Republican senator’s stance will make it increasingly difficult for party leaders to get the votes they need to eliminate the Affordable Care Act

This article is more than 2 years old

This article is more than 2 years old

John McCain said on Friday he could not “in good conscience” vote for the latest Republican proposal to replace the Affordable Care Act (ACA), dealing a potentially fatal blow to the plan.



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The Arizona senator, who in July derailed the last Republican repeal effort with a dramatic “no” vote, said in a statement he disapproved of the fast-track process GOP leaders are seeking to use to pass the reform, the latest draft of which was authored by Bill Cassidy of Louisiana and Lindsey Graham of South Carolina.

“I cannot in good conscience vote for the Graham-Cassidy proposal,” McCain said. “I believe we could do better working together, Republicans and Democrats, and have not yet really tried. Nor could I support it without knowing how much it will cost, how it will effect insurance premiums [sic], and how many people will be helped or hurt by it.”

McCain’s decision makes it increasingly difficult for Republican leaders to get the votes they need to fulfil their biggest promise of the last decade: to repeal the ACA.

Republicans hold a slim majority in the Senate, with 52 of 100 seats. The process the party is using to pursue healthcare reform, known as “reconciliation”, enables them to pass legislation with a simple majority: 51 votes.



If the Senate were split 50-50, Vice-President Mike Pence would break the tie. As a result, Republicans can afford to lose the votes of two senators. The Kentucky senator Rand Paul has said he is firmly against the Graham-Cassidy bill because he does not believe it does enough to repeal the existing healthcare law.

John Thune, from South Dakota and a member of GOP leadership, said McCain’s defection was “certainly not a good development” but added that there was still a chance his party could find enough votes.

“There are a couple of uncommitted members and there is an opportunity between now and 30 September, the end of next week, to get … an affirmative vote,” Thune said on Fox News. “We know this issue is not going away.”

Susan Collins, a Republican from Maine who also voted against the last attempt at repeal, said on Friday she was “leaning against” the new proposal.

Lisa Murkowski of Alaska, another who voted no in July, has also expressed deep skepticism over Graham-Cassidy.

McCain’s decision was also notable given his close friendship with Graham. “I take no pleasure in announcing my opposition,” he said. “Far from it. The bill’s authors are my dear friends.”

In a statement of his own, Graham said McCain’s decision had no bearing on their friendship and defended his legislation as the “best chance to repeal and replace Obamacare”.

“I feel an obligation to fix this disaster and intend to push forward for state-centric healthcare versus Washington-knows-best healthcare,” Graham said, adding: “We press on.”

Democrats cheered McCain’s decision and urged Republicans to resume negotiations over a bipartisan effort to stabilize insurance markets by providing certainty around ACA payments to insurers. Such talks stalled as Graham-Cassidy gained momentum.

“John McCain shows the same courage in Congress that he showed when he was a naval aviator,” said Chuck Schumer of New York, the Senate minority leader. “I have assured Senator McCain that as soon as repeal is off the table, we Democrats are intent on resuming the bipartisan process.”

The Graham-Cassidy proposal has prompted significant backlash across the healthcare sector. Several leading physicians’ associations, the lobbying group that represents the insurance industry, consumer advocacy groups, hospitals, governors and Medicaid officials all came out against the bill.



Graham-Cassidy would eliminate the ACA expansion of Medicaid, the federal program that helps provide access to healthcare to low-income individuals. It would also gut coverage requirements for pre-existing conditions, enabling insurers to charge higher premiums to sick people or to refuse coverage entirely.

The latter was highlighted by the comedian Jimmy Kimmel, who dedicated the opening monologues of his late-night talkshow this week to attacking the Republican plan and branding Cassidy a liar.



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Cassidy, who appeared on Kimmel’s show in May, created the so-called “Jimmy Kimmel test”, under which no family would be denied healthcare because they could not afford it. The issue has been deeply personal for Kimmel, who shared the story of his newborn son requiring surgery for heart problems that qualify as a pre-existing condition.



The bill Cassidy wrote with Graham would also allow states to opt out of coverage requirements established under the ACA for “essential health benefits”, which include maternity care and prescription drugs.



The stated goal of the Republican plan, much like other failed attempts at repeal, is to give more control to the states. Under the bill, states would have more discretion over how to use federal funds to deliver healthcare coverage. However, under the complex formula used to calculate how funds would be distributed, most states – including Arizona – would receive less funding than under the ACA.



Graham-Cassidy would replace the ACA’s Medicaid expansion and insurance subsidies with a new block grant program for the years 2020, when it would go into effect, to 2026. Federal funding for Medicaid would also be capped.

An analysis released by the Kaiser Family Foundation found that 35 states would lose $160bn in federal funding under Graham-Cassidy. The Trump administration’s own data, which was reported by Axios, showed 31 states set to lose federal funding, with Alaska incurring a 38% cut in 2026.