowski of Alaska and Dean Heller of Nevada, who also voted against McConnell's repeal-and-replace bill last night. They'd likely prefer a skinny repeal that would leave intact all of the ACA's insurance subsidies for low-income Americans, its dramatic expansion of Medicaid, its requirements for more expansive coverage and its protections for people with preexisting conditions.

Particularly pivotal are Collins and Murkowski, who were the only two Republicans to vote against yesterday's motion to proceed to debate. Neither of their offices responded last night to questions about whether they'd vote for "skinny repeal."

Regardless, expect a chaotic, unpredictable couple of days on Capitol Hill, now that Senate Republicans have succeeded without a certain plan for what legislation they might pass in its place. (Check out my story with Amy Goldstein to understand the policies being considered and read the latest update from our colleagues Sean Sullivan, Juliet Eilperin and Kelsey Snell.)

Yesterday's proceedings were marked by high drama, including Sen. John McCain’s (R-Ariz.) return to the Capitol just a week and-a-half after undergoing surgery related to brain cancer and Vice President Pence’s move to cast the tie-breaking vote, Sean, Juliet and Kelsey reported.

"The intensity of the debate, including protesters who yelled 'Kill the bill!' inside the Senate chamber after voting had begun, underscored the stakes involved in overhauling a health-care system that affects one-sixth of the nation’s economy and how tens of millions Americans receive medical treatment," my colleagues write. "The GOP has struggled mightily to get to this point, and there is no guarantee they will win final passage of a bill changing Obamacare."

Showing how muddled the situation remains, McCain took to the floor after voting to move ahead and declared, “I will not vote for the [the Senate leadership bill] as it is today. It’s a shell of a bill right now.” But then, he did.

Here's the goal for Senate GOP leadership: Find some health-care bill that some way, somehow can get the 50 votes to pass. Then Republicans can claim they fulfilled their vow to repeal Obamacare -- even if they mostly didn't.

“The endgame is to be able to move something at the end of this process across the Senate floor that can get 50 votes and then to get into conference with the House,” said Sen. John Thune (R-S.D.), a top McConnell lieutenant.

There's even a possibility that McConnell could bring up another version of his repeal-and-replace bill (the BCRA). Some observers didn't expect it to fail by such a wide margin last night. In addition to Paul, Lee, Collins, Murkowski and Heller, Sens. Lindsay Graham of South Carolina, Bob Corker of Tennessee, Tom Cotton of Arkansas and Jerry Moran of Kansas voted against it, Sean noted:

Don't worry if you're confused about what legislation the Senate is considering; we are, too. There are numerous versions of GOP bills at this point, and legislative text that might get voted on today and tomorrow is in flux as you read this. USA Today's Paul Singer summarized the situation this way:


AHH: There was so much drama on the Senate floor yesterday that few reporters had time to follow all the Obamacare supporters protesting the whole thing. But there was a lot going on outside the Capitol Building. "On Tuesday, for the second time, Democrats and progressive activists watched a partial repeal of the Affordable Care Act rise from the dead. For the umpteenth time, Democrats and activists fanned across Capitol Hill, trying — failing, for now — to make the vote excruciating for Republicans," my colleague David Weigel reports.

"The Democrats’ day began with dueling rallies that got sparse media attention. House Democrats held a news conference promoting the 'Better Deal' agenda that had been released on Monday; a coalition of progressive groups held their own event on the lawn just north of the House," Dave writes. "A press stand set up for cameras stayed empty as Nina Turner, the new president of Our Revolution, emceed a formal introduction of the progressive 'People’s Platform.'"

--After the vote to start health-care debate, most Senate Democrats headed down the stairs of the Capitol, where TV cameras were waiting for them. Democratic leader Charles E. Schumer (N.Y.) saw a crowd of a hundred-odd protesters that had gathered across the plaza. They started out to meet them — and were stopped by Vice President Pence’s motorcade, rolling out.

“Get the sergeant of arms out here,” Schumer said to a staffer. “The vice president’s gone. We want them to come up here.”

"While staffers negotiated the details of how close protesters could get, Schumer and the Democrats walked into the 'Senate swamp' and started talking to protesters," Dave reports. "There was no amplification; protesters reached over each other for photos, cheering for Democrats they recognized."

“We are going to fight and fight and fight until this bill is dead!” said Schumer.

OOF: Sen. Susan Collins (R-Maine) was caught saying yesterday on a hot mic that Rep. Blake Farenthood (R-Tex.) is "huge" and "unattractive." Some context: Farenthold suggested last week that he would duel the three female Republican senators (including Collins) who were opposed to the GOP healthcare bill, were they men. Collins' conversation with Sen. Jack Reed (D-R.I.), per The Post's Philip Bump:

“Did you see the one who challenged me to a duel?” Collins asks.

“I know,” Reed replies. “Trust me. Do you know why he challenged you to a duel? ‘Cause you could beat the s— out of him.”

“Well, he’s huge,” Collins replies. “And he — I don’t mean to be unkind, but he’s so unattractive it’s unbelievable.”

“Did you see the picture of him in his pajamas next to this Playboy bunny?” she continues, referring to an infamous photo of Farenthold:

Politico video editor Beatrice-Elizabeth tweeted the photo:

OUCH: All this talk about passing a "skinny repeal" -- which would eliminate the individual mandate to buy insurance without putting an alternative incentive in its place -- is worrying actuaries, who understand how the individual insurance market works. Yesterday, the American Academy of Actuaries wrote to McConnell and Schumer to warn that eliminating the individual mandate would lead to premium increases, more federal costs for insurance subsidies and less solvency for insurers (who are already eyeing the marketplaces warily and even leaving).

"Eliminating the mandate would likely result in lower coverage rates in the individual market and a deterioration of the risk pool," the actuaries write. "Premiums would increase as a result."


--For a moment yesterday, President Trump praised Republicans, calling their vote to start the health-care debate a "big step" toward "truly great health-care for the American people." He had especially kind words for McCain (R-Ariz.), who returned for the vote despite battling brain cancer.

"This is a big step," the president said at a Rose Garden news conference with the prime minister of Lebanon. "We want to thank Senator John McCain. He’s a very brave man. He made a tough trip to get here and vote.”

Trump also made some big promises, considering it's not even certain Republicans will be able to unite around any legislation at all.

"Over the next week or two we will come up  with a plan that will be really really wonderful for the American people," the president said. "Obamcare is a disaster failing at every front. It’s too expensive; it gives horrible coverage. It was gotten by a lie. 28 times a lie. You can keep your doctor, you can keep your plan. People are sick of it. We will come up with a great plan to take care of people in need.”

Watch his remarks:

Trump added that it's a “shame” no Democrats voted for the motion to proceed. “Very unfortunate," he said. “We ended up with 51 vote to whatever. I don’t know what it is. It was 51-50. Two Republicans went against us. Very sad, I think, very very sad for them."

And then Trump dialed up the pressure on his fellow Republicans. "Any senator who votes against repeal and replace is telling America that they are fine with the Obamacare nightmare," the president said at a rally in Youngstown, Ohio last night. "And I predict they'll have a lot of problems."

This morning, the president went after Murkowski, one of nine Republicans who voted against McConnell's repeal-replace measure late last night:


--Health and Human Services Secretary Tom Price called the commencement of the health-care debate "an important step today toward providing Americans relief from a flawed and failing health-care law." My colleague Kelsey spotted Price on the Senate floor yesterday afternoon:


--Senate votes on various Obamcare-targeting measures begin again this morning, with McConnell planning to restart things around 11:30. A maximum of 20 hours of debate is allowed for a budget reconciliation bill. But those hours can be spread out over several days, so it's likely debate and votes will stretch into Thursday and possibly beyond. Senate GOP leaders are hoping the week culminates in the passage of at least narrow changes to the ACA (perhaps that "skinny" bill) that could become the basis for negotiations with the House in a conference committee.

“They expect us to tackle the big problems,” McConnell said on the Senate floor yesterday, referring to American voters. “So all we have to do today is to have the courage to begin the debate... Let the voting take us where it will.”

--There was one moment of unity in the Senate chamber yesterday, as McCain walked out onto the floor and members broke out in applause.

"The Arizona Republican received a hero’s welcome on Capitol Hill Tuesday, six days after announcing he has an aggressive form of brain cancer, when he arrived to cast a vote in support of starting debate on a Republican bill to amend the Affordable Care Act," The Post's Elise Viebeck, Paul Kane and Ed O'Keefe report.

"But while McCain’s support was crucial to the success of the vote, he said he would not support the Senate Republican health-care bill without changes and proceeded to chastise the Senate for gridlock and intense partisanship," they write.

“Our deliberations today — not just our debates, but the exercise of all of our responsibilities ... they are more partisan, more tribal, than at any time that I can remember,” McCain told senators in a speech on the floor. Watch the speech:

--Some reporters noted that McCain had previously criticized McConnell for the secretive process of writing his health-care bill -- but then he voted to start debate on it, anyway:

From FiveThiryEight's Nate Silver:

From NBC News's Benjy Sarlin

An observation from IJR's Haley Byrd during McCain's speech:

McCain will soon start treatment for his brain cancer. My colleague PK asked how long he'll stay in Washington:

When McCain arrived in the chamber, Sen. Ron Johnson of Wisconsin was the final Republican yet to cast a vote on starting debate. Johnson was spotted conferring with McConnell and No. 2 Republican John Cornyn of Texas:


Bloomberg's Steven Dennis:

From my colleague Amber Phillips: 

As he walked into the chamber, Johnson wouldn't tell reporters how he would vote. Per the Washington Examiner's David Drucker:

HuffPost reporter Jennifer Bendery:

After both McCain and Johnson voted, bringing the total to 50 votes for starting debate, Vice President Pence showed up to break the tie:

But as Republicans voted, protesters inside the chamber broke out in chants of "Kill the bill, don't kill us," requiring an intervention from the sergeant at arms:


My colleague Ed:

And from The Post's Mike DeBonis:

Here are McConnell's remarks after he had successfully led Republicans to start health-care debate:


--It's looking less and less likely Republicans will be able to pass a health-care bill that blocks Medicaid dollars from Planned Parenthood, but the women's health and abortion provider isn't taking any chances. The group is holding a rally at 5 p.m. outside the Capitol building to protest a defunding provision included in the Senate repeal-and-replace bill.

A Planned Parenthood spokeswoman told The Health 202 that its supporters made 13,000 calls to Capitol Hill offices yesterday. Over the last several months, the group says they have made more than 180,000 calls to lawmakers, organized more than 2,400 events and delivered more than one million signatures opposing the defunding effort.

Planned Parenthood President Cecile Richards blasted the GOP health-care efforts on Twitter:

And here are a few more good reads from The Post:

Boston University researchers found CTE in 99 percent of brains of former NFL players, and 87 percent of all football players. Brains studied were mostly donated by concerned families.
Rick Maese
Men in Europe, North America and Australia have had dramatic declines in sperm quality, according to a meta-analysis of 185 studies.
Ariana Eunjung Cha
“It may be hard to put one’s mind into his,” Michael Stone's family said about his death.
Lindsey Bever
  • The House Energy and Commerce Subcommittee on Health will hold a hearing on examining the extension of special needs plans.
  • The Hill is hosting an event on health care affordability and access with Reps. Earl Blumenauer (D-Ore.), Larry Bucshon (R-Ind.) and Tim Murphy (R-Pa.).
  • Bloomberg Government hosts an event on the cost of health care.

Coming Up

  • A health-care rally is planned for Saturday in Washington, D.C. 

Schumer tells Republicans: "You will hurt the people of your states dramatically"

President Trump made 29 claims that were false, misleading or flip-flops between his two rallies this week:

Watch how heat causes dough to rise inside a truck:

Stephen Colbert says senators don't know what's in the health-care plan they;r considering: