WASHINGTON -- Senate Republicans are making one last push to repeal the Patient Protection and Affordable Care Act but face significant challenges to get it done before a final deadline at the end of the month.
The effort received a jolt of energy Monday when Gov. Doug Ducey, R-Ariz., endorsed the latest repeal bill. That put pressure on Sen. John McCain, R-Ariz., who in July was one of three Republican senators to stop the repeal movement but who has said he would seriously consider the views of his governor.
"I am not supportive of the bill yet," the Arizona senator told reporters Monday, adding that he wants a more thorough legislative process.
The leaders of the latest repeal effort, Sens. Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, say their drive is gaining momentum. Under their bill, millions could lose coverage, Medicaid would see the same magnitude of cuts as earlier repeal bills, and insurers in some states could charge higher premiums to people with pre-existing conditions.
In a Twitter post Monday, Ducey said: "Graham-Cassidy is the best path forward to repeal and replace Obamacare. I will continue to work with the Congress and the administration to give states more flexibility and more options moving forward. Congress has 12 days to say 'yes' to Graham-Cassidy. It's time for them to get the job done."
Graham welcomed the governor's support, saying Ducey and his team were "providing the conservative leadership that will get us over the top."
Already, Sen. Rand Paul, R-Ky., has said he will not vote for the measure because it leaves too much of the Affordable Care Act in place.
"It's another incarnation of replace. I won't support it," Paul told reporters, adding that it isn't a "kidney stone" you pass to "just get rid of it."
Asked about the likelihood that the bill would get enough GOP support to pass, Paul said, "Two weeks ago I would have said zero. But now I'm worried."
House Speaker Paul Ryan, speaking to reporters during a stop in Menomonee Falls, Wis., said the bill is the "last chance to get repeal and replace done."
Because of Senate deadlines, there would be no time for the House and Senate to try to work out their differences. The House backed a bill in May that went nowhere in the Senate. Ryan, encouraging every Republican senator to vote for the measure, signaled that he would try to get the House to pass the Senate bill.
McCain had already expressed misgivings that the Senate would try again to pass a bill that had not been examined by committees with expertise -- and with no Democratic support.
"Why did Obamacare fail? Obamacare was rammed through with Democrats' votes only," he said on CBS' Face the Nation on Sunday. "That's not the way to do it. We've got to go back. If I could just say again, the way to do this is have a bill, put it through committee."
Graham said last week that Senate Majority Leader Mitch McConnell, R-Ky., said he was "all in" to help the two bill sponsors round up the 50 votes to pass the bill. Graham said they could have as many as 48 votes if the vote were held now. But a number of Republican senators have yet to get on board, including the three who defeated McConnell's plan in July -- Susan Collins of Maine, Lisa Murkowski of Alaska and McCain.
Collins "has a number of concerns" about the new proposal, including the cuts to Medicaid and the effect on people with pre-existing conditions, spokesman Annie Clark said Monday. She will examine the budget analysis of the bill's impact, Clark said.
Murkowski is getting a hard sell from Republican backers of the bill. Moments before she walked into McConnell's office Monday, she said she's working with Cassidy's office to learn what the bill would mean for Alaska.
"What I'm trying to figure out is the impact to my state," Murkowski told reporters. "There are some formulas at play with different pots of money with different allocations and different percentages so it is not clear."
CLOCK TICKING
Graham and Cassidy expressed a sense of urgency. If the Senate does not vote by the end of next week, it will become nearly impossible to repeal the law because the drive to kill the Affordable Care Act will lose the procedural protections that allow it to pass the Senate with a simple majority, rather than the 60 votes that would otherwise be needed. The budget reconciliation bill they're using to provide those protections expires at the end of the month.
The House passed a repeal bill in early May, by a vote of 217-213. But the seven-year Republican push to undo President Barack Obama's signature health care law appeared to reach a dead end in July, when multiple versions of repeal legislation failed to gain even a simple majority in the Senate.
Graham and Cassidy have come up with yet another bill. McConnell has told them he will find time for it on the Senate floor if they can muster 50 votes, which would ensure passage with Vice President Mike Pence on hand to break a tie.
McConnell is pressing the Congressional Budget Office for a quick analysis of the Graham-Cassidy bill.
But on Monday the Democratic leaders, Sen. Chuck Schumer of New York and Rep. Nancy Pelosi of California, asked the budget office for detailed answers to these questions: "How many people will lose health insurance under the Graham-Cassidy bill? How much will premiums and out-of-pocket health costs increase, particularly for older Americans? How much will Medicaid be cut?" And how would the bill affect people with pre-existing conditions and the stability of insurance marketplaces?
The budget office said Monday that it will offer a partial assessment of the measure early next week, but that it won't have estimates of its effects on the deficit, health insurance coverage or premiums for at least several weeks.
Democrats are warning that the proposal is a serious threat.
"This bill is worse than the last bill," Schumer told reporters Monday. "It will slash Medicaid, get rid of pre-existing conditions. It's very, very bad."
Later at a news conference, Schumer said voting on the measure without a full CBO analysis would be "legislative malpractice."
WHAT'S NEW
The Graham-Cassidy bill has two major elements, one that is new and one that was found in many other Republican repeal bills this year.
The new element is a block grant. Graham and Cassidy would give each state a fixed amount of federal money for health care and health insurance each year from 2020-2026. The allotments total $1.2 trillion over the seven years. That is slightly less than what the federal government is expected to spend under the Affordable Care Act on the expansion of Medicaid, on premium tax credits and on subsidies to reimburse insurers for reducing the out-of-pocket costs of low-income consumers.
States would have sweeping new discretion over how to use the money, and they could receive federal block grant funds without putting up state money.
In addition, the Graham-Cassidy bill would make deep cuts in Medicaid. It would end the expansion of eligibility under the Affordable Care Act, which has extended coverage to 13 million people. And it would put the entire program, which serves more than 70 million people, on a budget, ending the open-ended entitlement that now exists.
The Congressional Budget Office has estimated that 15 million fewer people would have Medicaid as a result of similar proposals in other Republican bills.
Graham and Cassidy would distribute federal block grant funds to the states. It is difficult for any state to be sure how much it would receive. The authors of the bill say they intend to reduce expected federal payments to high-cost states like Massachusetts and increase federal payments to states that have not expanded Medicaid.
With the proposed block grant, Cassidy said, "we equalize how much each American receives toward her care, irrespective of where she lives." By 2026, the per-beneficiary amount for each state would be within 10 percent of the national average.
Graham and Cassidy said that their bill would also enhance the ability of states to waive "Obamacare regulations." Insurers would still have to offer insurance to anyone who applied, but states could obtain federal waivers allowing insurers to charge higher premiums to sick people or to omit some of the benefits they are now required to provide, such as maternity care, mental health care or treatment for drug addiction.
Critics have taken notice.
Sixteen groups representing patients and heath care providers came out Monday in opposition to the bill. Among those who issued a joint statement opposing it were the American Heart Association, the American Diabetes Association, the March of Dimes and the lobbying arm of the American Cancer Society.
"Much of the proposal just repackages the problematic provisions of the Better Care Reconciliation Act," which the Senate rejected in July, the groups said.
Information for this article was contributed by Robert Pear of The New York Times; by Laura Litvan, Erik Wasson, Zachary Tracer and Sahil Kapur of Bloomberg News; and by Paige Winfield Cunningham of The Washington Post.
A Section on 09/19/2017