WASHINGTON — Health insurers, who had been strangely quiet for much of the year, came off the sidelines to criticize it. Many state Medicaid directors could not stomach it, either.
For months now, proposals to repeal and replace the Affordable Care Act have risen and fallen in the House and the Senate, almost always uniting health care providers and patient advocacy groups in opposition but winning support among conservatives, including Republican policymakers. But the version drafted by Sens. Lindsey Graham of South Carolina and Bill Cassidy of Louisiana — and hastily brought into the spotlight last week — went further.
It brought much of the health care world together to stop it, an effort that appears to have succeeded — not for ideological reasons, but for the simple reason that administrators, caregivers, advocates and insurers believed it would not work.
Senate Republican leaders hoped to bring the measure to the Senate floor for a vote this week. But the bill is on life support after Sen. John McCain, the unpredictable Arizona Republican whose dramatic "no" vote killed the previous repeal effort, announced Friday that he could not "in good conscience" vote for the bill. He joined Sen. Rand Paul, R-Ky., in opposition — and Sen. Susan Collins, R-Maine, is leaning hard toward no.
The three would be enough to doom the bill.
"I think Republicans remain pretty trapped between an abstract promise to repeal the Affordable Care Act and the reality of what that would mean," said Matthew Fiedler, an economist at the Brookings Institution who advised President Barack Obama on health policy. "That basic tension is going to remain."
Should the Graham-Cassidy measure die, it would almost surely end the long Republican quest to repeal and replace the Affordable Care Act, Obama's signature domestic achievement. If the Senate does not vote by Sept. 30, the drive to kill the law will lose special protections under Senate rules that allow it to pass with a simple majority, rather than the 60 votes necessary to overcome a filibuster.
The Senate Finance Committee has scheduled a hearing on the measure for Monday, and proponents of the repeal bill say they are not giving up. "The deadline is still a week away," said Tommy Binion, who handles government relations for the Heritage Foundation, a conservative policy organization. "It is one of the last trains leaving the station, and it is a political imperative for the Republican Party. I think we are going to go through a couple more loop de loops on this roller coaster before we are all done."
In a series of tweets early Saturday, President Donald Trump, who has embraced the legislation in recent days, appeared to be nurturing hopes that the legislative effort could be kept alive. He voiced optimism that Paul would rethink his opposition "for the good of the party." He also indicated that he thought Sen. Lisa Murkowski, R-Alaska, who had wavered publicly about the measure, would support it, though her spokeswoman has said only that the senator was studying the bill.
At the same time, Trump vented his frustration with McCain, saying he had let his state down and been deceived by Democrats into abandoning a promise.
Patient advocacy groups, who also oppose the Graham-Cassidy measure, say they will continue their fight. "We are certainly not relaxing our efforts, because the vote count is not clear," said Sue Nelson, a vice president of the American Heart Association, which is fighting to preserve the 2010 health law. "We are going full-steam ahead with advertising, lobbying and grass-roots efforts to contact members of Congress."
The pressure on Republicans to fulfill their promise has been intense — not only from the voters who helped elect them, but also from conservative donors. Doug Deason, a wealthy Dallas businessman who manages money for his billionaire father, said he had formed a loose-knit coalition of donors who warned senior Republicans — including Sen. Mitch McConnell of Kentucky, the majority leader — that contributions would dry up if Congress did not overhaul the tax code and repeal the Affordable Care Act.
"We said we're not interested in meeting with him until he gets something done," Deason said, recounting a telephone conversation he had with McConnell over the summer. "He needs to lead."
The drive for repeal of the Affordable Care Act appeared to be dead at the end of July, after McCain's "no" vote on a "skinny repeal" measure that was designed purely as a vehicle to permit negotiations with the House, which had passed a much more ambitious bill. That measure also had critics who called it unworkable and potentially disastrous for the insurance market, but Republican leaders could argue that they never intended to actually enact it. They were prepared to discard their handiwork as soon as House-Senate negotiations could start.
The talks never did.
"It is time to move on," a dejected McConnell declared at the time.
But behind the scenes, Graham, whose main expertise is in military affairs, and Cassidy, a gastroenterologist, had already been working with Rick Santorum, a Republican former senator from Pennsylvania, on a measure that morphed into the Graham-Cassidy bill.
Their collaboration, Santorum said, grew out of a chance meeting between him and Graham in the Senate barbershop last spring. Santorum had already been working with members of the conservative House Freedom Caucus on a bill to take much of the money spent under the Affordable Care Act and send it to states, with vast discretion over how to use it for health care.
"I thought maybe I should bounce this idea off Lindsey and see what he thinks," Santorum said, adding that he thought the measure could attract the votes of Senate Republican moderates.
Santorum argues that giving governors control over how to spend health care dollars will create efficiencies in the system, and disputes as a "false narrative" the idea that states will get less money under the bill.
The bill would require states to organize their own health care systems by 2020 — a time frame that many health care experts say is unworkable — and would also give states a way to roll back protections for people with pre-existing conditions.
If enacted, the measure would constitute "the largest transfer of financial risk from the federal government to the states in our country's history," said the National Association of Medicaid Directors, whose members run the program for more than 70 million Americans.
Beyond that fast time frame, the bill faces other hurdles, said Fiedler of the Brookings Institution. Politically, it almost appears designed to fail, because many more states would lose money under it than would gain. Many of those losing states are represented by Republican senators whose votes are vital: Rob Portman of Ohio, Shelley Moore Capito of West Virginia, Cory Gardner of Colorado, McCain and Collins, to name a few.
And the legislation would set a cap on how much federal support states would receive per person enrolled in the Medicaid program, while health care costs are rising more quickly than the scheduled growth rate for the cap.
"One of the objectives that Republicans have come to this debate with is to reduce federal spending on health care, and it is very difficult to do that, ultimately, without reducing the people covered," Fiedler said. "If you're not making the underlying health care delivery system more efficient, all you're doing is shifting around the costs."
The bill would take money spent under the Affordable Care Act and give it to states in the form of block grants. State officials, including some who initially supported the Graham-Cassidy bill, were dismayed when they saw how much money their states could lose.
"We equalize how much each American receives toward her care, irrespective of where she lives," Cassidy said. "I don't see why a lower-income American in Mississippi should receive so much less than a lower-income American in Massachusetts."
The bill would, in effect, penalize states that have expanded coverage through Medicaid and the public marketplaces created by the Affordable Care Act. An analysis by the consulting firm Avalere Health found the measure would reduce overall federal funding to states by $215 billion through 2026, and by more than $4 trillion over a 20-year period.
Graham and Cassidy, unlike some Republicans, have tried to explain and defend their proposal. But they have been overwhelmed by a tidal wave of criticism from doctors, hospitals, insurers, governors and patients — and even late-night comedian Jimmy Kimmel. Critics object to these provisions:
— The bill could weaken consumer protections in the Affordable Care Act. It envisions waivers of federal law that would allow insurers to charge higher premiums to sick people or omit some of the benefits that are now guaranteed, such as maternity care, mental health services or treatment for drug addiction.
— It would eliminate the federal tax credits and other subsidies that make health insurance more affordable for people with low and moderate incomes, letting states decide how to use the money.
— It would end the expansion of Medicaid, which has provided insurance to low-income people in 31 states of all political hues. The states include Alaska, Arizona, Arkansas, Colorado, Indiana, Louisiana, New York and West Virginia.
"People are scared," said Sen. Sherrod Brown, D-Ohio. "They read in the paper, they see on TV, they see online that their insurance might be taken away. There's a lot of fear in this society injected by government, and they should be ashamed of themselves."
Julie Hirschfeld Davis contributed reporting from Somerset, N.J.