âI think the odds have improved,â said Senator John Thune of South Dakota, a member of the Republican leadership. âI just told Bill Cassidy heâs kind of the grave robber. This thing was six feet under, and I think heâs revived it.â
It is still too early for Republican leaders to celebrate. Mr. McCain said he would pay attention to the views of his governor, but he also lamented that the bill was subject to no committee hearings or a full analysis by the Congressional Budget Office to assess its cost or impact on health coverage and insurance premiums.
In response to such concerns, two Senate committees announced they planned to hold hearings on the Graham-Cassidy bill early next week.
âIâm not interested in only having an up-or-down vote on whatâs one-fifth of the gross national product,â Mr. McCain said.
Ms. Collins was similarly skeptical.
âIâm concerned about what the effect would be on coverage; on Medicaid spending in my state; on the fundamental changes in Medicaid that would be made without the Senate holding a single hearing to evaluate them; and also on what the effect would be on premiums, particularly for older Americans between 50 and 64,â she said.
In the latest fight, unlike the July showdown, repeal advocates must overcome one ânoâ vote from the right: Senator Rand Paul, Republican of Kentucky, who said the new bill would leave too much of the Affordable Care Act in place.
âThis bill keeps 90 percent of the spending of Obamacare and reshuffles it,ââ Mr. Paul said on Monday. âReally, when you look at how it reshuffles it, it does it just to take money from the Democrat states and give it to Republican states.ââ
Ms. Murkowski said she was still considering her vote.
If the Senate does not vote by the end of next week, it will become nearly impossible to repeal the health 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.
Democrats sounded the alarm Monday, and the Senate Democratic leader, Chuck Schumer of New York, geared up for an all-out effort to block the Graham-Cassidy bill, which has support from President Trump.
âAfter a few weeks of lying dormant, Trumpcare is back, and its meaner than ever,ââ Mr. Schumer said, adding: âThis is so outrageous and so harmful that weâre going to look at every possible way to slow the bill down.ââ
Mr. Schumer said it would be much better for Congress to advance a bipartisan bill being drafted by Senators Lamar Alexander, Republican of Tennessee, and Patty Murray, Democrat of Washington. That bill would provide money to insurers to compensate them for reducing out-of-pocket costs for low-income people. Without those payments, insurers say, they will sharply increase premiums or withdraw from additional markets next year.
The House passed an Affordable Care Act repeal in early May, by a vote of 217-213. But the movement 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 took another tack. 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 the âcost-sharing reductionâ payments to insurers on behalf 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.
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.
âRight now, 37 percent of the revenue from the Affordable Care Act goes to Americans in four statesâ â California, New York, Massachusetts and Maryland, Mr. Cassidy said. âThat is frankly not fair.â
Mr. Graham and Mr. Cassidy said that their bill would also enhance the ability of states to waive âObamacare regulations.â 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. âLess-healthy people would face extremely high premiumsâ 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 âmaintain access to adequate and affordable health insurance coverage for individuals with pre-existing conditions.â
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.
âMuch of the proposal just repackages the problematic provisions of the Better Care Reconciliation Act,â which the Senate rejected in July, the groups said.
The Graham-Cassidy bill would eliminate the requirement for most Americans to have health insurance and for larger employers to offer it to employees. Like prior Republican bills, it would also cut off federal funds for Planned Parenthood for a year â a provision opposed by Ms. Collins and Ms. Murkowski.
The outlook for the Senate bill in the House is unclear. Some Republicans from states that lose money under the block grant could balk. But House Republicans would be under immense pressure to support the bill and fulfill their longtime promise to dismantle the law, which was passed seven years ago.