Sen. Susan Collins (R-Maine) became the third GOP senator to confirm a no vote on the latest Republican attempt to repeal and replace the Affordable Care Act (ACA), a move that likely seals the bill’s fate.

The bill has the support of President Trump and many GOP leaders but has been roundly criticized by medical groups for insuring fewer Americans, failing to provide adequate protections for people with preexisting conditions, and barring Planned Parenthood from Medicaid participation.

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“Sweeping reforms to our health care system and to Medicaid can’t be done well in a compressed time frame, especially when the actual bill is a moving target,” Sen. Collins said in a Sept. 25 statement announcing her opposition to a bill sponsored by Sen. Lindsey Graham (R-S.C.), Sen. Bill Cassidy (R-La.), Sen. Dean Heller (R-Nev.), and Sen. Ron Johnson (R-Wis.).

Since its introduction in mid September, the bill has undergone at least four published revisions, including providing additional funding to Maine and Alaska in an effort to flip Sen. Collins and Sen. Lisa Murkowski (R-Alaska) to the yes column. Both were no votes that helped kill a previous ACA repeal and replace effort.

“The fact is, Maine still loses money under whichever version of the Graham-Cassidy bill we consider because the bill uses what could be described as a ‘give with one hand, take with the other’ distribution model” to maintain the budget neutrality of the Medicaid block grants sent to states, Sen. Collins said. “Huge Medicaid cuts down the road more than offset any short-term influx of money.”

Sen. Collins’ opposition came on the heels of a damaging analysis from the Congressional Budget Office (CBO). The preliminary analysis looked at an earlier version of the bill and found that the number of people with comprehensive health insurance would be reduced by millions and the impact would be particularly large starting in 2020, when the bill would make changes to Medicaid funding and the nongroup insurance market.

Since Senate Republicans are using the budget reconciliation process to pass this legislation, they only need 50 votes to pass the legislation, with Vice President Mike Pence providing the tie-breaking vote. But with a slim 52-seat majority, there was little margin for error. Sen. John McCain (R-Ariz.) had already announced his opposition to the Graham-Cassidy bill on Sept. 22, primarily on process grounds.

“We should not be content to pass health care legislation on a party-line basis, as Democrats did when they rammed Obamacare through Congress in 2009. If we do, our success could be as short-lived as theirs, when the political winds shift, as they regularly do,” Sen. McCain said in a statement. “The issue is too important, and too many lives are at risk, for us to leave the American people guessing from one election to the next whether and how they will acquire health insurance. A bill of this impact requires a bipartisan approach.”

He praised the work of Senate Health, Education, Labor & Pensions Committee Chairman Lamar Alexander (R-Tenn.) and Ranking Member Patty Murray (D-Wash.), who have been working together on a small, focused package aimed at stabilizing the individual insurance market.

“Senators Alexander and Murray have been negotiating in good faith to fix some of the problems with Obamacare,” Sen. McCain said. “But I fear that the prospect of one last attempt at a strictly Republican bill has left the impression that their efforts cannot succeed. I hope they will resume their work should this last attempt at a partisan solution fail.”

Sen. Rand Paul (R-Ky.) also came out publicly against the Graham-Cassidy bill, though his opposition stems from it not going far enough in repealing elements of the ACA.

During a Sept. 25 Senate Finance Committee hearing on the Graham-Cassidy bill, Teresa Miller, acting secretary of the Pennsylvania Department of Human Services, testified that the real problem – the cost of health care – is getting pushed aside as everyone focuses on the coverage issue.

“This whole debate, for the last several years, has been about coverage and we haven’t been talking about the cost of health care,” Ms. Miller told the committee. “At the end of the day, insurance is a reflection of the cost of health care. So if we don’t have a debate in this county and discussion about how we get at the underlying cost of care, we have a major problem. That’s really the debate we should be having.”

Senate Majority Leader Mitch McConnell (R-Ky.) has not signaled whether he would still bring Graham-Cassidy to a vote, given that it appears not to have the votes needed for passage. If he chooses to move forward with the bill, the vote would need to happen before the end of the day on Sept. 30 to use the budget reconciliation process and gain passage with a simple majority.

gtwachtman@frontlinemedcom.com

Sen. Collins deals likely fatal blow to GOP’s health bill