A revised version of Senate Republicans’ latest plan to repeal the Affordable Care Act is similar to the original, but it appears to have been modified to garner votes from senators who have been reluctant to support it.

Like earlier repeal efforts, the new plan would also repeal the individual mandate to purchase insurance and get rid of certain subsidies for out-of-pocket health expenses.

But the measure still has important differences from the three bills that failed to pass the Senate in July and the one that passed the House in May. And it is those differences that create more uncertainty about the bill’s impact on the lives of millions of Americans.

How the Cassidy-Graham plan compares with other Republican bills

Cassidy-Graham Skinny repeal Partial repeal Repeal and replace House-passed plan Repeal Repeal Repeal Repeal Repeal Repeal Repeal Repeal Repeal Repeal Subsidies for out-of-pocket costs Repeal Keep Repeal Repeal Repeal Tax credits for premiums Repeal Keep Repeal Change Change Medicaid expansion Repeal Keep Repeal Change Change Essential health benefits Up to states Keep Keep Up to states Up to states Prohibitions on annual and lifetime limits Up to states Keep Keep Up to states Up to states Pre-existing conditions policy Up to states Keep Keep Up to states Up to states Restrictions on charging more for older Americans Up to states Keep Keep Up to states Up to states Taxes created under Obamacare Change Change Change Change Repeal Health savings account Change Change Change Change Change Dependent coverage until 26 Keep Keep Keep Keep Keep Vote results Expected

next week Failed

49-51 Failed

45-55 Failed

43-57 Passed

217-213 Increase in the number of uninsured in 10 years No score 16 million 32 million No score 23 million

The latest bill — introduced by Senator Bill Cassidy of Louisiana and Senator Lindsey Graham of South Carolina — gives states sweeping discretion to come up with their own health care systems through federal block grants.

“This would mean the biggest devolution of federal money and responsibility to states ever, and the results would be very unpredictable,” said Larry Levitt, a policy expert at the Kaiser Family Foundation.

1. States would get block grants in place of money for Affordable Care Act programs.

The Cassidy-Graham bill would repeal the expansion of Medicaid coverage to poor adults and cancel subsidies that help middle-income Americans afford insurance.

Beginning in 2020, states would get block grants they could use to replicate the Affordable Care Act programs, if they wanted to, or develop their own health care plans.

In the latest version of the Cassidy-Graham bill, states represented by senators who have been on the fence, including Alaska and Maine, would receive more money than under the current law.

HOW IT COMPARES

No other Republican plan called for replacing money for Medicaid expansion and subsidies with lump sums to states. Under most of the earlier plans, the way those programs are funded would have changed, but the Medicaid expansion and subsidies would not have been completely de-funded.

Lump sums were made available to the states in both the House bill and one of the earlier Senate bills, but the amounts were smaller and were intended to cover costs like premium increases that would result from repealing the individual mandate or creating high-risk pools.

IMPACT

The effects of the plan would depend entirely on what health insurance systems states decided to create, but over all, there would be less federal money to work with. And states that have expanded coverage for more of their residents under the Affordable Care Act would get less money under the plan.

While some states may use their block grants to replicate Affordable Care Act programs or provide other forms of health insurance, others may use the block grants to substitute for existing state spending instead of using it to offer health insurance to people covered under the Affordable Care Act. That choice could mean widely disparate outcomes in how many people retain coverage from state to state.

2. States can set many of their own health insurance standards.

Under the revised bill, states would not have to preserve some of the Affordable Care Act’s insurance regulations if they did not want to.

States could, for example, decide to allow insurers to omit some of the benefits they are currently required to provide, like coverage for maternity care, mental health care and drug addiction treatment. They could also let companies offer much skimpier plans.

Experts say that the language in the bill is confusing and inconsistent, but it appears that the revised bill would weaken the protections for people with pre-existing conditions and allow insurers to charge higher prices based on a person’s health status.

HOW IT COMPARES

The Cassidy-Graham bill proposes keeping the insurance market rules but asks states to waive them if they like. By contrast, one of the Senate plans that failed to pass had proposed waiving the rules at the federal level, but it would have allowed states to keep them if they liked.

The House bill had proposed allowing states to seek waivers for the regulations but also allowed for an $8 billion fund to help people with pre-existing conditions.

IMPACT

Under the plan, people with pre-existing conditions could be at risk of being priced out of the market because insurers in some states could charge them higher prices. It is possible that even if they could afford insurance that the skimpier benefit rules would mean that their plan did not cover some of the services they needed.

Republican leaders have repeatedly said that they would like to preserve protections for those with pre-existing conditions. President Trump said that the Cassidy-Graham bill would protect them, but that would be true only in states that chose not to eliminate those rules.

3. Federal funding disappears in 2027.

The state block grant program established under the bill would end after 2026 unless Congress decided to renew it.

HOW IT COMPARES

While previous bills proposed cuts and modifications to the Affordable Care Act programs, neither the House bill nor the earlier Senate bills proposed letting the funding expire.

IMPACT

If Congress did not renew the block grants, tens of millions of people would lose health insurance because states would have to roll back coverage or replace federal dollars. Any new programs states created with the block grants would most likely end.