It’s crunch time for the latest Republican healthcare bill — and it doesn’t look good

Bill Cassidy and Mitch McConnellAlex Wong/Getty Images

Republican lawmakers in the Senate are days away from perhaps a final deadline on repealing and replacing the Affordable Care Act, a seminal promise from the party for more than seven years.

The Senate must pass the Graham-Cassidy healthcare bill by September 30 under the budget reconciliation process, which would allow it to pass with a simple majority.

Failure to pass the legislation would complicate prospects for the GOP to roll back the landmark healthcare law known as Obamacare.

But despite pressure on Republican senators, two members have already said they would vote against the bill — and several others are on the fence, leaving the future of the Graham-Cassidy bill in doubt.

“It’s very difficult for me to envision a scenario — scenario where I would end up voting for this bill. I have a number of serious reservations about it,” Sen. Susan Collins of Maine said Sunday on CNN.

Tough timeline

Republicans are working with a difficult, crunched timeline. Here’s the gist:

• Monday: The first order of business is the Senate Finance Committee’s hearing on the bill at 2 p.m. ET. There will be six witnesses at the event.
• Tuesday: The Congressional Budget Office will issue a preliminary score for the bill. To qualify under budget reconciliation rules, the Graham-Cassidy plan has to save the same or more than the $119 billion projected to be cut from the federal deficit in the House’s American Health Care Act. The CBO said the score would not provide a detailed estimate of changes to insurance coverage or the stability of the insurance markets.
• Also on Tuesday: The Senate GOP will hold its weekly luncheon. It will give leaders an indication of where they stand on getting 50 votes for the bill. (Vice President Mike Pence would break any tie.) With only 52 Republicans in the Senate, there is little margin for error.
• Wednesday: The day will likely bring the beginning of rulings from the Senate parliamentarian on the bill. All provisions of Graham-Cassidy are subject to the Byrd rule, which mandates all parts of a bill being considered under budget reconciliation must in some way impact the deficit. Anything that is ruled a violation of the Byrd rule would be stripped out.
• Also on Wednesday: The day Senate Majority Leader Mitch McConnell starts the process to vote on the bill — if it’ll happen.
• Thursday: This will likely be the last day for Senate Majority Leader Mitch McConnell to introduce the bill to try to pass it before the deadline. If he does, it would trigger what is known as a vote-a-rama, which would allow senators of both parties to add as many amendments as possible.
• Saturday: The cutoff day to pass the bill.

Key opposition

Going into a hectic weak for healthcare, the outlook for the Graham-Cassidy bill does not look particularly promising for Republican leaders.

On Friday, Sen. John McCain said he would vote against the bill because it has been rushed without going through the process of regular order.

“I would consider supporting legislation similar to that offered by my friends Senators Graham and Cassidy were it the product of extensive hearings, debate, and amendment,” McCain said. “But that has not been the case. Instead, the specter of September 30 budget reconciliation deadline has hung over this entire process.”

Additionally, Sen. Ted Cruz said at a festival in Texas on Sunday that he does not support the current form of hte legislation.

“Right now, they don’t have my vote, and I don’t think they have Mike Lee’s either,” Cruz said, referring to the Republican Utah senator.

Sen. Rand Paul has been adamant about his opposition to the bill since the legislative text was introduced, calling it “Obamacare-lite.” The Kentucky senator had been working on concessions that could get him to a yes, but his spokesperson said on Monday that Paul remains a “no” on the bill even after a new version was released Sunday.

Rand Paul.Chip Somodevilla/Getty Images

In the more moderate wing of the GOP, Collins said she is “leaning no” on the bill, while Sen. Lisa Murkowski of Alaska has not indicated her stance. Collins and Murkowski opposed every previous iteration of the Republican healthcare bills.

While the bill’s authors are tweaking the legislation to try to appeal to some of the wavering members, the political calculus is dicey. Moving the bill to the right to appease Paul, Cruz, and Lee risks cementing Collins and Murkowski’s opposition — and vice versa.

Working on some rewrites

The authors of Graham-Cassidy released a new version of the bill on Sunday night.

The bill divides federal funding to the states in a block grant form — a lump sum of sorts paid upfront to states — rather than the current percent match of actual spending.

The original bill used a formula that saw most states lose considerably, while a handful of mostly rural, Republican-controlled states gained funding. In the new version, the formula would be tweaked to benefit the states of members that have opposed or are wavering on the legislation.

WASHINGTON, DC – FEBRUARY 01: U.S. Sen. Susan Collins (R-ME) speaks during a news conference on Capitol Hill February 1, 2011 in Washington, DC. Sen. Joseph Lieberman (I-CT) and Collins discussed the release of a report that says that less than one percent of the 4,000-mile U.S.-Canada border is monitored by U.S. border officials.Alex Wong/Getty Images

Maine (Collins), Kentucky (Paul), Arizona (McCain), and Alaska (Murkowski), all get more federal funding than the original in the new version, according to a state-by-state breakdown released by the authors. But that does not account for the reduction in overall spending due to the Medicaid per capita caps in the bill — which would give states a set amount of money per Medicaid enrollee instead of fluctuating along with actual spending.

This means that the bill would still slice significant federal healthcare funding over the next 10 years and still drop off completely after that timeframe.

The bill also would loosen, and may even weaken further, protections for Americans with preexisting conditions — an issue highlighted by late-night host Jimmy Kimmel last week.

Under the new version, states can outline plans to bring down costs for healthcare in their state including loosening regulations created under Obamacare. That would allow states to loosen regulations that mandate insurers that keep costs down for people with preexisting conditions, possibly pricing them out of their care.

Additionally, states could introduce two different risk pools in their plan — which would allow sick people to be placed in a separate, likely much more expensive pool than healthier people.

Larry Levitt, a senior vice president at the Kaiser Family Foundation, a nonpartisan health policy think tank, said the new version should end debate over whether sick people are protected under Graham-Cassidy.

“If there was any question about Graham-Cassidy’s removal of federal protections for pre-existing conditions, this new draft is quite clear,” Levitt tweeted Sunday. “The language in the revised Graham-Cassidy bill on insurance regulation is quite convoluted. It could take time to sort out. But…”