For Republicans, Rounding Up Health Care Votes Could Prove Impossible

Updated at 4:30 p.m. ET

Republicans are facing even more uncertainty when it comes to finding the votes to pass a bill to repeal major parts of the Affordable Care Act, as familiar voices in divergent wings of the party show just how difficult it is for the GOP to unite on the issue of health care.

Withholding final judgment on GOP legislation to repeal the Affordable Care Act and remake the Medicaid system, Sen. Susan Collins, R-Maine, said Sunday morning on CNN's State of the Union that it's "difficult to envision a scenario where I would end up voting for this bill" and indicated she will make a final decision on Monday after the Congressional Budget Office provides a report on the legislation.

If Collins comes out against the bill, crafted by GOP Sens. Lindsey Graham and Bill Cassidy, it would not have the votes to pass and would be the last Republican attempt to repeal former President Barack Obama's signature legislation before a Sept. 30 procedural deadline that allows the GOP to pass health care legislation without the support of any Democrats or independents.

Collins reiterated some of what is giving her pause, including the major changes the bill would make to Medicaid, potential impact on premiums and deductibles, and what she fears would be lesser protections for people with pre-existing conditions.

The Graham-Cassidy bill would take the funds used for subsidies and the expansion of Medicaid under Affordable Care Act, also known as Obamacare, and transfer them to states in block grants, phasing out the funds completely by 2027. It would also change the open-ended entitlement structure of Medicaid, instead giving states money on a per-capita basis.

GOP senators and the Trump administration are still working to get Collins on board. Collins said she spoke to Vice President Pence on Saturday. "I told him about the various analyses of the impact that concern me. He told me he would get me more numbers on the impact on the state of Maine and on the nation."

Collins also said that senators are continuing to change the bill as they lobby to keep it from failing and that those changes could make it difficult for the Congressional Budget Office to provide a full analysis. She expects CBO to reinforce other private reports like one from the Brookings Insititution that shows 21 million fewer people would be insured by 2026 if the law were enacted, as opposed to projections under current law. CBO put out a statement saying that it would provide a partial assessment with projections of how the bill would affect the deficit but that it would not be able to provide projections for how many people would be insured and how much the legislation would cost for several weeks.

Cassidy, one of the bill's sponsors, told ABC's This Week that he will introduce a new bill Monday given the revisions that have been worked out, nullifying what CBO releases Monday.

Republicans need 50 of their 52 senators to vote for the bill under special budget rules that allow them to avoid the typical 60-vote threshold, which would require Democratic support. Those rules expire on Sept. 30.

Sens. Rand Paul and John McCain have already announced they are against it, leaving the bill within one vote of failure and earning them criticism from President Trump.

McCain criticized the closed process of drafting the bill, as opposed to going through "regular order" with open public hearings and votes in Senate committees. "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. But that has not been the case," he said in a statement on Friday.

Collins reiterated that criticism on Sunday morning, in addition to her concern about the impact of the policy.

Paul said he opposes the bill because it doesn't go far enough in repealing the Affordable Care Act, by maintaining many of the taxes while redirecting the funds to states. "I won't be bribed or bullied," Paul said as Trump has lambasted him.

Sen. Lisa Murkowski, R-Alaska, has not given any indication about which way she would vote. And during an appearance with The Texas Tribune on Saturday, Sen. Ted Cruz, R-Texas, made it clear that he is not on board after changes he proposed were left out of the bill. Cruz suggested that Utah Sen. Mike Lee might not support the bill, either. Opposition from any one of them would scuttle the bill regardless of how Collins eventually decides to vote.

Along with Paul, Cruz and Lee have sought changes to GOP bills all year long that would reduce federal health care funding beyond other Republican proposals. But such changes would likely cause Collins and Murkowski to oppose a bill, highlighting a simple math problem for GOP leadership trying to corral 50 votes — and it may prove to be insurmountable.

Senate Majority Leader Mitch McConnell's office said he "intends" to bring the Graham-Cassidy bill to the floor this week, but it's not known whether that would still happen if it's known to fail.

After Collins, McCain and Murkowski voted to sink the last GOP attempt to repeal Obamacare in July, bipartisan efforts to fix the health care system began. Those have been put on hold, but if Republicans can't pass a bill in the Senate by the end of the week, bipartisan efforts could pick up again.

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