Bill Cassidy, Lindsey Graham (copy)

In this July 13, 2017, file photo, Sen. Bill Cassidy, R-La., left, and Sen. Lindsey Graham, R-S.C., right, talk while walking to a meeting on Capitol Hill in Washington. Senate Republicans are planning a final, uphill push to erase President Barack Obama's health care law. But Democrats and their allies are going all-out to stop the drive. The initial Republican effort crashed in July in the GOP-run Senate. Majority Leader Mitch McConnell said after that defeat that he'd not revisit the issue without the votes to succeed. Graham and Cassidy are leading the new GOP charge and they'd transform much of Obama's law into block grants and let states decide how to spend the money. (AP Photo/Pablo Martinez Monsivais, File)

Pablo Martinez Monsivais

WASHINGTON — Months of furious work on a conservative health care overhaul by U.S. Sen. Bill Cassidy of Louisiana and his staff will reach a culmination this week in a frenzied final uphill push for votes.

The odds appear to be stacking against the proposal Cassidy co-authored with Sen. Lindsey Graham, R-South Carolina, to repeal and replace the Affordable Care Act, also known as Obamacare, with several Republican colleagues wavering over whether to support the bill just days from a Saturday legislative deadline to pass it through the Senate on a simple-majority, party line vote.

The Cassidy-Graham plan is slated for a late Monday morning hearing before the U.S. Senate's finance committee, the first stop on a potentially frenetic rush toward a vote on the Senate floor. A partial, initial analysis of the bill by the nonpartisan Congressional Budget Office is also expected on Monday morning.

Despite increasingly long odds against them, Cassidy and Graham have forged ahead, continuing to try to sell their colleagues on their strategy to fulfill years of Republican campaign promises to scrap the 2010 Affordable Care Act, the signature legislative achievement of former President Barack Obama. Their efforts have perhaps been buoyed by President Donald Trump, who prodded undecided Republican senators and ripped into opponents of the bill in a series of tweets Saturday morning.

Two key Republican senators — Arizona's John McCain and Kentucky's Rand Paul — have publicly indicated they'll vote against the Cassidy-Graham plan. Losing one more Republican vote would erase the party's narrow majority and, given united Democratic opposition, sink the bill. Sen. Susan Collins, R-Maine, told CNN on Sunday morning it was "very difficult for me to envision a scenario where I would end up voting for this bill" but said she was waiting to review the CBO score on Monday before making a final decision.

Just one more Republican defector joining McCain and Paul against the Cassidy-Graham proposal would kill it.

Sen. Lisa Murkowski, R-Alaska, is also seen as a key potential swing vote on the Cassidy-Graham plan. Murkowski joined McCain and Collins in killing Senate Republicans' previous attempt to repeal Obamacare in July and has expressed concerns about deep cuts to Alaskan federal health care funding under the Cassidy-Graham plan.

"Alaska had a 200% plus increase in premiums under ObamaCare, worst in the country. Deductibles high, people angry! Lisa M comes through," Trump tweeted shortly before sunrise Saturday morning.

"Right now, they don’t have my vote, and I don’t think they have (Sen.) Mike Lee’s, (R-Utah) either," Sen. Ted Cruz, R-Texas, said at a Sunday morning event in Austin, Texas.

Cruz's surprise skepticism of the Cassidy-Graham plan adds to growing unease from the Republican Party's conservative firebrands, likely complicating any efforts by the bill's sponsors to win over moderates like Collins and Murkowski through tweaks to the plan or its funding formulas.

The bill, largely drafted by Cassidy and his staff over more than a month of relentless work, would keep many (though not all) of the Affordable Care Act's taxes in place. Instead of spending billions of federal dollars on the Medicaid expansion and individual insurance subsidies, the Cassidy-Graham plan would package most of that money into block grants for states.

The formula would shift billions in funding away from states that expanded Medicaid — including Louisiana — or that have enrolled large numbers of moderate-income residents in subsidized insurance plans under the Obamacare exchanges. Most states that opted not to expand Medicaid would see a bump in funding under Cassidy-Graham.

The bill would repeal penalties for individuals who don't buy health insurance and repeal requirements that businesses of a certain size provide employer-sponsored health insurance. Also, federal funding for traditional Medicaid would be capped under the plan.

Sens. Ron Johnson, R-Wisconsin, and Dean Heller, R-Nevada, are co-sponsoring the plan. Former Sen. Rick Santorum, R-Pennsylvania, helped craft the proposal and has been lobbying former colleagues.

Analyses of Cassidy-Graham by a range of groups, including several left-leaning think tanks as well as the Trump administration's Centers for Medicare and Medicaid, have indicated the proposal would cut federal health care funding by billions.

Opposition to the plan, which could potentially have far-reaching implications for health care in the United States, especially for the disabled and those with low incomes, has extended beyond the Democratic minority in Congress and includes a bipartisan group of governors and a number of health groups.

Sens. Rob Portman, R-Ohio, Shelley Moore Capito, R-West Virginia, and Cory Gardner, R-Colorado, have not indicated publicly which way they'll vote. All represent swing states that expanded Medicaid and would likely stand to lose out on funding under Cassidy-Graham.

The national Blue Cross Blue Shield Association and America's Health Insurance Plans, two major trade groups for the insurance industry, have come out against Cassidy-Graham, as did insurance firm Kaiser Permanente.

The American Medical Association, the nation's largest association of physicians, and the American Hospital Association also urged lawmakers to vote against it.

study by the centrist Brookings Institution estimates that about 21 million more people would be without health insurance each year under Cassidy-Graham block grants than under the Affordable Care Act. The study's authors described those estimates as conservative, noting that individual states might face addition problems setting up their own health care systems.

Jeff Drozda, CEO of the Louisiana Association of Health Plans, which represents the health benefits industry, including managed-care companies that cover more than 1 million Medicaid recipients, said his group is optimistic the Cassidy-Graham bill could address issues in the health insurance markets.

But Drozda said he's also concerned about some of the language in the bill, particularly its impact on the roughly 435,000 Louisianans covered under the Medicaid expansion. Drozda, who has a meeting with Cassidy in Washington this week to discuss this bill and other issues, said he remains hopeful some language in the proposal could be tweaked.

"In the end, we’re very optimistic that there can be some movement on the issues on which we’re concerned," Drozda said Friday. 

“Louisiana hospitals support proposals that improve access to affordable coverage and critical medical services throughout our state,” said Paul Salles, president and CEO of the Louisiana Hospital Association. “We have concerns about the potential impact of the Graham-Cassidy-Heller-Johnson proposal and urge Senators to wait for a thorough analysis by the Congressional Budget Office. We appreciate Senator Cassidy’s engagement in health reform and want to continue working with him in this area."

"While several of this bill's provisions are cause for concern, our most pressing worry is centered around this bill's threat to the Medicaid program," said Ryan Sinitiere, a spokesman for the Louisiana Primary Care Association, a nonprofit group that represents community health centers across the state. "While we agree that state control over its policies and budget can be beneficial, we think that block granting Medicaid will be detrimental to Community Health Centers and their patients."

In general, key stakeholders in Louisiana's health care system appeared alarmed by the potential cuts in Medicaid funding and what the plan would likely mean for those covered by the Medicaid expansion.

But several also noted that premium increases and limited competition in the individual insurance markets under the Affordable Care Act — just two companies now offer plans — leave a serious problem to be addressed.

"From our prospective, consumers will not be able to afford what is coming in 2018, the (health insurance) plans are going to be limited, more narrow networks and no competition," said B. Ronnell Nolan, president and chief executive of the Baton Rouge-based Health Agents for America, Inc. "Washington needs to do something, because status quo is not working unless you are not working. We support this bill because it is a step in the right direction."

"We agree that change is needed. The ACA is not working as it is," said John Maginnis, spokesman for Blue Cross Blue Shield of Louisiana, which did not take a position on the bill. "We applaud Sen. Cassidy for being willing to take action in proposing changes to improve the individual health insurance market."

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Bipartisan talks, led by Sens. Lamar Alexander, R-Tennessee, and Patty Murray, D-Washington, had aimed to craft some solutions to issues in the individual markets. Those talks, though, appeared to collapse last week amid the last-minute push to build support for Cassidy-Graham.

McCain, an 81-year-old Republican elder statesman now battling brain cancer, urged his colleagues to restart those discussions. 

"The issue is too important, and too many lives are at risk, for us to leave the American people guessing from one election to the next whether and how they will acquire health insurance," McCain said in a statement Friday afternoon outlining his opposition to Cassidy-Graham. "A bill of this impact requires a bipartisan approach."

Graham, speaking with The Advocate on Tuesday, called the idea of a bipartisan solution to problems with the Affordable Care Act "an illusion" and contended the Republican majority in the House of Representatives would never pass "anything that props up Obamacare."

Addressing undecided colleagues like Murkowski, Graham pitched the repeal-and-replace proposal as the only alternative.

"That's the reality you have to deal with," Graham said. "All of us."

EDITOR'S NOTE: An earlier version of this story incorrectly indicated Jeff Drozda has been meeting with Cassidy about the bill. In fact, Drozda is scheduled to meet with the senator this week about the bill and other matters. This story was modified on Sept. 24 to correct the error.

Follow Bryn Stole on Twitter, @BrynStole.