Public Health: One Reason to Take the Latest Obamacare Repeal Seriously, and Three Reasons It Could Fail

But the bill faces substantial challenges, both political and procedural. Here are three reasons the effort may not succeed — and one very important reason it might.

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Bill Cassidy and Lindsey Graham in July. The two Republican senators are the originators of the latest effort to repeal the Affordable Care Act.

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Pablo Martinez Monsivais/Associated Press

1) Rand Paul is a hard no, which makes the math difficult.

Senator Rand Paul of Kentucky has been making a big point of how he dislikes this bill and won’t vote for it. He said so in a series of tweets on Monday. Then he held a news conference, saying he was immovable.

Without his vote, Senate leadership can afford to lose only one more. Senator John McCain of Arizona has offered mixed messages on the bill, and suggested on Monday that he was not yet endorsing the bill but might eventually.

So far, Senator Lisa Murkowski of Alaska and Senator Susan Collins of Maine have voted against every previous repeal attempt. They even voted against opening debate on the process that permitted consideration of the Graham-Cassidy option. If Mr. Paul holds firm, one of those two will need to change her mind.

It’s possible that Mr. Paul will switch sides, but he’s made it hard for himself to do so. Ms. Murkowski and Ms. Collins have said nothing about their intentions. But both raised objections about cuts to Medicaid in the earlier bill, and the new bill contains similar reductions. The bill’s funding formula also appears to be unkind to both Alaska and Maine.

2) There’s a huge redistribution of money between states in the bill’s formula. Losers include states with must-get senators.

The legislation sets up a complex formula for who gets what chunk of federal health care spending. The formula is devised to “equalize” spending among states. Currently, some states spend much more on Medicaid and the exchanges than others, either because they cover more people or because their systems are more generous or expensive. That redistribution of money means that some states would come out as big winners, but others would absorb big reductions.

Mr. Cassidy has pointed out that more than a third of Affordable Care Act spending goes to four states: California, New York, Massachusetts and Maryland. That’s roughly true. These are populous states that expanded their Medicaid programs and tend to have costly health care systems.

But it’s not just big, blue states that would lose out. According to estimates from the Center on Budget and Policy Priorities, a left-leaning think tank, Alaska, Arizona, Kentucky, Ohio and West Virginia, for example, would end up with less money by the end of a decade.

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Blue States Face Biggest Cuts Under New Republican Health Care Plan

Which states would gain or lose federal funding in 2026.



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Those states all contain Republican senators who have expressed some unease with earlier versions of Obamacare repeal, and they might wish to keep the bill off the floor to avoid a tough vote that would pit their broad political commitments to repeal against the more parochial concerns of their constituents. (Similar concerns might also crop up in the House, where a final vote would eventually need to be held.)

Over the long term, every state would lose money under the proposal. The big block grants would expire altogether in 2027.

3) The timing is tight, and the bill still has a long way to go, leaving little room for error.

Republicans are trying to pass the bill using a special budget procedure called reconciliation. That process allows them to pass the bill without needing any Democratic support, but it comes with a number of rules.

Under the reconciliation process, the bill requires an estimate of costs from the Congressional Budget Office. The office indicated that it would offer an initial assessment by “early next week,” but could not provide detailed estimates about what would happen to insurance coverage or premiums for several weeks. The score could discourage some senators from supporting the bill; an incomplete assessment might discourage others.

The bill will also need to be reviewed by the Senate’s parliamentarian to ensure that its provisions adhere to rules for the budget process. Some provisions, including restrictions on funding for abortion providers and the new option of work requirements for Medicaid beneficiaries, could run afoul of the rules and be scrubbed out in the “Byrd Bath.”

Any funding formula changes made to the bill to please reluctant senators could slow things down.

The parliamentarian has said that the Senate process needs to be wrapped up by the end of the month. That means that the bill needs a score, a Byrd Bath rules review and a vote in the Senate by the end of Saturday, Sept. 30. Then the legislation would need to go back to the House, where, after midnight of that day, it could not be changed again, only voted up or down.

1) But Obamacare repeal is a core promise for Republicans.

Republicans have been running on a promise to repeal Obamacare since 2010, and this bill appears to be their last chance to achieve that goal in the foreseeable future. Though they could initiate a new budget process to try again with health care, the president and congressional leadership want to use the process instead to pass tax reform.

Many members of Congress (and their staffs) are weary of the recent health care fight, which has been bruising and has yielded little political upside. But even for lawmakers with doubts about this particular piece of legislation, the prospect of a win on an issue dear to their base — not to mention getting President Trump to stop jeering that they are “wasting time” and “couldn’t get it done” — could be a powerful motivating force.

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