Senate Republicans and the White House pressed ahead Tuesday with their suddenly resurgent effort to undo the Affordable Care, even as their attempt was dealt a setback when a bipartisan group of governors came out against their proposal.
The collective criticism from 10 governors arrived as Vice President Pence and Senate Majority Leader Mitch McConnell tried to rally support for the bill, which is sponsored by GOP Sens. Bill Cassidy (La.), Lindsey O. Graham (S.C.), Dean Heller (Nev.) and Ron Johnson (Wis.).
But it was unclear whether the opposition would ultimately derail the attempt, as key Republican senators including Lisa Murkowski of Alaska said they had yet to make up their minds.
“We ask you not to consider the Graham-Cassidy-Heller-Johnson amendment and renew support for bipartisan efforts to make health care more available and affordable for all Americans,” the governors said in their letter.
They added that they prefer a bipartisan push to stabilize the insurance marketplaces that Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) had been negotiating before talks stalled on Tuesday evening.
The governors who signed the bill are particularly notable, since some are from states represented by Republican senators who are weighing whether to back the bill. Among them: Alaska Gov. Bill Walker (I), who holds some sway over Murkowski, a potentially decisive vote who opposed a previous Republican effort to repeal and replace the Affordable Care Act.
Nevertheless, Murkowski said Tuesday afternoon that she was still weighing her options and explained how her position on the bill might ultimately differ from her opposition to an earlier repeal bill that failed dramatically in July.
“If it can be shown that Alaska is not going to be disadvantaged, you gain additional flexibility. Then I can go back to Alaskans, and I can say, ‘Okay, let’s walk through this together.’ That’s where it could be different,” she said.
But Murkowski, who has been in close touch with Walker, said she did not yet have the data to make such a determination.
Alaska’s other Republican senator, Dan Sullivan, said he was still mulling whether to support the bill.
On Tuesday, Pence traveled from New York, where he was attending the annual U.N. General Assembly, to Washington with Graham in a sign of the White House’s support for the proposal.
“My message today is I want to make sure that members of the Senate know the president and our entire administration supports Graham-Cassidy,” Pence told reporters on the flight down. “We think the American people need this.”
Graham added that President Trump called him at 10:30 p.m. Monday.
“He says, ‘If we can pull this off, it’ll be a real accomplishment for the country,’ ” he recalled.
Pence attended the weekly Senate Republican policy luncheon, where he said the current health-care system is collapsing and the bill fulfills key GOP promises to return control to states and rein in federal entitlement programs, according to several GOP senators.
Afterward, McConnell declined to ensure a vote on the bill but said his team is working to secure sufficient support.
“We’re in the process of discussing all of this. Everybody knows that the opportunity expires at the end of the month,” said McConnell, referring to the limited window Republicans have to take advantage of a procedural tactic to pass a broad health-care bill without any Democratic support.
The current bill would give states control over billions in federal health-care spending and enact deep cuts to Medicaid. The Medicaid cuts are a major source of concern to the governors, both in terms of imposing a per capita cap on what states would receive as well as putting restrictions on how they could spend any federal aid on their expanded Medicaid populations.
The fact that the bill also would bar states from taxing health-care providers to fund their Medicaid programs posed a problem for several governors, as well.
In a sign of how alarmed state officials are about the prospect of the possible funding cuts, the Louisiana Health Secretary sent a letter to Cassidy on Monday saying the bill “singles-out Louisiana for disproportional cuts to our Federal funding” and “introduces the specter” of a state waiver process that could eliminate protections “affecting those with pre-existing conditions or complex and costly conditions.”
“This would be a detrimental step backwards for Louisiana,” wrote Gee, who posted her letter on Twitter Tuesday.
And while Walker has not played a visible role in the national health-care debate until now, certain aspects of the new bill pose an even bigger challenge for Alaska than previous proposals. Health-care premiums are particularly expensive in the state, given its many remote areas: premiums on the ACA market average roughly $1,000 a month for an individual, according to the most recent federal data.
Since the federal tax credits over time would be equalized and based on the number of low-income people in a given state, that new calculation would eliminate the more generous subsidies Alaska now enjoys.
“It’s a substantial amount of money, for Alaska,” said Larry Levitt, senior vice president for special initiatives at the Henry J. Kaiser Foundation.
Given the complex nature of the Graham-Cassidy proposal, it is difficult for both state officials and health-care analysts to predict exactly how much money a given state would gain or lose if it were enacted. But early estimates suggest that states with expanded Medicaid programs and active participation on the ACA market could face major cuts.
An initial estimate for Colorado, according to state officials, suggests that it could lose at least $700 million in annual federal funding by 2025. Since the state has roughly 450,000 in its Medicaid expansion program and another 100,000 receiving premium tax credits on its health care exchange, that could translate into hundreds of thousands of Coloradans losing coverage.
The governors who have been most outspoken in their criticism of the bill have been negotiating behind the scenes to bring as many state executives on board as possible, according to aides, tweaking the letter’s language over the past couple of days to get maximum support.
Also among the governors signing the letter: John Kasich (R-Ohio) and Brian Sandoval (R-Nev.). Sandoval’s positioning puts him at odds with Heller, who has been touting the bill as a co-sponsor.
Pence said Trump told him to reach out to some Democrats. He spoke to Sen. Joe Manchin III (D-W.Va.) over the weekend. But after reviewing the bill, Manchin said, the senator told Pence’s aides he could not support the legislation.
Schumer said he’s confident no Democrat will vote for the legislation because “it hurts people in every state.”
Democrats had been working furiously in the past 24 hours to advance talks between Alexander and Murray on a deal to immediately stabilize insurance marketplaces with federal subsidies. The negotiations rapidly escalated after weeks of slow but consistent talks after it became clear that Senate GOP leaders were serious about holding a health-care vote before the end of the month, according to several Senate aides.
Alexander on Tuesday downplayed expectations of reaching an agreement this week, telling reporters that the pair had reached an impasse.
“During the last month, we have worked hard and in good faith but have not found the necessary consensus among Republicans and Democrats to put a bill in the Senate leaders’ hands that could be enacted,” Alexander said in a statement.
Several Republicans said those talks were stymied last week after a group of 15 Democrats led by Sen. Bernie Sanders (I-Vt.) introduced a “Medicare for all” plan to extend federal benefits to all Americans.
Graham said the decision for his colleagues on health care is stark: “Socialism or federalism.”
“If you’re a Republican, chances are you believe in federalism. . . . I believe that most Republicans like the idea of state-controlled health care as opposed to Washington-controlled health care,” Graham said.
Ed O’Keefe and Ashley Parker contributed to this report.