Part of the Cassidy-Graham bill is tailored to sway a potential holdout

Senate Republicans are trying to revive the momentum to overhaul the Affordable Care Act with the Cassidy-Graham proposal. Here are five things to know about the plan and the rush to pass it. (Jenny Starrs/The Washington Post)

The sponsors of Senate Republicans’ latest effort to abolish much of the Affordable Care Act have woven favors into their bill for a potential key holdout, as evidence mounts that most states would lose billions of federal dollars for health coverage.

A few sentences embedded in the 140-page Cassidy-Graham legislation would allow Alaska to avoid a big reduction in government funding for low-income residents on Medicaid. The potential holdout, Sen. Lisa Murkowski (R-Alaska), has been negotiating privately this week with Senate GOP leaders.

Neither Murkowski nor the state’s junior senator, Dan Sullivan (R), have disclosed how they would vote if the bill is brought before the full Senate next week, as Senate Majority Leader Mitch McConnell (R-Ky.) maintains he will do.

It remained unclear late Thursday whether McConnell could amass the 50 votes needed under special budget procedures so that the measure — named for its primary sponsors, Sens. Bill Cassidy (R-La.) and Lindsey O. Graham (R-S.C.) — could pass without any Democratic support. Given a previous bill’s dramatic last-minute failure in July, with critical opposition by Murkowski, some Republicans say they do not believe leaders will put the current plan to a vote unless its passage is certain.

The courting of Alaska’s senior senator comes as intense efforts by advocates and critics to influence opinion shift to outside Washington.

At home in South Carolina, Graham is doing television and radio interviews and planning to call fellow senators and others to try to build support. “Phone firmly planted to his cheek,” his spokesman said.

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Only one Republican senator is holding sessions with constituents on the measure. At a town hall meeting in Charles City, Iowa, Sen. Joni Ernst said Thursday that she was “leaning yes.” She characterized the plan as the only viable alternative to what she called the ACA’s failures.

When audience members asked about the bill’s cuts to Medicaid spending, Ernst emphasized that spending would increase, just at a slower pace than under the current law.

Yet three independent analyses, released this week, found that the bill would slash federal spending on health coverage and cause most states to lose billions of dollars in such aid.

The latest report, by the Kaiser Family Foundation, said the plan would cut federal spending on health insurance by an average of 11 percent between 2020 and 2026 in the 31 states, plus the District of Columbia, that have expanded their Medicaid programs under the law. The states that have not expanded Medicaid — all but one led by Republicans — would gain an average of 12 percent during that period.

As a result, states that kept their Medicaid programs small would receive an extra $73 billion, while the federal money to the Medicaid expansion states would decrease by a total of $180 billion.

The bill would kill central features of the ACA, including its insurance subsidies, coverage requirements for individual Americans and large businesses, and benefits and other rules for health plans sold in marketplaces created under the law. Instead, in a devolution of unprecedented scale, a smaller amount of health-care money would be reshuffled around the country as block grants for much of the coming decade, with states having great freedom on how to spend it.

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“I am all for some state flexibility,” Kaiser President Drew Altman said Thursday, “but by cutting and dramatically redistributing federal funds and asking each state to come up with their own health system, this bill runs the risk of a free-for-all with confusion and potentially chaos for many years to come.”

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The forecasts are significant because the measure is hurtling toward a vote so quickly that the Congressional Budget Office is still working on only a rudimentary official projection.

Kaiser calculates an overall reduction of $160 billion between 2020, when most of the legislation’s changes would begin, and 2026, when it would stop funding the block grants.

Each of the analyses show that, regardless of whether Congress renewed spending for the block grants after 2026, federal aid for Medicaid would plummet nationwide, because the program’s entitlement funding would be replaced with a per-person cap. And over time, annual increases under that new method would tighten.

The specific provision in the bill that would help Alaska would exempt “low-density” states from the per-person cap if their block grants would decrease or stay level. That would help only Alaska and Montana.

Murkowski’s state is one of a few in which state officials are doing their own assessment of the legislation’s effects. Gov. Bill Walker (I) joined nine other governors this week in sending a letter to Senate leaders to express their opposition to the Cassidy-Graham bill in its current form. In an interview Thursday, Walker said, “I’m concerned about protecting Alaskans, and my comfort level is just not there yet.”

Murkowski’s office did not respond to a request for comment. Sullivan’s spokesman, Mike Anderson, suggested the bill is still evolving and that the senator “will comment when the final draft is released and he’s had time to review the language and the data.”

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Sean Sullivan and David Weigel contributed to this report.