WASHINGTON — Just when the effort to repeal the Affordable Care Act appeared to be dead, a last-ditch push to obliterate the law could be nearing a showdown vote in the Senate, and a handful of Republicans insist they are closing in on the votes.
The effort received a jolt of energy on Monday when Gov. Doug Ducey of Arizona, a Republican, strongly endorsed the latest repeal bill. That put pressure on Senator John McCain, Republican of Arizona, who cast the deciding vote in July that seemed to stop the repeal movement, but who has said he would seriously consider the views of his governor.
The leaders of the latest repeal effort, Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, say their drive is gaining momentum. But it is still a long shot. Under their bill, millions could lose coverage, Medicaid would see the same magnitude of cuts that earlier repeal bills extracted, and insurers in some states could charge higher premiums to people with pre-existing conditions.
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Already, Senator Rand Paul, Republican of Kentucky, has said he will not vote for the measure because it leaves too much of the Affordable Care Act in place.
And Mr. McCain 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’s “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.”
Senators Susan Collins of Maine and Lisa Murkowski of Alaska, Republicans who steadfastly opposed previous repeal efforts, have not said where they stand. But the new bill holds the same provisions that they opposed this summer: deep cuts to Medicaid and a temporary elimination of federal funding to Planned Parenthood.
Mr. Graham and Mr. Cassidy express 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.
In a Twitter post on Monday, Governor Ducey of Arizona 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.”
Mr. Graham welcomed the governor’s support, saying Mr. Ducey and his team were “providing the conservative leadership that will get us over the top.”
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.
Refusing to accept defeat, Mr. Graham and Mr. Cassidy have come up with yet another bill. The Senate majority leader, Mitch McConnell of Kentucky, 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.
Mr. McConnell is pressing the Congressional Budget Office for a quick analysis of the Graham-Cassidy bill.
But on Monday the Democratic leaders, Senator Chuck Schumer of New York and Representative 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 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. Mr. Graham and Mr. Cassidy would give each state a fixed amount of federal money for health care and health insurance each year from 2020 to 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. States would receive a per-beneficiary allotment of federal money.
The Congressional Budget Office has estimated that 15 million fewer people would have Medicaid as a result of similar proposals in other Republican bills. It is not clear when the budget office will issue a report on the Graham-Cassidy bill, showing its effects on federal spending and the number of people without insurance.
Mr. Graham and Mr. Cassidy would distribute federal block grant funds to the states using a complex formula that, like any such formula, creates winners and losers. 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.
“Right now, 37 percent of the revenue from the Affordable Care Act goes to Americans in four states” — California, New York, Massachusetts and Maryland, Mr. Cassidy said. “That is frankly not fair.”
With the proposed block grant, Mr. 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.
Mr. Graham and Mr. 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, like maternity care, mental health care or treatment for drug addiction.
Coverage, while theoretically available, could become unaffordable for some people with costly conditions like cancer or AIDS, health policy experts say. “Less-healthy people would face extremely high premiums” in states that obtained waivers involving both benefits and premiums, the Congressional Budget Office said in analyzing a similar provision of the bill passed by the House.
Mr. Cassidy played down that concern. Under the Graham-Cassidy bill, he noted, a state seeking a waiver would have to describe how it intends to “maintain access to adequate and affordable health insurance coverage for individuals with pre-existing conditions.”
But 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.
Aides to Senator Collins said she was concerned about cuts to Medicaid and protections for people with pre-existing conditions under the Graham-Cassidy bill.
The Cassidy-Graham bill would eliminate the requirement for most Americans to have health insurance and for larger employers to offer it to employees. Like prior Republicans bills, it would also cut off federal funds for Planned Parenthood for a year.
The House is unlikely to accept the bill in its current form. Some Republicans from states that lose money under the block grant could balk. But passage of the bill in the Senate could lead to negotiations with the House, reviving prospects for repeal of the Affordable Care Act.
The block grant would be established under a part of the Social Security Act that provides money to states for the Children’s Health Insurance Program, but it would dwarf that program. Republicans said they took that approach because the child health program serves a low-income population, is popular with governors and provides states with a high degree of flexibility.
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