Senate Republican leadership will release a draft of their healthcare bill on Thursday, and few lawmakers know what's inside.

But one of the bill's thorniest issues will likely come in how it deals with Medicaid, the government program that helps low-income Americans access health insurance.

Based on the Congressional Budget Office's score on May 24, the House's American Health Care Act would cut $834 billion over the next 10 years from the program.

That's mainly for two reasons: First, the cutback of the Affordable Care Act's Medicaid expansion, which extended the income limit for qualifying Medicaid recipients to 138% of the federal poverty limit. Second, the shift to per-capita caps for federal funding to Medicaid, which would give federal aid based on the number of people and adjust this for a person's age and any disabilities.

The Senate version is expected to adhere similarly to those cuts, but based on reports outlining the discussions, some changes could make the bill more politically palatable for GOP lawmakers.

Here are the two big issues surrounding Medicaid to look out for in the Senate healthcare bill:

1. When will Obamacare's Medicaid expansion be phased out? That will be critically important for GOP senators in states that expanded Medicaid under the Affordable Care Act. West Virginia, Ohio, Alaska, Nevada, and Arkansas all have Republican senators and expanded the program. They originally asked for a seven-year phase out of federal funding for the program after 2020, but some reports have suggested that it could be as little as three to cater to more conservative senators. As of now, 11 million people have access to coverage through the expansion, so these states could either take on the financial burden or allow people to drop off the rolls over time.
2. How quickly will Medicaid spending grow? To compute the rate of growth for federal Medicaid caps after 2020, there are a number of formulas under consideration. The House version currently uses the consumer price index (CPI) for medical costs, which tracks the price increase for out-of-pocket medical costs, plus 1%. Currently, reports suggest the Senate bill will use simple CPI for all goods instead after 2025. The overall CPI is much lower than the CPI for medical costs, and would mean that after 2025, the cuts to the program would be even deeper. Either way, the growth rate would not be fixed, and there is typically a significant variance in the annual cost increase of Medicaid in each state.

The answers to these questions will likely shape how a number of Republican senators approach the legislation. For one thing, senators from Medicaid expansion states would have a tougher time swallowing a faster phase out of the expansion.

On the other hand, a more generous phase-out of the expansion and higher Medicaid growth caps could alienate conservatives that want substantial savings from the bill.

From a non-vote perspective, the Congressional Budget Office's estimate that 23 million fewer people will have health insurance in 2026 than under the current system was based in large part due to losses in Medicaid coverage losses. How Senate alterations affect the coverage score, if at all, could color public reaction to the bill.

Republicans can only afford to lose two votes for the bill to pass without Democratic support.

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The Senate Republican healthcare bill is set to be released on Thursday, but we're already starting to get some indications of what it will look like.

Several reports have begun to detail the contours of the bill, including provisions on Medicaid, tax credits, and more. Here's what we've seen and heard so far:

• Tax credits: The Senate bill reportedly proposes tax credits to help people pay for insurance based on income level, like Obamacare, rather than flat credits based on age, like the House version of the bill. The bill would reportedly make anyone earning up to 350% of the poverty level eligible for credits, a slightly lower level than Obamacare.
• Medicaid expansion: Obamacare's Medicaid expansion, which extended the program to those making between 100% and 138% of the federal poverty limit, would be phased out over three or four years (there are conflicting reports) starting in 2020.
• Medicaid spending growth: The Senate bill will still contain the House's per-capita cap for federal Medicaid spending. After 2025, however, growth in spending would shift from the consumer price index (CPI) for medical care to the CPI for all goods, a lower level of growth.
• Cost-sharing subsidies: The bill would allocate money for cost-sharing subsidies through 2019. The payments offset the costs for insurers to offer low-income Americans plans with smaller out-of-pocket costs. The uncertainty around these payments has led to instability in the individual insurance market.
• State waivers for Obamacare regulations: The Senate bill would reportedly allow states to obtain a waiver to do away with Obamacare's so-called essential health benefits, which mandate all plans must cover 10 basic types of care. That was a key sticking point in the House legislation, one that allowed it to ultimately pass. However, the Senate bill would not allow states to repeal community rating, the provision that mandates all people in a certain area of the same age be charged the same amount. That's a change from the House bill, which drew criticism from health policy experts who said a repeal of community rating would allow insurers to charge people with preexisting conditions more.
• Repeal Obamacare's taxes: Much like the House version, the Senate would do away with things like the Obamacare 3.8% tax on investment income.
• Shift around key funding to prevent it from going to healthcare providers involved in abortion procedures: The House bill's $115 billion state-stability fund that would help to stabilize the individual markets currently contains language to prevent it from being used to fund a healthcare organization that provides abortions. That would not fly under the Senate's strict rules for the process, through which the healthcare bill will proceed. The Senate version would funnel this money through the Children's Health Insurance Program (CHIP) which is already subject to the abortion rule, essentially a roundabout way to restrict money from going to abortion providers.

The full text of the bill will be posted online on Thursday, Senate Majority Leader Mitch McConnell has said.

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Sheldon Adelson, the billionaire casino magnate and Republican megadonor Sheldon Adelson could stand to benefit heavily from the House plan to overhaul America's healthcare system.

A new report from the Center for American Progress Acion Fund, a liberal think tank, and Tax March found that Adelson could see his tax bill slashed by millions of dollars if the American Health Care Act becomes law.

A Business Insider analysis of the report determined that Adelson could see his tax bill decline by about $43.5 million in 2017 if the AHCA is passed and the tax effect is retroactive to the current year.

The primary way Adelson would benefit is the repeal of Obamacare's Net Investment Income Tax, which adds a 3.8% tax to investment income — from dividends and capital gains — for people with over $200,000 in annual earnings (or couples with over $250,000).

Based on Adelson's most recent Form 4 filing with the Securities and Exchange Commission, the megadonor and his family own 392,735,403 shares of his casino company, Las Vegas Sands.

Las Vegas Sands pays an annualized dividend of $2.92 per share, meaning that with Adelson's current ownership stake he would receive about $1.14 billion in income via those dividends in 2017.

Adelson would be subject to the 3.8% tax NIIT. If the AHCA repeals that tax, the casino magnate will avoid nearly $44 million in payments.

This does not account for any capital gains that Adelson may accrue through sales of his shares or any income from other investment vehicles Adelson owns, which means the savings could be even larger.

The money from this tax goes to fund the expenditures like the expansion of Medicaid and tax credits that offset the cost for people to get insurance from the individual health insurance exchanges.

Adelson is worth roughly $36 billion. Based on the spending per Medicaid recipient in 2014, a $44 million break would be equivalent to the government's Medicaid bill to cover about 7,670 Americans.

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Senate Republican leadership released a draft of its long-awaited healthcare bill Thursday, ending weeks of speculation and a secretive process that frustrated Democrats and even some Republicans.

The legislation — called the Better Care Reconciliation Act of 2017 — would roll back much of the Affordable Care Act, the healthcare law better known as Obamacare, including various tax provisions.

It would also scale back funding that goes toward health coverage for low-income Americans and tax credits for middle-income earners who purchase their own health insurance, according to the draft released Thursday.

The plan would also provide funding designed to help stabilize the Obamacare insurance markets in the near term and funnel money through programs to cut off access to funding for abortion providers.

The Senate legislation contains key differences from the American Health Care Act, the House GOP's legislation to dismantle Obamacare. The disparities could be sticking points if the two chambers have to compromise on the bill, which they would have to do before it could reach President Donald Trump's desk.

But first, the legislation faces an uncertain future in the Senate, as it faces some pushback from both conservative members who think it may not go far enough in repealing Obamacare and moderates concerned about its slashing of Medicaid spending. Like the House legislation, it could be subject to significant change to get the needed number of votes.

Senate Majority Leader Mitch McConnell is pushing for a vote by the end of next week, in part to avoid further public scrutiny of the bill over the weeklong July 4 recess. Similar scrutiny periled the original version of the House legislation. McConnell can afford to lose just two members of his conference for the bill to pass.

Here's a rundown of what is in the bill (you can see the full legislation below):

• Tax credits:
  • What's in the bill: To help people pay for insurance, the Senate bill proposes tax credits based on income level, a feature of Obamacare, rather than on age, as the House bill calls for. The bill would make anyone earning up to 350% of the poverty level eligible for credits; Obamacare caps that at 400%. It would, however, adjust the credits so they were less generous as a person aged. for instance, a person age 33 making 175% of the federal poverty limit would receive enough in credits so they were spending 5.3% of their income on premiums. For people over age 59, that would increase to 8.3% of their income. Additionally, the credits would be capped at a lower percentage of overall medical costs than those under Obamacare, making them less generous overall.
  • What it means: While the tax credits would be more generous for older Americans than the House bill, fewer middle-income people would get financial support to pay for coverage — and those who do would get less.
• Medicaid expansion:
  • What's in the bill: Obamacare's Medicaid expansion, which extended the program to those making 100% to 138% of the federal poverty limit, would be phased out over four years. 90% of the current federal funding would be provided in 2020 and it would decrease by 5% each year until 2023, after which it would be eliminated. People would not be allowed to join the expansion from 2020 onwards. The tax credits will be available to people that fall off the expansion.
  • What it means: While this would save the federal government money, it also means the millions of people that have gained access to Medicaid would be rolled off. These people would be able to fall back on the less generous tax credit and access coverage through the individual insurance market.
• Medicaid spending growth:
  • What's in the bill: The Senate bill retains the House's per capita cap for federal Medicaid spending. After 2025, however, growth in spending would shift from the consumer price index for medical care to the CPI for all goods, a lower level of growth.
  • What it means: States would receive less funding each year from the federal government to help cover low-income Americans, and after 2025 the rate of growth would decline, leading to even deeper potential cuts for the program.
• States can institute Medicaid work requirements:
  • What's in the bill: This would allow states to create a provision under which people must maintain employment, as the state defines, for a period of time, also determined by the state, in order for a person to receive Medicaid.
  • What it means: This is another long-time wish for Republicans, but it also gives a significant amount of leeway to states to define what counts as work and for how long someone has to hold a job. It does not apply to students, pregnant women, or the disabled.
• Cost-sharing subsidies:
  • What's in the bill: The bill would allocate money for cost-sharing subsidies through 2019. These payments offset the costs for insurers to offer low-income Americans plans with smaller out-of-pocket costs. The uncertainty around these payments has led to instability in the individual insurance market.
  • What it means: This should reassure insurers desperate for guidance ahead of the 2018 plan year and could bring down premium increases for next year's individual insurance market.
• State waivers for Obamacare regulations:
  • What's in the bill: The Senate bill would allow states to request a waiver to opt out of Obamacare's so-called essential health benefits, which mandate that all plans must cover 10 basic types of care. The ability to opt out of providing those benefits was a key sticking point in the House legislation, and its inclusion ultimately allowed it to pass. The Senate bill, however, would not allow states to repeal community rating, the provision mandating that all people of the same age in the same area be charged the same amount. That's a change from the House bill, which drew criticism from health-policy experts who said a repeal of community rating would allow insurers to charge people with preexisting conditions more.
  • What it means: If a state receives a waiver for the EHBs, this would allow skimpier coverage offerings on the state's insurance market, which would have cheaper premiums but higher out-of-pocket costs.
• Repeal Obamacare's taxes:
  • What's in the bill: Much like the House version, the Senate would do away with things like Obamacare 3.8% tax on investment income on people earning an annual income above $200,000.
  • What it means: The taxes in Obamacare fall predominantly on a small percentage of wealthy Americans, who would see their tax bills fall. For instance, Republican megadonor and casino magnate Sheldon Adelson could have his 2017 tax bill cut by roughly $44 million.
• A fund to provide grants to fight the opioid crisis:
  • What's in the bill: The bill would establish a $2 billion fund for states for programs to "support substance use disorder treatment and recovery support services for individuals with mental or substance use disorders."
  • What it means: This is a one-time fund for 2018, but will likely be favored by senators from states hit hard by the opioid crisis. This was a key ask from Ohio Sen. Rob Portman.
• No funds can be used for abortions:
  • What's in the bill: No plans purchased using funding from the bill can cover abortions. Additionally, none of the funds allocated by the bill can be given to healthcare providers that are involved with abortion.
  • What it means: In addition to restricting anyone who uses the credits or other funds from getting plan that covers abortions, this would effectively defund Planned Parenthood. It is unclear if this will pass Senate rules.

Here is the full bill:

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The much-anticipated GOP health care bill is finally here.

Republican Senate leaders released their version of a healthcare bill that will roll back much of the Affordable Care Act, also known as Obamacare.

The bill cuts back on funding for lower-income and middle-class Americans. The bill also aims to stabilize the recently volatile health care industry in the short term.

The bill still has to pass a vote in the Senate and a reconciliation process with the House of Representatives before President Trump would be able to sign it into law. Republican Senate leaders are hoping to hold a vote on the bill before a week-long July 4 recess.

Read more about the details of the health bill from Business Insider's Bob Bryan here.

Healthcare investors seem to appreciate the new bill. Several insurance, pharmaceutical, and healthcare provider stocks are rallying after the bill was released and as pundits begin to digest its contents.

Here are some of the most notable movers:

• Anthem (ANTM) +1.46%
• Pfizer (PFE) +0.97%
• UnitedHealth (UNH) +1.69%
• Tenet Healthcare (THC) +7.41%
• Community Health Systems (CYH) +8.96%
• Humana (HUM) +1.77%
• HCA Holdings (HCA) +3.76%

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President Donald Trump gave his reaction to the release of the Senate Republican healthcare bill during a meeting Thursday with two-dozen CEOs and leaders from the tech industry.

"How do you like the healthcare, folks?" Trump asked the assembled group. "It's going to be very good. Little negotiation, but it's going to be very good."

The lukewarm endorsement of the Better Care Reconciliation Act stood in contrast with the ringing reaction from Trump following the release of the House's American Health Care Act.

After the release of the release of the House bill, Trump referred to it as "our wonderful new healthcare bill" in a tweet and said the bill would "end in a beautiful picture."

Trump has seemingly soured on the House version of the legislation in recent weeks, telling senators last week that it was "mean." Polls have shown the House bill to be the least popular piece of major legislation since 1990.

Some conservatives have criticized the Senate version of the bill, arguing that it keeps many provisions on Obamacare, like income-based subsidies and cost-sharing reduction payments to insurers.

Senate Republicans can lose only two votes for the legislation to pass.

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The Congressional Budget Office will release its score for the Senate's healthcare bill early next week.

The report from the CBO and the Joint Committee on taxation will estimate changes to the number of people with healthcare coverage, changes to the federal deficit, and other potential effects of the Better Care Reconciliation Act released by Senate Republicans on Thursday.

"CBO and the staff of the Joint Committee on Taxation are in the process of preparing an estimate for the Senate health care plan and aim to release it early next week," read the release from the CBO."The estimate will be published on CBO’s website."

The score for the House's healthcare bill, the American Health Care Act, projected 23 million fewer Americans would have health insurance under the AHCA than under the current system. It also estimated that the bill would cut the federal deficit by $119 billion over t10n years. The Senate bill must cut at least that much from the deficit to qualify under the reconciliation process.

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Hours after the release of the Better Care Reconciliation Act (BCRA), the Senate Republican vehicle to repeal and replace Obamacare, four Republican senators signaled they opposed it in its current form.

Sens. Rand Paul, Ted Cruz, Mike Lee, and Ron Johnson said they will not support the current version of the bill, enough defections to prevent the legislation from passing the Senate.

"Currently, for a variety of reasons, we are not ready to vote for this bill, but we are open to negotiation and obtaining more information before it is brought to the floor," the joint statement said. "There are provisions in this draft that represent an improvement to our current health care system, but it does not appear this draft as written will accomplish the most important promise that we made to Americans: to repeal Obamacare and lower their health care costs."

"The current bill does not repeal Obamacare. It does not keep our promises to the American people," Paul said in a separate statement. "I will oppose it coming to the floor in its current form, but I remain open to negotiations."

Other Republican senators also issued tepid statements indicating they weren't ready to offer support for the bill.

One group that is skeptical is members in states that expanded the Medicaid program under the Affordable Care Act, the law better known as Obamacare. Sen. Dean Heller of Nevada, whose state expanded Medicaid and is up for reelection in 2018, said proposed cuts to Medicaid leave his support for the bill up in the air.

"At first glance, I have serious concerns about the bill’s impact on the Nevadans who depend on Medicaid," Heller said in a statement following the release. "I will read it, share it with Governor Sandoval, and continue to listen to Nevadans to determine the bill’s impact on our state. I will also post it to my website so that any Nevadans who wish to review it can do so. As I have consistently stated, if the bill is good for Nevada, I’ll vote for it and if it’s not – I won’t."

Arizona Sen. Jeff Flake, whose state also expanded Medicaid, said he had not made up his mind on the bill.

"Just got my copy of the healthcare bill and I'm going to take time to thoroughly read and review it,"Flake tweeted.

Senate GOP leadership drafted the bill in closely guarded quarters over the past few weeks, and many members of the conference have not had access to the details of the plan.

A spokesperson for Sen. Susan Collins of Maine, another moderate Republicans who has expressed concern with the bill, said the senator will not pass judgment yet on the legislation.

"She has a number of concerns ans will be particularly interested in examining the forthcoming CBO analysis on the impact on insurance coverage, the effect on insurance premiums, and the changes to the Medicaid program,"said the spokesperson.

Senate Majority Leader Mitch McConnell wants to vote on the bill by the end of next week.

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In a rare public statement, former President Barack Obama published a Facebook post on Thursday slamming the Senate Republicans' healthcare bill, the details of which were released on Thursday. 

Echoing the criticism of top Democratic lawmakers, Obama argued that the intent of the bill, known as the Better Care Reconciliation Act, is not to improve healthcare, but to hand a "massive" tax break to wealthy individuals and businesses. 

"The Senate bill, unveiled today, is not a health care bill," he wrote. "It’s a massive transfer of wealth from middle-class and poor families to the richest people in America."

Obama did not mince words in predicting that, if the bill is passed next week, it would harm vast numbers of Americans. 

"Simply put, if there’s a chance you might get sick, get old, or start a family – this bill will do you harm," he wrote. "It would raise costs, reduce coverage, roll back protections, and ruin Medicaid as we know it," according to healthcare providers and non-partisan analysts. 

He listed the ways in which the bill would reduce coverage. 

"Those with private insurance will experience higher premiums and higher deductibles, with lower tax credits to help working families cover the costs, even as their plans might no longer cover pregnancy, mental health care, or expensive prescriptions," Obama wrote. "Discrimination based on pre-existing conditions could become the norm again. Millions of families will lose coverage entirely."

Obama also repeated a claim that he has made in the past: that he would support a Republican healthcare bill that improved upon his signature legislation, the Affordable Care Act. 

"If Republicans could put together a plan that is demonstrably better than the improvements we made to our health care system, that covers as many people at less cost, I would gladly and publicly support it," Obama wrote. 

He concluded that the healthcare debate is "something bigger than politics," and defines the nature of America.  

"It’s about the character of our country – who we are, and who we aspire to be," he said.

The Better Care Reconciliation Act of would roll back much of the Affordable Care Act (better known as Obamacare), including various tax provisions, and scale back funding that goes toward health coverage for low-income Americans and tax credits for middle-income earners who purchase their own health insurance.

The plan would also provide funding designed to help stabilize the Obamacare insurance markets in the near term and funnel money through programs to cut off access to funding for abortion providers.

Moderates in the Senate are concerned about the bill's slashing of Medicaid spending. Obamacare's Medicaid expansion, which extended the program to those making 100% to 138% of the federal poverty limit, would be phased out over three years starting in 2020.

Senate Majority Leader Mitch McConnell is pushing for a vote on the bill by the end of next week.

Bob Bryan contributed to this report.

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Doctors and patient groups slammed the Better Care Reconciliation Act released by Republican Senators on Thursday, taking issue in particular with Medicaid cuts in the bill.

The groups, including the American Academy of Pediatrics and American Hospital Association, are critical of Republican efforts to repeal and replace the Affordable Care Act, better known as Obamacare.

The Senate's plan, like one passed by the
House of Representatives rolls back many of the provisions of Obamacare, including taking deep cuts from the Medicaid program.

Here's what the groups thought of the bill

The American Academy of Pediatrics, which represents 66,000 pediatricians, opposed the BCRA, especially because it was left out of the conversation around its drafting.

"The bill that the Senate unveiled today was crafted without the benefit of groups like pediatricians weighing in with what children need," Dr. Fernando Stein, president of the AAP, said in a statement. "The result is that the bill would tear down the progress we've made by achieving health insurance coverage for 95% of America's children."

The AAP was critical of the changes to Medicaid.

"The bill includes misleading 'protections' for children by proposing to exempt them from certain Medicaid cuts," Stein said. "A 'carve-out' for children with 'medically complex' health issues does little to protect their coverage when the base program providing the coverage is stripped of its funding." 

 The American Lung Association also opposed the bill, citing the Medicaid cuts. 

"The proposed cuts to Medicaid under this bill will be devastating for children, seniors and people living with disabilities for whom healthcare is critical. Cuts to Medicaid will lead to more asthma attacks," ALA President Harold Wimmer said in a statement Thursday. 

Leading up to the bill's release, the ALA didn't get a chance to share their thoughts on the BCRA. 

"You're never going to get everything right," Erika Sward, the assistant vice president of national advocacy at the ALA told Business Insider. But when you completely exclude patient organizations from the conversations, "you're more likely to get it wrong," she said. 

The March of Dimes criticized the cuts to coverage for children and pregnant women.

"This bill penalizes pregnant women, children and families at every turn," the organization's president Stacey Stewart said in a statement.  

The American Hospital Association, which represents thousands of hospitals and health systems, was unhappy with the cuts to the Medicaid program. 

"Medicaid cuts of this magnitude are unsustainable and will increase costs to individuals with private insurance. We urge the Senate to go back to the drawing board and develop legislation that continues to provide coverage to all Americans who currently have it," AHA President Richard Pollack said in a statement on Thursday. 

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After weeks of speculation and a secretive process that frustrated politicians on both sides of the aisle, Senate Republican leaders released a draft of their long-awaited healthcare legislation on Thursday.

Beyond Republicans' sweeping attempt to overhaul the system, healthcare has been hotly debated in the US for years.

And it's not hard to see why: Americans spend more on healthcare than residents of any other developed nation on the planet, yet lack virtually every possible measure of a clean bill of health that would justify it. Americans don't live very long, they're not very happy, and many of their health outcomes continue to differ starkly along racial and socioeconomic lines.

What's going so wrong?

The Organization for Economic Cooperation and Development (OECD) summed it up nicely in its latest report on health in the US in 2015, citing two factors as the main culprits for our relatively low life expectancy:

1. Rising obesity and alcohol consumption

Obesity rates around the world are on the rise, but according to a comprehensive study published this year in the New England Journal of Medicine, they're rising faster and more significantly in the US than in any other country.

2. A highly-fragmented US healthcare system

Some of the most notable issues plaguing the US healthcare system include its failure to properly treat people with chronic diseases like asthma and diabetes, its failure to provide coverage for low-income people and people of color, its dismal vaccination rates, and the soaring cost of life-saving drugs.

Americans with chronic diseases like asthma end up in the hospital more frequently than they do in other OECD countries. In most developed countries, chronic disease sufferers are more likely to receive the preventive medicine that would help stave off a potentially life-threatening scenario. They're also more likely to be treated by primary care doctors rather than having to have their problems addressed by emergency physicians.

While life expectancy in the US is still increasing, it is doing so at a slower pace than in many other developed countries. Life expectancy also varies significantly by skin color in America. In 2009, the average black American could expect to live to just 75, the same life expectancy white Americans enjoyed 30 years earlier in 1979. Today, black Americans remain far more likely than white Americans to die from cancer and diabetes, according to the Centers for Disease Control and Prevention.

In addition to these obstacles, Americans vaccinate their children at lower rates than many other developed countries, which can lead to outbreaks of diseases like measles and Hepatitis B.

Last, the US's life-saving pharmaceutical drugs cost a fortune. Unlike other countries, whose governments regularly haggle with drug companies to reduce drug prices, US Medicare is forbidden from engaging in such negotiations. As a result, Americans pay hundreds to thousands more for their medications than people in other countries pay for the exact same pills.

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The release Thursday of a draft of the Senate Republican leadership's healthcare legislation has set off a scramble to secure enough commitments for a vote that Majority Leader Mitch McConnell wants to hold next week.

Democrats blasted the bill, which was drafted in secret, while most Republicans took a more measured approach and left their intentions unknown, with many moderate members saying they were taking time to read the bill and analyze its impact.

Four GOP senators, however — Rand Paul, Ted Cruz, Mike Lee, and Ron Johnson — quickly announced they would not support the bill in its announced form, though they all remained open to negotiation.

The uncertainty and outright opposition put the bill short of the 50 votes needed to pass — only two Republicans can defect, since Democrats plan to universally oppose it. That puts the Better Care Reconciliation Act of 2017 in a dicey position from the start.

Greg Valliere, the chief strategist and a longtime political analyst at Horizon Investments, said in a note to clients Friday that the conservative members besides Paul were likely to relent since failure to pass the bill "would mean Obamacare wins."

But in addition to Paul, Valliere identified another likely "no" vote from the GOP in Sen. Dean Heller, who is facing an uphill battle for reelection in 2018 in Nevada, which is trending Democratic.

If Paul and Heller were to vote against the bill, the decisive vote would most likely come from a moderate like Sen. Susan Collins of Maine or Sen. Lisa Murkowski of Alaska.

"Susan Collins's popularity in Maine would surge if she votes no, and Lisa Murkowski in Alaska is on the fence," Valliere wrote. "Throw in a handful of other shaky moderates like Rob Portman of Ohio, and McConnell is in trouble, with zero margin for error."

Much of the outcome could hinge on the BCRA's proposed cuts to the Medicaid program. Portman, Murkowski, Heller, and other key GOP senators represent states that expanded Medicaid under the Affordable Care Act. They have expressed concerns over the bill's changes to the program, which provides low-income Americans with financial support to access health insurance.

As it stands, the BCRA rolls back the Medicaid expansion and includes deep cuts to the rest of the program, which could be a deal-breaker for those lawmakers.

Valliere pointed to public reaction, which has been heavily against the GOP's healthcare overhaul. The House version of the legislation, the American Health Care Act, has the lowest support in polls of any major piece of legislation dating back to 1990.

"Polls support the opponents — and Barack Obama, still popular, will lead the charge," Valliere said. "There are other wild cards: the CBO 'score' early next week; strong opposition from the AARP, whose members vote; potential parliamentary objections; Planned Parenthood funding; and a lack of enthusiasm among House Republicans, who stuck out their necks only to have Trump call their bill 'mean.'"

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Sen. Bernie Sanders called the Senate Republican healthcare bill, the details of which were released on Thursday, "barbaric" and promised to introduce Medicare-for-all legislation during an interview with CNN's Anderson Cooper.

Sanders tweeted on Thursday that the bill, which would repeal and replace the Affordable Care Act (commonly known as Obamacare), is "the most harmful piece of legislation I've seen in my lifetime."

Cooper asked him to elaborate on that claim. 

"If you throw 23 million people off of health insurance, if you cut Medicaid by over $800 billion, there is no question, but that thousands of Americans will die," Sanders said. "This is barbaric. Frankly, this is what oligarchy is all about."

In response to the Republicans' argument that Obamacare is destined to fail due to increasing premiums and healthcare costs, Sanders admitted that the healthcare law is flawed, but argued that the GOP is deliberately "sabotaging" it, and that the replacement GOP bill would reverse all the gains made by President Barack Obama's signature legislation.  

"If you talk to the insurance industry, what they will tell you is that [President Donald] Trump and the Republican leadership are sabotaging the Affordable Care Act," he said. "Nobody denies that premiums are too high, that deductibles and copayments are too high."

Sanders went on to say that in order to solve the Obamacare's long term problems, Congress must pass new legislation that guarantees government-sponsored health insurance to every American who needs it. He said that he will introduce "Medicare-for-all" legislation in the "near future."

Throughout the 2016 campaign and Trump's time in office, Sanders, a former contender for the Democratic presidential nomination, has pressured the president to keep his promise to protect Medicaid, Medicare, and Social Security. 

In January, Sanders brought a blown up print out of a tweet sent by then-candidate Trump in which he boasted that he was the "first & only" Republican presidential candidate to vow to prevent any defunding of Medicaid and other social programs that primarily benefit the elderly and the poor.

Trump's May 2015 tweet read: "I was the first & only potential GOP candidate to state there will be no cuts to Social Security, Medicare & Medicaid. Huckabee copied me."

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Hillary Clinton voiced her sharpest criticism yet of the Senate Republicans' healthcare bill in a tweet on Friday afternoon in which she said the GOP would be "the death party" if they pass their proposed legislation.

Quoting a study of the bill's impact conducted by the liberal Center for American Progress in conjunction with Harvard researchers, the former Democratic presidential nominee wrote, "Forget death panels. If Republicans pass this bill, they're the death party."

The study Clinton shared found that there would be one "excess death" for every 830 people who lose coverage as a result of the GOP's Obamacare-replacement legislation. It estimated that the loss of coverage would result in between 18,000 and about 28,000 deaths in 2026, and about 217,000 excess deaths over the next decade. 

Clinton sent a series of tweets critical of the GOP bill since the details of the draft legislation were released on Thursday. 

In one, she called on constituents to contact their senators to voice their concern about the bill. In another she retweeted a graphic alleging that 39% of children — and 76% of poor children — rely on Medicaid. She also tweeted former President Barack Obama's Facebook post, in which he called the bill a "massive transfer of wealth from middle-class and poor families to the richest people in America." 

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The future of the Senate Republican leadership's healthcare bill, released on Thursday, is already in doubt as at least five Republican senators have come out in opposition of the legislation in its current form.

Even if Majority Leader Mitch McConnell successfully wrangles his members and gets the bill through, though, he would run into another wall: House conservatives.

Despite substantial differences between the House's American Healthcare Act and the Senate's Better Care Reconciliation Act, The Hill's Scott Wong reported Thursday that a member of the House GOP conference close to the leadership said the Republican brass wanted to take up and pass whatever came out of the Senate.

That would suggest a breeze for Republicans' healthcare legislation to President Donald Trump's desk.

But some of the changes made in the Senate version of the bill are unlikely to fly with conservative members of the House, especially the House Freedom Caucus. The Freedom Caucus forced House Speaker Paul Ryan to pull the first version of the AHCA from the floor just minutes before a scheduled vote. They eventually won a number of concessions to the final version of the bill that passed.

Rep. Mark Meadows, head of the Freedom Caucus, poured cold water all over the idea of a quick passage on Friday. The North Carolina representative told reporters the Senate bill "does not have enough conservative support" to get by the House without changes.

Separately, a source close to the Freedom Caucus told Business Insider that while the group does not yet have an official position, since the members won't meet until Monday, it does have a preference.

"The Freedom Caucus strongly supports going to conference with the Senate on healthcare legislation," the source said.

That could mean weeks to come of negotiations to craft a bill that would not only satisfy the hardline conservatives in the Freedom Caucus, but also moderate Senate Republicans who are already wavering on a Senate bill that is less conservative than the AHCA.

For Republican leaders, that won't be an easy task.

Said Greg Valliere, the chief strategist at Horizon Investments: "Odds of enactment are still below below 50%, but the horse trading has just begun as this drama intensifies."

SEE ALSO: Republicans have 'zero margin for error' to pass the Senate healthcare bill

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WASHINGTON (AP) — President Donald Trump said he doesn't think congressional Republicans are "that far off" on passing a health overhaul to replace "the dead carcass of Obamacare" and believes his majority party is "going to get there."

Trump's optimism runs counter to the public opposition of five Republican senators so far to the Senate GOP plan that would scuttle much of former President Barack Obama's health law.

Unless those holdouts can be swayed, their numbers are more than enough to torpedo the measure developed in private by Senate Majority Leader Mitch McConnell, R-Ky., and deliver a bitter defeat for the president.

McConnell has said he's willing to make changes to win support, and in the week ahead, plenty of back-room bargaining is expected as he tries pushing a final package through the Senate.

"We've a very good plan," Trump said in an interview broadcast Sunday. "We have a few people that are I think, I could say modestly, they're not standing on the rooftops and screaming. They want to get some points. I think they'll get some points."

The president said he thinks Republicans in the Senate are doing enough to push through the bill. "I don't think they're that far off. Famous last words, right? But I think they're going to get there," Trump told "Fox and Friends."

In addition to the five senators who have announced their outright opposition, several other GOP senators, both conservatives and moderates, have yet to commit to the new overhaul.

The Senate bill resembles legislation the House approved last month that the nonpartisan Congressional Budget Office said would mean 23 million additional uninsured people within a decade and that recent polling shows is viewed favorably by only around 1 in 4 Americans.

"Health care is a very, very tough thing to get," Trump said. "But I think we're going to get it. We don't have too much of a choice because the alternative is the dead carcass of Obamacare."

Besides the five who have announced their outright opposition, several other GOP senators — both conservatives and moderates — have declined to commit to the new overhaul.

With unanimous opposition from Democrats, McConnell can afford to lose just two of the 52 GOP senators and still prevail on the bill.

Trump bemoaned the lack of help from Democrats on health care.

"It would be so great if the Democrats and Republicans could get together, wrap their arms around it and come up with something that everybody's happy with," the president said. "It's so easy. But we won't get one Democrat vote, not one. And if it were the greatest bill ever proposed in mankind, we wouldn't get a vote and that's a terrible thing. Their theme is resist."

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Billionaire tycoons Charles and David Koch are unhappy with the Senate's healthcare bill which may be voted on this week, officials who work for the brothers' political apparatus said.

They were staunchly opposed to the House of Representatives' version of the bill as well — called the American Health Care Act — and promised millions in campaign donations to Republicans who helped sink it. Officials say the brothers will also lobby for changes to the Senate's bill.

At a weekend event with conservative donors, top aides to Charles Koch said the Senate bill does not go far enough to dismantle former President Barack Obama's signature healthcare law, also known as Obamacare.

“We have been disappointed that movement has not been more dramatic toward a full repeal,” said Tim Phillips, president of Americans for Prosperity, a grassroots advocacy group backed by Charles and David Koch.

The Senate's 142-page proposal, worked out in secret by a group led by Senate Majority Leader McConnell, aims to deliver on a central campaign promise of President Donald Trump to repeal Obamacare, which has provided coverage to 20 million Americans since its passage in 2010. Senate Republicans' approach to writing the bill prompted significant blowback for its secretive negotiating process and because there were no public hearings or debate on the bill until it was unveiled earlier this week. 

Trump has long pushed to repeal and replace the "dead carcass" of Obamacare. Although he helped craft and promote the House's replacement measure, he reportedly told Republican senators the bill was "mean" and that he hoped the Senate would pass a more "generous" bill. Trump appeared to confirm those reports during an interview on Sunday.

Obama sharply criticized the Senate's bill and said it would shift costs to older and sicker Americans. He also said that no amount of "tweaks" would change the "fundamental meanness" of the Republican effort. When asked to respond to Obama's critiques, Trump replied, "Well he used my term, 'mean'. That was my term because I want to see — and I speak from the heart, that's what I want to see.  I want to see a bill with heart."

Republicans view the Affordable Care Act as a costly government intrusion and say individual insurance markets created by it are collapsing.

Phillips and other aides to the Koch network told Reuters they want to see the Senate bill do more to roll back Obamacare's expansion of the Medicaid program for poor and disabled Americans. They also contend the bill does not do enough to reform the US healthcare system and cut costs.

The aides said lobbying efforts to reshape the bill are continuing ahead of a planned vote.

Similar concerns helped steer the House’s version of the bill in a more conservative direction. A primary mover of that effort, Mark Meadows, a Republican congressman from North Carolina, attended the Koch donor event.

Meadows, chairman of the conservative Freedom Caucus in the House, said he is prepared to support the Senate bill if it clears that chamber, a sign that quick action to land the legislation on Trump’s desk is possible.

However, Meadows said the Senate version of the bill would need to be amended to allow insurers who sell plans on Obamacare’s insurance exchanges to offer less-expensive plans that do not comply with that law’s coverage requirements.

Republican Senator Ted Cruz of Texas, who currently opposes the Senate bill, has offered an amendment along those lines. Cruz attended the Koch event in Colorado Springs, as did Senators Jeff Flake of Arizona and Ben Sasse of Nebraska, who remain undecided.

Meadows also seeks an amendment that would allow some consumers who have private health savings accounts to deduct the cost of insurance premiums from their taxes.

Senate leaders have set a goal of passing the healthcare measure by the end of this week, ahead of the July 4 congressional recess, which would then send it back to the House.

If the Senate passes legislation this week that is palatable to the House, Meadows said it is conceivable the House could pass that version and choose to forgo a formal conference committee that would reconcile the Senate and House bills. That, he said, could result in sending the bill to Trump’s desk for his signature before the recess.

Getting a vote by the end of the week could be difficult.

Five Senate Republicans, including Cruz, have publicly voiced their opposition to the current Senate draft. No Senate Democrats are expected to back it, which means McConnell cannot afford to lose more than two Senate Republicans.

As a sign of the Koch network’s influence, Phillips said his organization is prepared to spend as much as $400 million before next year’s congressional elections to advocate for the network’s conservative causes.

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WASHINGTON (Reuters) - Republican Senator Susan Collins of Maine said on Sunday she has extreme reservations about the U.S. Senate's healthcare overhaul and does not think it will be able to pass this week.

Collins, a moderate Republican who has not taken a formal stance on the bill, said she was concerned it would cut Medicaid too deeply and said she wants to see an upcoming analysis by the Congressional Budget Office before making a decision.

"I have very serious concerns about the bill," she said on ABC's "This Week" program. "It's hard for me to see the bill passing this week."

Republican Senate leader Mitch McConnell of Kentucky has pushed for a vote before the July 4th Independence Day holiday recess that begins at the end of this week. He can afford to lose the support of only two Republicans in the face of unanimous Democratic opposition.

Five Republican senators have announced they will not support the bill, which is designed to repeal and replace Obamacare, in its current form.

One of those senators, Ron Johnson of Wisconsin, called on Sunday for a slowdown in the process to give the Senate and the public time to evaluate the healthcare bill.

"We don't have enough information. I don't have the feedback from constituencies who will not have had enough time to view the Senate bill. We should not be voting on this next week," he said on NBC's "Meet the Press."

Another senator who has announced that he does not support the current version of the bill, Rand Paul of Kentucky, said he would back it if the Senate reached an impasse on healthcare.

"If we get to impasse, if we go to a bill that is more repeal and less big government programs, yes I’ll consider partial repeal," Paul said on ABC.

The Senate's 142-page proposal, worked out in secret by a group led by McConnell, aims to deliver on a central campaign promise of President Donald Trump to undo former President Barack Obama's signature healthcare law, which has provided coverage to 20 million Americans since it was passed in 2010.

Republicans view the law, formally known as the Affordable Care Act, as a costly government intrusion and say individual insurance markets created by it are collapsing.

"I think they have, at best, a 50-50 chance of passing this bill," Senate Democratic leader Chuck Schumer of New York said on ABC. He said Democrats "are doing everything we can to fight this bill because it's so devastating for the middle class."

The House of Representatives has passed a measure similar to the Senate plan. The Senate would phase out Obamacare's expansion of the Medicaid program for the poor more gradually than the House bill, waiting until after the 2020 presidential election, but would enact deeper cuts starting in 2025. 

(Reporting by Lindsay Dunsmuir and John Whitesides; Editing by Dan Grebler)

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