Last week, Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana (with their co-sponsors, Senators Dean Heller (R-NV) and Ron Johnson (R-WI)) released the "Graham-Cassidy-Heller-Johnson Amendment" ("Graham-Cassidy bill"), which would repeal major sections of the Patient Protection and Affordable Care Act (ACA).

By way of background, this past July, the Health Care Freedom Act (the so-called skinny bill) failed to pass the United States Senate by a vote of 49-51. Senators Susan Collins (R-ME), John McCain (R-AZ), and Lisa Murkowski (R-AK) (recently dubbed the "Big Three") were the only Republicans to vote against the bill alongside all of the Democratic Senators.

If passed, the Graham-Cassidy bill would repeal the ACA's individual and employer mandates, end the Medicaid expansion in 2020, replace the ACA's subsidy program with state block grants (which would allow states to decide how their healthcare system operates), weaken restrictions against pre-existing condition protections, and defund Planned Parenthood.

President Donald Trump has expressed his avid support of the bill, as have fifteen Republican governors from the states of Wisconsin, Arkansas, Indiana, Iowa, Kansas, Kentucky, Maine, Mississippi, Missouri, Nebraska, North Dakota, Oklahoma, South Dakota, Tennessee, and Utah. Conversely, Senators from Colorado, Ohio, Alaska, Montana, Pennsylvania, Virginia, Nevada, Massachusetts, Vermont, and even Senator Cassidy's home state, Louisiana, have urged the Senate to abandon the bill and return to "open, bipartisan approaches" to achieve healthcare reform.

In order to be considered under reconciliation rules, the Graham-Cassidy bill must be analyzed by the Congressional Budget Office (CBO) to ensure that it reduces the deficit in both its first decade and afterward. In addition, the parliamentarian would have to rule that the bill complies with other aspects of the Byrd rule, which governs the kinds of legislation the Senate may consider through reconciliation. The CBO has made it clear that it will not have the opportunity to provide estimates of the bill's full impact, but hopes to release a preliminary analysis early this week.

Without the CBO's analysis, Senators would have to rely upon the CBO's earlier analysis of the skinny bill (which included similar restructuring of the Medicaid program and the gradual end of the Medicaid expansion) as a resource to guide their decisions. In the skinny bill analysis, the CBO asserted that passage of the bill would reduce federal spending by $772 billion by 2026 and leave approximately 15 million Americans uninsured. Senators Graham and Cassidy continue to assure their Senate colleagues, and the American public at large, that this bill is the first step in the right direction toward healthcare reform.

Congress has until the end of this week to use its 2017 Budget Reconciliation Bill as a way to repeal the ACA, and the senators now in the spotlight appear to be the same three whose votes led to the defeat of the skinny bill: Susan Collins (R-ME), John McCain (R-AZ), and Lisa Murkowski (R-AK). Moreover, Ted Cruz (R-TX) has recently expressed reservations about the bill.