Alaska Sen. Lisa Murkowski is the key vote on the Obamacare repeal, and everyone wants her on their side

Eliza Collins | USA TODAY

Show Caption Hide Caption Here's a glimpse at the latest GOP health care bill, Graham-Cassidy The bill would end the Affordable Care Act's Medicaid expansion and institute a per-person spending cap for the program. Video provided by Newsy

WASHINGTON — An ad urging Sen. Lisa Murkowski “to stand strong and vote ‘no’ on health care repeal” started airing on televisions across Alaska on Tuesday. That same day, Murkowski sat in a Republican-only lunch and listened as Vice President Pence urged the GOP caucus to get behind a bill that would overhaul the Affordable Care Act.

As Republican senators try once more to repeal and replace Obamacare before a Sept. 30 deadline, Murkowski — who voted against all three previous repeal attempts in the Senate this year — is facing pressure from all sides.

Supporters of Obamacare are showing up at her offices, calling, tweeting and blitzing her with ads asking her to vote against the Republican repeal bill. White House officials and her Senate colleagues are doing all they can to convince her to support it.

Because no Democrats are expected to vote for the bill, Republican leaders need 50 GOP votes in order to pass the repeal legislation sponsored by Sens. Lindsey Graham, R-S.C., Bill Cassidy, R-La., Dean Heller, R-Nev., and Ron Johnson, R-Wis. Right now, lawmakers estimate they’re just a few votes short of getting the bill passed. The Senate is expected to vote on the bill next week.

There are 52 Republicans in the Senate. Sen. Rand Paul, R-Ky., has indicated that he will not support the bill because it does not go far enough in repealing Obamacare. Sens. Susan Collins, R-Maine, and John McCain, R-Ariz., have both voted against prior repeal efforts and have not said whether they are ready to support this one.

The Graham-Cassidy bill would keep most of the existing taxes from Obamacare in place but send the money back to states in the form of block grants. The states could then design their own health care systems. But the bill would also end the Affordable Care Act expansion of Medicaid eligibility, stop government reimbursements to Planned Parenthood for non-abortion services and allow states to change protections for people with pre-existing conditions — all issues Murkowski has expressed concern with on previous bills.

The legislation would also overhaul traditional Medicaid funding nationally. Instead of reimbursing states for most of the cost of caring for Medicaid recipients, the federal government would send states a per capita allotment with limited growth. But according to an analysis from the nonpartisan Kaiser Family Foundation, the bill has a carveout that would specifically exempt Alaska and Montana from Medicaid cuts under this formula.

A group called Save My Care has launched a TV ad saying Murkowski "stood strong" in opposing a prior repeal bill and, once again, "we’re counting on you to stand strong and vote ‘no’ on health care repeal.”

Meanwhile, Republicans are lobbying Murkowski for her vote.

On Thursday, Graham, Cassidy and former senator Rick Santorum — who has been helping push the bill — made their pitch to Murkowski. It was not the first conversation she’d had with the bill’s co-sponsors.

Before Pence spoke at Tuesday's GOP lunch, he said, ”I want to make sure that members of the Senate know the president and our entire administration supports Graham-Cassidy. We think the American people need this.”

The White House told reporters that officials had been lobbying Alaska Gov. Bill Walker — an independent — to support the legislation as a way to influence Murkowski.

But on Tuesday, Walker signed on to a letter with a bipartisan group of governors urging Senate leadership to drop consideration of Graham-Cassidy and instead focus on a bipartisan solution to the flaws in Obamacare insurance markets.

"I’m not in support of it because I’m not convinced that it doesn’t hurt Alaskans," Walker told USA TODAY in an interview Thursday. “When you talk about straight block grants, we don’t fare well."

Alaska has a small population spread out over a massive rural state and has some of the highest health care costs in the country. One reason costs are so high is because much of the state isn’t connected by roads. Sometimes people have to fly or take boats to get to nearby cities for health care, and what would be an ambulance ride in another state ends up as a much more expensive helicopter or plane ride.

“I’ve talked to her regularly and she’s going through the same process I was going though," Walker said about Murkowski. He said he has shared his concerns with both of the states' senators, though Alaska’s other Republican senator, Dan Sullivan, has not raised public objections about the bill and voted for all three previous repeal attempts.

The state only has one insurance company available for people buying insurance on the individual market, Blue Cross Blue Shield. In a statement Wednesday, the insurer said that Graham-Cassidy would "increase uncertainty in the marketplace, making coverage more expensive and jeopardizing Americans’ choice of health plans."

Roughly one-fourth of the state is also on some form of Medicaid, including 36,000 who benefited from the Medicaid expansion under Obamacare.

"I was very, very comfortable in my decision to accept Medicaid expansion," Walker said.

Alaska was one of 31 states, along with Washington, D.C., that expanded Medicaid under the ACA to serve more low-income adults. If passed, the Graham-Cassidy bill would end the expansions in 2020. Instead, states would receive, through 2026, a block grant to apply their own system for helping low-income residents.

Walker’s opinion “is important to me … remember when you block grant things to states, it’s the governors that really determine ‘OK, what are we as a state of Alaska going to be doing?’ ” Murkowski told reporters Wednesday.

Murkowski has also expressed concern over bills that would end federal reimbursements for Planned Parenthood, which Graham-Cassidy would do for one year.

"I, for one, do not believe that Planned Parenthood has any place in our deliberations on the Affordable Care Act," Murkowski said in an address to Alaska state lawmakers earlier this year. "Taxpayer dollars should not be used to pay for abortions, but I will not vote to deny Alaskans access to the health services that Planned Parenthood provides."

It is already illegal for taxpayer dollars to be used for abortions, so any federal reimbursements are going to non-abortion related services.

“Our patients are counting on her to protect access once again like she did the last time,” Jessica Cler, Alaska public affairs manager with Planned Parenthood Votes, told USA TODAY. Cler said that dozens of activists have fanned out to Murkowski’s offices across the state to let her know they support her previous votes and want her to vote “no” again.