- Republicans are trying to replace Obamacare with a bill that will sharply cut federal health care spending and leave millions fewer Americans with insurance.
- The bill, Graham-Cassidy, would repeal Obamacare's expansion of Medicaid.
- To pass, Republicans need 22 more votes from among the 24 GOP senators representing states that would get less money.
"All politics is local," like the law of gravity, usually overpowers opposing forces. On repealing Obamacare, Republicans are testing it one more time.
With special rules preventing a Democratic filibuster set to expire in 10 days, President Donald Trump and the GOP-led Congress aim to quickly pass the bill sponsored by Republican Sens. Lindsey Graham of South Carolina and Bill Cassidy of Louisiana. Like earlier failed attempts to replace Obamacare, it would sharply cut federal health spending and leave millions fewer Americans with insurance.
But Graham-Cassidy, through its formula for allocating that shrinking federal pie, makes unusually vivid trade-offs between states that win and lose in the process. To pass it, GOP leaders will need the votes of Republican senators whose states will receive less money so that other states can receive more.
The biggest reason is that the bill repeals Obamacare's expansion of Medicaid. Under the expansion, the 31 states plus the District of Columbia that have been willing to cover more people under Medicaid got a large chunk of federal money to do so. Graham-Cassidy takes that money back, throws it into a giant federal pot with other current Obamacare subsidies, and then distributes it among all states in the form of block grants.
The result: All 16 states that would get more health-care money in 2026 than under Obamacare are states that have declined to expand Medicaid, according to calculations by the health-care consulting firm Avalere. Of the 27 Republican senators representing those states, none has yet signaled opposition to the bill.
To pass Graham-Cassidy, however, Republicans need 23 more votes from among the 25 GOP senators representing states that would get less money. That won't be easy.
Two "yes" votes will come from Cassidy and co-sponsor Sen. Dean Heller of Nevada. They are defying opposition from Louisiana's health secretary and Nevada's governor, who fear the bill would harm their states.
Yet others aren't so willing. Sen. Rand Paul of Kentucky, which Avalere calculates would receive $5 billion less in 2026, has announced his opposition; the staunch conservative explained that Graham-Cassidy doesn't do enough to get rid of Obamacare. Sen. Susan Collins of Maine, which would get $1 billion less, has signaled her likely "no" vote.
With all Democrats opposed, that means one additional Republican defection would sink the bill. The Republican-controlled state that would lose the most is Arizona, which would get $11 billion less in 2026.
That turns up the heat on Arizona Sens. John McCain, whose opposition sank the previous Obamacare repeal effort, and Jeff Flake, who voted for the last bill. Arizona's Republican Gov. Doug Ducey, by endorsing Graham-Cassidy, has made it easier for them to vote "yes."
Other Republican governors from states that would lose ground have not been so accommodating. Gov. Bill Walker of Alaska, which would lose $1 billion, has joined a bipartisan group of governors in opposition. That increases pressure on Alaska's GOP Sens. Lisa Murkowski, who also opposed the earlier Obamacare repeal, and Dan Sullivan.
So did Gov. John Kasich of Ohio, which would lose $9 billion. That makes it harder for wavering GOP Sen. Rob Portman to vote yes. Other loser states with Republican senators include Florida ($4 billion), Arkansas ($6 billion), Pennsylvania ($6 billion), and West Virginia ($1 billion).
In the end, undecided Republican senators could look past the impacts on their own states and vote with their party to avoid backlash from core supporters over a broken promise on Obamacare repeal. Trump has supported each iteration of the repeal effort even though the loss of health benefits would disproportionately harm his white working-class base.
But more often than not home-state interests prove decisive. Sen. Ted Cruz of Texas once burnished his reputation as an ideologically pristine champion of fiscal conservatism by opposing legislation aiding victims of Superstorm Sandy. He reversed course in recent weeks after Hurricane Harvey ravaged Texas.
Moreover, Cruz has broken with his normal ideological ally, Paul, to support Graham-Cassidy. According to Avalere, Texas would receive $35 billion more federal money in 2026 under the law, making it the biggest winner of any state.
Correction: This article was updated to reflect how Sen. Jeff Flake voted on the previous Obamacare repeal effort.