Sen. Susan Collins (R-ME) said Monday she opposes the Graham-Cassidy bill to repeal and replace Obamacare, likely the final blow to the legislation unless one of its opponents unexpectedly changes his or her mind.

Collins joins Sens. John McCain (R-AZ) and Rand Paul (R-KY) in opposing the bill. Because 50 of the 52 Senate Republicans must support Graham-Cassidy for it to pass, those three votes would be enough to kill it.

“Health care is a deeply personal, complex issue that affects every single one of us and one-sixth of the American economy,” Collins said in a statement. “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.”

Collins cited three concerns with the bill, which would turn much of Obamacare’s funding into a block grant while also overhauling Medicaid:

The Medicaid cuts

The rollback of protections for people with preexisting conditions

The opposition of various health care groups, which said the bill would lead to higher premiums and millions fewer people having health coverage

Collins was long suspected to be a “no” — she opposed all previous attempts this year to repeal the health law — but she made it official after the Congressional Budget Office released a preliminary analysis that said millions fewer Americans would have health insurance under Graham-Cassidy.

All three Republican dissenters are objecting for different reasons:

McCain objects to the rushed process that produced the bill and wants to return to bipartisan legislating on health care. His position is almost certainly not going to change.

Paul has opposed the plan because, he argues, it keeps too much of Obamacare and creates a new Republican spending program. The Kentucky senator has argued that Republicans should either fully repeal the law with no replacement or focus on only repealing the parts of the law on which Republicans broadly agree, like the “skinny” repeal bill that got 49 votes in late July.

While Paul has left the door open to negotiating on Graham-Cassidy, his demands include eliminating the block grant program at the heart of the bill. So his opposition also looks entrenched, barring a remarkable reversal.

Not only would Senate leaders need to convert a current opponent to pass Graham-Cassidy, but other holdouts — like Sen. Lisa Murkowski (R-AK) and Ted Cruz (R-TX) — would also need to come around to get to 50 votes. The path looks impossibly long, with only a few days left for unlikely flip-flops and for skeptics to be won over.

Senate Republicans still have until September 30 to pass the bill using the current “budget reconciliation” privileges that allow it to pass with only a bare majority. After that, they would have to at the very least pass a new budget resolution to restart the process.

Collins’s full statement is below.

Health care is a deeply personal, complex issue that affects every single one of us and one-sixth of the American economy. 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. Today, we find out that there is now a fourth version of the Graham-Cassidy proposal, which is as deeply flawed as the previous iterations. The fact that a new version of this bill was released the very week we are supposed to vote compounds the problem.

I have three major concerns with both the proposal that we were discussing last week and the newest version that was put together this weekend:

First, both proposals make sweeping changes and cuts in the Medicaid program. Expert projections show that more than $1 trillion would be taken out of the Medicaid program between the years 2020 and 2036. This would have a devastating impact to a program that has been on the books for 50 years and provides health care to our most vulnerable citizens, including disabled children and low-income seniors.

Second, both bills open the door for states to weaken protections for people with pre-existing conditions, such as asthma, cancer, heart disease, arthritis, and diabetes. Some states could allow higher premiums for individuals with pre-existing conditions, potentially making their insurance unaffordable. States could also limit specific categories of benefits for Affordable Care Act policies, such as eliminating coverage for mental health or substance abuse treatment.

Third, physicians, patient advocates, insurers, and hospitals agree that both versions of this legislation would lead to higher premiums and reduced coverage for tens of millions of Americans.

The CBO’s analysis on the earlier version of the bill, incomplete though it is due to time constraints, confirms that this bill will have a substantially negative impact on the number of people covered by insurance.

There has been some discussion that the new version of the bill includes additional money for my home state of Maine. The fact is, Maine still loses money under whichever version of the Graham-Cassidy bill we consider because the bills use what could be described as a “give with one hand, take with the other” distribution model. Huge Medicaid cuts down the road more than offset any short-term influx of money. But even more important, if Senators can adjust a funding formula over a weekend to help a single state, they could just as easily adjust that formula in the future to hurt that state. This is simply not the way that we should be approaching an important and complex issue that must be handled thoughtfully and fairly for all Americans.

The Affordable Care Act has many flaws that need to be addressed. The current state of health insurance, where premiums are skyrocketing, choices are limited, and small businesses are struggling, needs fixing. My focus will remain on remedying these problems.

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