It seems like this should be an easy call for Murkowski. Photo: Chip Somodevilla/Getty Images

The Republicans’ latest health-care bill, Graham-Cassidy, is widely acknowledged to be even worse than their previous plans to repeal Obamacare. In addition to allowing states to waive protections for people with preexisting conditions, it takes the federal funding that would have gone toward Medicaid and helping people buy private insurance and lets states do whatever they want with it. Overall, the federal government would provide less funding than it does under Obamacare, but thanks to a complex distribution formula some states — generally red states that refused to expand Medicaid — would see a windfall, while other (typically blue) states would see devastating cuts. And it gets worse: If Congress fails to reauthorize the money, it all goes away after 2026.

Now an estimate from the Trump administration on how all that would affect individual states threatens to turn a key Republican senator against the bill.

As during the last Obamacare repeal push, the focus is on how Alaska senator Lisa Murkowski will vote. Murkowski was one of three Republican senators who killed “skinny repeal” in July, and with Maine senator Susan Collins and Kentucky senator Rand Paul suggesting they’re hard no’s, it’s likely she’ll be the deciding vote once again.

Though in the past Murkowski has said she’s in favor of protecting people with preexisting conditions, expanding coverage, and following regular order in the Senate — none of which are features of Graham-Cassidy — she remains officially undecided. Following a meeting with the bill’s sponsors earlier this week, she said she needed to see numbers on how the bill would affect Alaska.

“I have asked for nothing except the data that we’re going to need to better understand the impact to a high-cost, low-density state like Alaska,” Murkowski said.

With the GOP up against a September 30 deadline, there’s no time for the Congressional Budget Office to analyze the bill. While several independent analyses have shown significant losses for Alaska under the bill, Murkowski said she was seeking numbers from the Centers for Medicare and Medicaid Services and the Department of Health and Human Services, and “working with our state’s Medicaid directors.”

On Thursday night, those sources weighed in on Graham-Cassidy, and their prognosis was grim. Axios reported that the projections from CMS, a federal agency within the Department of Health and Human Services, show that under Graham-Cassidy overall federal health funding would be 9 percent lower in 2026 compared to the current law, and 31 states would lose federal money.

Some of the figures are almost unbelievable, like Connecticut’s loss of 52 percent of its federal health dollars by 2026, and Mississippi’s 347 percent funding increase. Arizona — home of potential “no” vote John McCain — would lose 9 percent of its funding. But the most significant figure may be Alaska’s loss of 38 percent of its federal dollars by 2026.

There are various rumors about Republicans making tweaks to Graham-Cassidy to make it more generous to Alaska — which has incredibly high health-care costs — to win Murkowski’s vote. There was even a report on Thursday that they were offering to let Alaska essentially keep Obamacare if Murkowski would just vote to take it away from the rest of the country. That may be unconstitutional, and back in June Murkowski said she wouldn’t take a deal like that.

“Let’s just say that they do something that’s so Alaska-specific just to, quote, ‘get me,’” Murkowski said. “Then you have a nationwide system that doesn’t work. That then comes crashing down and Alaska’s not able to kind of keep it together on its own.”

If Murkowski needs any more convincing, she can also turn to the unprecedented statement from all 50 state Medicaid directors opposing Graham-Cassidy. In the statement released Thursday, the National Association of Medicaid Directors said they’re concerned that the bill would put a massive burden on the states and “fail to deliver on our collective goal of an improved health care system.”

They say the block grants and per-capita caps on federal Medicaid spending would amount to “the largest intergovernmental transfer of financial risk from the federal government to the states in our country’s history.” They also highlight one major issue that’s received relatively little attention: Every state would have to set up a system to distribute the health funding in the block grants. That was a difficult process under Obamacare, and this time states would have just two years and no federal help in setting up an entirely new state health system.

The Medicaid directors say the states can’t accomplish that:

The scope of this work, and the resources required to support state planning and implementation activities, cannot be overstated. States will need to develop overall strategies, invest in infrastructure development, systems changes, provider and managed care plan contracting, and perform a host of other activities. The vast majority of states will not be able to do so within the two-year timeframe envisioned here, especially considering the apparent lack of federal funding in the bill to support these critical activities.

It was clear Graham-Cassidy failed Murkowski’s criteria for an Obamacare repeal plan days ago. Now she has the data and expert testimonials to prove it. And Alaska’s governor is against it. And the local news in Alaska is featuring parents begging Murkowski to vote no. What reason could she possibly have to support the bill?

Allow Republican senator Chuck Grassley to explain: