Senate Republicans are already under pressure from 11 governors â including five fellow Republicans and a pivotal Alaskan independent â who this week urged the Senate to reject the last-ditch repeal effort.
The two major trade groups for insurers, the Blue Cross Blue Shield Association and Americaâs Health Insurance Plans, announced their opposition on Wednesday to the Graham-Cassidy bill. They joined other groups fighting the bill, such as the American Medical Association, the American Hospital Association, AARP and the lobbying arm of the American Cancer Society.
âThe bill contains provisions that would allow states to waive key consumer protections, as well as undermine safeguards for those with pre-existing medical conditions,ââ said Scott P. Serota, the president and chief executive of the Blue Cross Blue Shield Association. âThe legislation reduces funding for many states significantly and would increase uncertainty in the marketplace, making coverage more expensive and jeopardizing Americansâ choice of health plans.â
Americaâs Health Insurance Plans was even more pointed. The legislation could hurt patients by âfurther destabilizing the individual marketâ and could potentially allow âgovernment-controlled single payer health care to grow,â said Marilyn B. Tavenner, the president and chief executive of the association. Without controls, some states could simply eliminate private insurance, she warned.
Insurers had been reluctant to speak out against the Republicansâ previous proposals in hopes that the White House and Congress would agree to stabilize insurance markets by providing critical funding for subsidies aimed at low-income Americans. But with hopes of securing that money before they finalize their rates virtually extinguished, insurers have less to lose by coming out against the proposal.
And many within the industry are worried that the next two years will be chaotic, with little support for the current market while states scramble to come up with a new way for individuals to buy policies.
âItâs just basically injecting chaos in 50 state capitals for the next two years,â said Sabrina Corlette, a research professor at Georgetown University.
At this point, Republicans have not secured the 50 votes they would need to pass the bill, with help from Vice President Mike Pence to break a tie. But President Trump, in New York for meetings with world leaders at the United Nations, said he thought the health care bill had âa very good chanceââ of passing.
It has âtremendous support from Republicans â certainly weâre at 47 or 48 already,ââ he said, and âa lot of others are looking at it very positively.ââ
âA great Bill,â Mr. Trump concluded on Twitter later Wednesday.
The latest Republican drive to repeal the Affordable Care Act has created painful choices for Republican senators from states that stand to lose money under the legislation.
The bill would eliminate penalties for people who go without insurance, and it would funnel federal funds to states in the form of block grants for health care or coverage. States could decide how to spend the money, which is now being used for the expansion of Medicaid and for subsidies to help low- and middle-income people buy private insurance.
State officials were racing to try to figure out the impact, looking to experts to help them do the calculations.
âStates such as Alaska, Connecticut, Delaware, New Hampshire, New Mexico, New York, Oregon, Vermont and Washington would see reductions of 25 percent or more over the 2020 to 2026 period,â compared with what they would receive under current law, said a monograph issued on Wednesday by Manatt Health, a unit of Manatt, Phelps & Phillips, a national law firm that advises many states on health care issues.
Among the Republicans agonizing over how to vote is Ms. Murkowski, who has said the billâs effect on her state will be her paramount consideration.
Becky Hultberg, the president and chief executive of the Alaska State Hospital and Nursing Home Association, said on Wednesday that the cuts in the bill could have a âhuge impactâ on Alaska.
âThe cuts could be devastating to our health care system, including rural and frontier hospitals that operate on razor-thin margins,â Ms. Hultberg said in an interview. âThese hospitals are often accessible only by airplane or ferry, so the loss of a hospital means an expensive and disruptive medical evacuation out of the community.â
âUltimately,â Ms. Hultberg said, âpatients will bear the consequences, through reduced access to health care and lost insurance coverage.â
The authors of the new repeal bill, Mr. Graham and Mr. Cassidy, say decisions about health care are best made at the local level.
Mr. McCain is a close friend of Mr. Graham, but is still studying the bill and has not said how he would vote.
The other Republican senator from Arizona, Jeff Flake, had no such hesitation. âGiven the choice between Arizona or Washington deciding how federal health care dollars are spent in the state,ââ he said, âIâll take Arizona every day of the week.ââ
The Manatt study said Arizona would lose money under the bill, and a study by Avalere, a health policy consulting company, reached a similar conclusion. Both studies indicated that Tennessee would gain money.
Senator Bob Corker, Republican of Tennessee, said he liked the latest repeal bill. âIâd be ecstatic if we could finally make something happen on health careââ by passing it, he said, adding: âIâm a statesâ rights kind of guy. Our state has been well run for a long time. To know that our state would have the flexibility to carry out the program with more money than it now has could be a real win for us.ââ
The studies by Manatt and Avalere suggest that West Virginia would lose money under the bill. Ms. Capito âis still evaluating the proposal,â said her spokeswoman, Ashley Berrang.
But the stateâs senior senator, Joe Manchin III, a Democrat, said, âThe numbers do not work at all for West Virginia, with an older, sicker population and an opioid addiction problem.â
âAs a former governor, I like the concept of block grants because they give you flexibility,â Mr. Manchin said. âBut the cuts are deeper than the needs we have, and our needs are greater than the money we would have under the bill.â