WASHINGTON (AP) — Republican Sen. Susan Collins says she finds it "very difficult" to envision backing the last-chance GOP bill that would repeal the Obama health care law.

Her likely opposition leaves the Republican drive to fulfill one of the party's chief campaign promises dangling by a thread.

The Maine moderate's comments on CNN's "State of the Union" leave her all but certain to join two GOP senators who've declared their opposition — Arizona's John McCain and Kentucky's Rand Paul.

Unless the White House and party leaders can persuade at least one of the three to come around, three GOP "no" votes will be enough to kill the legislation because all Senate Democrats oppose it.

The measure would repeal much of the Affordable Care Act and shift money and power to the states.

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Republicans are taking one last stab at repealing and replacing the Affordable Care Act, but experts say their latest attempt runs the risk of bringing chaos to the US healthcare system.

Experts say the so-called Graham-Cassidy healthcare bill, whose legislative fate became more uncertain Friday, would set up a deadline for states that could cause massive upheaval and sow uncertainty in insurance markets.

The legislation would keep intact several provisions of the law known as Obamacare for 2018 and 2019. But it would force states to set up an entirely new individual insurance market — for people who don't get coverage through an employer —  and Medicaid by 2020.

The bill's authors have presented the two-year window as a cushion to ensure no disruption for people in those insurance markets. But Larry Levitt, a senior vice president at the Kaiser Family Foundation, said the transition isn't nearly long enough.

"This would be a really heavy lift for states," Levitt told Business Insider in an email. "They’d have two years to figure out what kind of health insurance system they want to create, starting essentially from scratch, and then implement it. This is close to unprecedented."

The Graham-Cassidy bill would give states a chunk of money, known as block grants, every year based on a formula around the number of enrollees in certain programs. The states would be allowed to determine how people in the individual market received care.

The legislation's proponents argue it would give states new flexibility. But it would also force states to pass legislation to create a formula for dividing up subsidies that help people buy insurance — as well as to create state-level enforcement and regulatory schemes.

Matthew Fiedler and Loren Adler, health policy analysts at the Brookings Institution, said the challenges for states would be even more daunting than amid the implementation of the Affordable Care Act.

"States would have only around 15 months to get new policies in place to do so before insurers would need to begin developing products for 2020 and only about 27 months before the new rules would have to be in effect," Alder and Fiedler wrote as part of an analysis Friday. "For comparison, the process of drafting and implementing the ACA began close to five years before the new rules would be in effect. It seems likely that many states would simply fail to meet this timeline or meet the timeline only by deploying ineffective policies."

The researchers said the challenges would lead to an increase in the number of people uninsured due in part to the heightened uncertainty for insurers and beneficiaries.

"Transitions are difficult even under the best of circumstances. Government agencies need to gain experience administering their states’ new regulatory regimes and subsidy programs," their analysis said. "Private insurers need to learn to set premiums for a new market, while individuals need to learn how to access new coverage arrangements."

Levitt pointed to the rapidly changing market and possibility of market disruption as consequences that would likely scare off insurers, which like to set prices and participation areas in advance to get a sense of their bottom line.

"I think it’s quite unpredictable how insurers might react to passage of Graham-Cassidy," he said. "Insurers are not going to know what states will do, and some may exit the market now to wait and see how things shake out."

And Adler and Fiedler wrote that insurers may enter the new markets with higher premiums to counteract the uncertainty.

"As with the years leading up to 2020, uncertainty about what rules will govern the individual market in the future may put downward pressure on individual market participation, increasing premiums and reducing coverage," the analysis said.

That could also be a reaction to the lessons learned from Obamacare. Insurers underpriced many of their Obamacare plans in the first few years of the exchanges, leading to significant financial losses and rapidly rising premiums over the past few years.

So even with the two-year window, the massive upheaval would lead to a mad dash by states, insurer chaos, and potentially higher costs for insurers.

Or as Jon Kingsdale, a public health professor at Boston University, told the New Times Times: "That’s not enough time for most states to figure it out."

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Republican lawmakers in the Senate are days away from perhaps a final deadline on repealing and replacing the Affordable Care Act, a seminal promise from the party for more than seven years.

The Senate must pass the Graham-Cassidy healthcare bill by September 30 under budget reconciliation, the process that would allow it to pass with a simple majority.

Failure to pass the legislation using budget reconciliation would complicate prospects for the GOP to roll back the ACA, the landmark healthcare law known as Obamacare.

But despite pressure on Republican senators, two members have already said they will vote against the bill — and several others are on the fence, leaving its future in doubt.

"It's very difficult for me to envision a scenario — scenario where I would end up voting for this bill," Sen. Susan Collins of Maine said Sunday on CNN. "I have a number of serious reservations about it."

Tough timeline

Republicans are working with a difficult, crunched timeline. Here's the gist:

• Monday: The first order of business is the Senate Finance Committee's hearing on the bill at 2 p.m. ET. There will be six witnesses at the event.
• Tuesday: The Congressional Budget Office will issue a preliminary score for the bill. To qualify under budget reconciliation, the plan has to save the same as or more than the $119 billion projected to be cut from the federal deficit in the House's American Health Care Act. The CBO said the score would not provide a detailed estimate of changes to insurance coverage or the stability of the insurance markets.
• Also on Tuesday: The Senate GOP will hold its weekly luncheon. It will give leaders an indication of where they stand on getting 50 votes for the bill. (Vice President Mike Pence would break any tie.) With only 52 Republicans in the Senate, there is little margin for error.
• Wednesday: The day will most likely bring the beginning of rulings from the Senate parliamentarian on the bill. All provisions of Graham-Cassidy are subject to the Byrd rule, which mandates all parts of a bill being considered under budget reconciliation must in some way affect the deficit. Anything that is ruled a violation of the Byrd rule would be stripped out.
• Also on Wednesday: The day Senate Majority Leader Mitch McConnell would start the voting process.
• Thursday: This is most likely the latest Senate Majority Leader Mitch McConnell can introduce the bill to try to pass it before the deadline. If he does, it will trigger what is known as a vote-a-rama, which would allow senators of both parties to add as many amendments as possible.
• Saturday: The cutoff day to pass the bill.

Key opposition

Entering a hectic weak for healthcare, the outlook for the Graham-Cassidy bill does not look particularly promising for Republican leaders.

On Friday, Sen. John McCain of Arizona said he would vote against the bill because it was not introduced through "regular order."

"I would consider supporting legislation similar to that offered by my friends Senators Graham and Cassidy were it the product of extensive hearings, debate, and amendment," McCain said. "But that has not been the case. Instead, the specter of September 30 budget-reconciliation deadline has hung over this entire process."

Additionally, Sen. Ted Cruz of Texas said at a festival in Texas on Sunday that he did not support the legislation as written.

"Right now, they don't have my vote, and I don't think they have Mike Lee's either," Cruz said, referring to the Republican Utah senator.

Sen. Rand Paul of Kentucky has been adamant about his opposition to the bill since the legislative text was introduced, calling it "Obamacare lite." The Kentucky senator had been working on concessions that could get him to a yes, but his spokesman on Monday said Paul remained a "no" on the bill even after a new version was released Sunday.

In the more moderate wing of the GOP, Collins said she was "leaning no" on the bill, while Sen. Lisa Murkowski of Alaska has not indicated her stance. Collins and Murkowski opposed every recent iteration of the Republican healthcare bills.

While the bill's authors are tweaking the legislation to try to appeal to some of the wavering members, the political calculus is dicey. Moving the bill to the right to appease Paul, Cruz, and Lee risks cementing Collins' and Murkowski's opposition — and vice versa.

Working on some rewrites

The authors of Graham-Cassidy released a new version of the bill Sunday night.

The bill divides federal healthcare funding to the states using block grant— a lump sum of sorts paid up front to states — rather than the current percent match of actual spending.

The original bill used a formula that saw most states lose considerably, while a handful of mostly rural, Republican-controlled states gained funding. In the new version, the formula would be tweaked to benefit the states of members who have opposed or are wavering on the legislation.

Maine, Kentucky, Arizona, and Alaska all get more federal funding than the original in the new version, according to a state-by-state breakdown released by the authors. But that does not account for the reduction in overall spending caused by Medicaid per capita caps in the bill — which would give states a set amount of money per Medicaid enrollee instead of fluctuating along with actual spending.

This means the bill would still slice significant federal healthcare funding over the next 10 years and eliminate the Medicaid expansion introduced by Obamacare altogether after that.

The bill also would loosen, and may even weaken further, protections for Americans with preexisting conditions — an issue highlighted by late-night host Jimmy Kimmel last week.

Under the new version, states can outline plans to bring down costs for healthcare in their state including loosening regulations created under Obamacare. That would allow states to loosen regulations mandating that insurers keep costs down for people with preexisting conditions.

Additionally, states could introduce two different risk pools in their plan — which would allow sick people to be placed in a separate, more expensive pool from one with healthier people.

Larry Levitt, a senior vice president at the Kaiser Family Foundation, a nonpartisan health-policy think tank, said the new version should end debate over whether sick people are protected under Graham-Cassidy.

"If there was any question about Graham-Cassidy's removal of federal protections for pre-existing conditions, this new draft is quite clear,"Levitt tweeted Sunday. "The language in the revised Graham-Cassidy bill on insurance regulation is quite convoluted. It could take time to sort out. But..."

SEE ALSO: The Republican healthcare bill would bring 'close to unprecedented' chaos in the health system

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Americans are not warming to the latest Republican healthcare push, as two new polls provided brutal results for the Graham-Cassidy bill.

Much like the previous GOP proposals to repeal and replace the Affordable Care Act, most Americans hold an unfavorable view of the Graham-Cassidy proposal. Fifty percent of people surveyed by Public Policy Polling said they were against the plan, with just 24% in favor and 27% undecided.

Meanwhile, 52% of people also said they thought the bill would increase costs for most people, versus 20% that said it would lower costs. And 53% said they believe it would decrease the number of people with healthcare coverage, while only 14% said it would increase coverage.

The bill, rolled out only just more than a week ago, represents the last-ditch effort for Republicans to try to repeal Obamacare on a party-line vote using the process known as budget reconciliation.

The Public Policy Polling survey also found that 63% of Americans want Congress to keep Obamacare and fix it, compared with 32% that want the law repealed entirely to start from scratch.

The PPP results, released Thursday, were echoed in a CBS News poll released Monday.

The CBS poll found that 52% of those surveyed disapproved of the Graham-Cassidy bill and just 20% said they were in favor. Even fewer than half of Republicans — 46% — approved of the bill.

Additionally, 74% of those surveyed in the CBS News poll said Obamacare should either be kept in place (9%) or said it had positive elements but needs some changes (65%).

Another poll from ABC News/Washington Post, released Friday, showed that 56% of Americans preferred Obamacare to the Graham-Cassidy legislation, while 33% preferred the new bill to the current law.

The numbers line up closely with the approval numbers for previous versions of the Republican healthcare overhaul. Both the House and Senate versions of Obamacare consistently had approval numbers in the 20s, making them the least popular major pieces of legislation since 1990.

SEE ALSO: The Republican healthcare bill would bring 'close to unprecedented' chaos in the health system

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President Donald Trump lobbed attacks at Senate Republicans, specifically Sen. John McCain and Majority Leader Mitch McConnell, in a radio interview on Monday in which he expressed disappointment at the lack of accomplishment on healthcare legislation.

Trump called into the "Rick & Bubba Show," a talk show based in Alabama, to discuss the state's Senate primary on Tuesday. The conversation quickly shifted to healthcare.

Trump said lawmakers should be disappointed they have not yet repealed Obamacare, as they promised for seven years.

"They should be. It's disgusting," Trump said. "When I ran, I was told I'd have a bill on my desk. I'd sign it Day One."

Trump also claimed Republicans are scared to actually pass a repeal bill now that they have a Republican president that will sign it, saying GOP members now just "pander" and "grandstand."

The president was somewhat fatalistic about the prospects of the new GOP healthcare push, which has revolved around legislation known as the Graham-Cassidy bill.

"Looks like Susan Collins and some others will vote against," Trump said of the Republican senator from Maine. "So we're going to lose two or three votes, and that's the end of that."

Republicans can only afford to lose two votes for the legislation to pass. Collins said on Friday that she is "leaning against" the new bill. McCain and Sen. Rand Paul already said they plan to vote against the bill, and other Republican members are leaning against it as well.

Trump's most pointed comments were reserved for McCain, who was among three Republican senators that helped kill the last round of Republican repeal attempts in July. He said Friday that he would vote against thew newest proposal, the Graham-Cassidy bill. The president said McCain's opposition amounted to a "tremendous slap in the face to the Republican Party."

"You can call it what you want, but that's the only reason we don't have it, because of John McCain," Trump said.

Trump has repeatedly attacked McCain on Twitter for his decision to come out against the Graham-Cassidy bill over the weekend and has leveled criticism of the Arizona senator on numerous occasions.

McConnell, another repeat Trump target, also drew criticism from Trump. The president said McConnell was "not, polling-wise, the most popular guy in this country."

Republicans have until September 30 to pass the Graham-Cassidy plan under the process known as budget reconciliation, which allows them to avoid a Democratic filibuster and approve the bill with a simple majority.

SEE ALSO: It's crunch time for the latest Republican healthcare bill — and it doesn't look good

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WASHINGTON — As the Senate Finance Committee carried out a public hearing on the economic ramifications of the latest Republican attempt to repeal and replace the Affordable Care Act, hundreds of protesters swarmed the building to express their disapproval of the Graham-Cassidy bill that is being considered.

Hundreds of Capitol Hill police officers surrounded the hearing room as demonstrators were dragged out for interrupting the hearing.

The walls outside the hearing room were lined with protesters, whom the police barricaded off from the rest of the public. The police then proceeded to remove protesters in small groups.

The protesters were shouting in unison, "No cuts to Medicaid, save our liberty," which could be heard from two floors beneath the hearing room.

Outside the Dirksen Senate Office Building, many of the protesters required powered wheelchairs, creating a backed-up line of arrested demonstrators. Capitol police have not released official arrest numbers, but 150-200 protesters were lined up outside and detained inside police tape as buses arrived to haul them off.

The protesters came to Washington from all over the country, according to Ryan Zeiger, who was one of the organizers for the disability rights group ADAPT.

Zeiger, who traveled to Washington, DC from Denver, told Business Insider their goal was "to do civil disobedience."

"Send a signal — a strong signal — to people," he said. "And for a lot of these people, a lot of people in ADAPT, this bill really is life or death. That means regressing back to a system where someone, a quadriplegic, gets three visits a week, you know like stuck in bed for days at a time. And that's just crazy."

The Graham-Cassidy healthcare plan has received very few hearings and was pushed through the Senate on a partisan basis. The lack of regular order prompted Sen. John McCain of Arizona to publicly come out against the bill, which has the legislation's future hanging by a thread.

The Republicans' condemnations prompted the bill's authors to revise certain aspects, giving more funding to the states whose senators were on the fence about voting yes.

However, Republicans are moving forward with the bill and plan to vote before the September 30 deadline to use the reconciliation process, allowing them to bypass a filibuster with a simple majority.

The bill divides federal healthcare funding to the states using block grants— a lump sum of sorts paid up front to states — rather than the current percent match of actual spending.

It would also slice significant federal healthcare funding over the next 10 years and eliminate the Medicaid expansion introduced by Obamacare altogether after that.

The bill also would loosen, and may even weaken further, protections for Americans with preexisting conditions — an issue highlighted by late-night host Jimmy Kimmel last week.

Bob Bryan contributed to this report.

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The latest attempt by Republicans in the Senate to repeal and replace the Affordable Care Act will leave "millions" of Americans without insurance, the Congressional Budget Office said.

The nonpartisan agency stopped short of putting a more specific number on its assessment, however, as it has in the past, saying it needs more time to do that.

The score for the plan, known as the Graham-Cassidy bill, is limited in scope because of the short time frame in which the CBO had to produce it and includes only the budgetary effects of the bill.

The office projected that the Graham-Cassidy bill would reduce the federal deficit through 2026 by more than the $133 billion in savings from the House's American Health Care Act. That ruling allows Republicans to bypass a Democratic filibuster.

The bill is required to save as much as or more than the House bill to qualify under the procedure known as budget reconciliation, which allows Republicans to pass it with a simple majority.

Monday's CBO score provided only a vague assessment of the insurance-coverage impacts of the bill.

"The number of people with comprehensive health insurance that covers high-cost medical events would be reduced by millions compared with the baseline projections for each year during the decade, CBO and JCT estimate," the CBO's report said. "That number could vary widely depending on how states implemented the legislation, although the direction of the effect is clear."

Additionally, contrary to the assertions by the bill's authors, the CBO found that protections for people with preexisting conditions would be weakened by the new bill.

"Nevertheless, with the modifications, coverage for people with preexisting conditions would be much more expensive in some of those states than under current law," the report said.

The CBO said it would need "at least several weeks" to produce a more comprehensive score of the bill.

18 Million

Independent analyses by the Brookings Institution and the Commonwealth Fund estimated that the bill would result in up to 18 million more uninsured through 2019 and 21 million more uninsured through 2026 from the current baseline if signed into law.

Additionally, since the Graham-Cassidy bill would shift federal healthcare funding in 2020 to block grants (lump sums paid up front every year based on the number of people enrolled in certain programs), it would require states to develop and implement an entirely new health system in just two years. Such a short time frame, experts say, could cause chaos in health-insurance markets.

Because of these analyses, combined with the massive amounts of federal assistance cut in the bill, GOP leaders have not been encouraged about the legislation's prospects. Two GOP members — Rand Paul and John McCain — have formally announced their intentions to vote against the bill. Several others from across the conference have also expressed misgivings.

Only two Republican senators can vote against the bill for it to pass.

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Sen. Susan Collins of Maine announced Monday that she will vote "no" on the latest Republican healthcare bill, all but surely ending the latest effort to repeal and replace Obamacare.

Collins joins Sens. John McCain and Rand Paul in opposition, and since two GOP members could oppose the bill for it to pass, the bill is likely dead. The Maine senator also opposed the previous iterations of the Republican healthcare bills, helping to end that push in July.

 "Sweeping reforms to our health care system and to Medicaid can’t be done well in a compressed time frame, especially when the actual bill is a moving target,"said a statement from Collins. "Today, we find out that there is now a fourth version of the Graham-Cassidy proposal, which is as deeply flawed as the previous iterations."

Collins pointed to three primary issues with the bill that caused her to oppose it:

1. Cuts to Medicaid, estimated at roughly $1 trillion from 2020 to 2036, by shifting to a block grant system:"This would have a devastating impact to a program that has been on the books for 50 years and provides health care to our most vulnerable citizens, including disabled children and low-income seniors," Collins said.
2. Weakened protections for people with pre-existing conditions: "Some states could allow higher premiums for individuals with pre-existing conditions, potentially making their insurance unaffordable."
3. Health insurance coverage losses:"Third, physicians, patient advocates, insurers, and hospitals agree that both versions of this legislation would lead to higher premiums and reduced coverage for tens of millions of Americans," said the statement.

Collins also said that despite the recent change by the authors of the Graham-Cassidy bill to include more money for her state in their formula for the new block grants, the overall cut was still too great for her to stomach. Additionally, Collins took issue with the seat-of-the-pants changes to the formula that lead to her state gaining more money.

"But even more important, if Senators can adjust a funding formula over a weekend to help a single state, they could just as easily adjust that formula in the future to hurt that state," Collins wrote. "This is simply not the way that we should be approaching an important and complex issue that must be handled thoughtfully and fairly for all Americans."

This is likely the last time in quite a while that Republicans will be able to advance any sort of large Obamacare repeal measure, since the deadline to use budget reconciliation — which allows a simple majority vote and no filibuster — runs out September 30.

Sen. Bill Cassidy, one of the authors of the new proposal, was frank about the prospects for the bill if Collins was not on board during an appearance with CNN's Wolf Blitzer just hours before the announcement.

"If you lose Susan Collins, it's over right?" asked Blitzer.

"Yes, yes it is," Cassidy replied.

SEE ALSO: The CBO says the newest Republican healthcare bill would leave 'millions' more without health insurance

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Late-night host Jimmy Kimmel on Monday expressed cautious optimism about the apparent death of the Graham-Cassidy healthcare legislation.

With Sen. Susan Collins of Maine coming out against the the Graham-Cassidy bill on Monday, it appears that the measure is dead — ending Kimmel's week-long run of impassioned attacks on the legislation.

Kimmel gave one more monologue on the subject Monday night, saying that after speaking out last week he met hundred of people at events over the weekend that thanked him and told him Obamacare saved their lives.

The late-night host pointed to polls showing that more American preferred the Affordable Care Act to the Graham-Cassidy proposal. He also highlighted Republican lawmakers' message on Obamacare.

"They don't care what you think, they want you to think what they think. That's why they keep calling Obamacare a disaster, you hear that word a lot," Kimmel said. "Obamacare definitely needs work, but think about it: did anyone have to convince you Hurricane Harvey was a disaster? No, because it was a disaster. If someone has to keep telling you something is a disaster, it probably isn't."

Kimmel also thanked Sen. John McCain for coming out against the bill on Friday.

"The truth is, John McCain probably saved the Republican Party by doing this," Kimmel said. "Because if you think Graham-Cassidy is unpopular now, wait until people have to live with it — or not live with — then who gets blamed? The Republican Party."

After defending himself against criticism from outlets like Fox News, Kimmel brought up Collins' defection and the apparent death of Graham-Cassidy. 

"Thank you Senator Collins, you know Maine needs affordable healthcare more than almost any state. You know the sewers up there are filled with child-eating clowns," Kimmel said, referring to the hit horror movie "It."

"The best news is now I can go back to talking about the Kardashians," he said.

Kimmel originally threw himself into the midst of the debate in May after his newborn son Billy needed to have open heart surgery hours after his birth. The legislation being debated at the time would have undermined protections for people with preexisting conditions and allowed insurers to reinstitute lifetime limits on healthcare payments.

GOP Sen. Bill Cassidy of Louisiana told Kimmel that any Obamacare repeal and replace legislation had to preserve those protections, dubbing it the "Jimmy Kimmel test."

When Cassidy helped roll out the Graham-Cassidy healthcare bill earlier in September, Kimmel slammed the Louisiana senator, since the bill allowed the erosion of those protections.

Watch below:

SEE ALSO: Susan Collins opposes Graham-Cassidy healthcare bill, dooming the Republican Obamacare repeal

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President Donald Trump on Tuesday expressed disappointment with GOP senators opposed to the latest plan to repeal and replace the Affordable Care Act, known as the Graham-Cassidy bill.

In order to pass Graham-Cassidy, Republicans needed 50 of their 52 members to vote for the bill. Sen. Susan Collins of Maine on Monday became the third GOP senator to come out against it, following Sens. Rand Paul and John McCain.

Trump did not appear pleased with the defections and yet another apparent failure by congressional Republicans to repeal Obamacare.

"We were very disappointed by a couple of senators — Republican senators, I must say," Trump said during a meeting with Republican lawmakers on tax reform. "We were very disappointed that they would take the attitude that they did."

Trump has repeatedly attacked McCain for his vote on Twitter and on an Alabama-based radio show Monday. Trump has also leaned on Paul to get on board with the plan, calling him a "such a negative force" on Twitter.

"And at some point there will be a repeal on my desk, but we'll see whether or not that point is now or will it be shortly thereafter," Trump said Tuesday. "But we are disappointed in certain so-called Republicans."

The ability for Republicans to use the budget reconciliation process, which allows them to bypass Democratic filibuster threats, runs out on September 30. After that date, the GOP must either pass a new budget to use reconciliation again or get Democrats on board with a healthcare bill.

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Republicans on Tuesday decided against bringing the Graham-Cassidy healthcare bill to the floor for a vote, a GOP aide told Business Insider, effectively killing the party's latest push to overhaul the US healthcare system.

Sens. Lindsey Graham and Bill Cassidy, two of the authors of the bill, said during a press conference with GOP Senate leaders that there were not enough votes to pass the measure.

"Well, to be clear, due to events under our control and not under our control, we do not have the votes," Cassidy said.

Graham said it was "not if but when" Republicans would pass his healthcare bill, but added that there was still work to be done before then.

"We know what we're against," Graham said. "We've had a hard time articulating what we're for."

Senate Majority Leader Mitch McConnell said the GOP conference would move on from the push to repeal and replace the Affordable Care Act, the law better known as Obamacare, to the attempt to reform the tax code.

It became apparent on Monday that Republicans did not have the 50 votes needed to get the bill through the Senate when Sen. Susan Collins announced her opposition to the bill, making her the third Republican senator to defect. Republicans hold 52 seats in the Senate.

Republicans' ability to use fiscal 2017 budget reconciliation, which allows for certain bills to pass with a simple majority, will expire on Saturday. After that, Democrats will be able to filibuster any healthcare bill put forward.

That means the GOP must either work with Democrats to get eight more votes on a healthcare bill or wait to mount another effort under reconciliation rules in either the fiscal 2018 or the fiscal 2019 budget.

"Look, we haven't given up on changing the American healthcare system. We're not going to do that this week," McConnell said. "But it still lies ahead of us."

SEE ALSO: Susan Collins opposes Graham-Cassidy healthcare bill, dooming the Republican Obamacare repeal

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• American policymakers need to stop obsessing over Obamacare and tackle the problem that could really bring down the whole healthcare system — exorbitant prices for drugs and care.
• The US pays far more than the rest of the world for healthcare, and the pharmaceutical industry is misleading us about the reasons why.
• There has yet to be a serious push to tackle the reasons for that.

The GOP has yet again failed to repeal Obamacare, and will likely lick its wounds and turn to other things until the next time it senses the opportunity to ram through a bill that will leave millions without healthcare.

Instead, perhaps we should consider tackling the worst problem in American healthcare: the cost of literally everything we pay for. 

Drugs, medical care, medical devices — you name it — are already more expensive than the rest of the world and prices are going up. This isn't just about 30 million people, it's about saving the entire system from getting too expensive and collapsing around our heads.

This is our fault

I recently spoke with Andy Slavitt, the man who ran Obamacare before Donald Trump became president. I'd intended to speak with him about pricing, but instead asked him about the volley back and forth between Senate Majority Leader Mitch McConnell, the Graham-Cassidy gentlemen, and the holdout Senators who seem to have won the day yet again.

By all accounts, it was some nasty horse trading. Senator Lisa Murkoswki (R-AK) wouldn't be bribed , Senator John McCain (R-AZ) just wants everyone to pass laws like adults, Senator Rand Paul (R-KY) was unclear about what his problem was but he was a hard no, and Susan Collins (R-ME) seems to be over of all this. Plus Jimmy Kimmel was sounding presidential.

As for the bipartisan effort to stabilize Obamacare going on at the same time, Slavitt said: "I am quite confident they came to a deal and it was yanked out from under them for political reasons."

That took up almost all time we had, so I barely got to talk to him about what I wanted to talk about — how to improve price transparency in healthcare. 

"It's going to take more than a few tweets from the President to bring real reform," Slavitt said, just before he hung up the phone. "Once pharmaceutical costs reach 25% of Medicare, we're not going to like the choices we'll have to make."

And that was that.

But we can fix it

Drug pricing isn't something we, as a country, have liked to talk about. Over the few decades, you were more likely to hear someone on cable news say Americans have the best healthcare system in the world than anything else. At least until last year.

That's when the entire country was scandalized by Martin Shkreli, the jailed pharma CEO who jacked up the price of an AIDS medication up 5,000%. And yes, pretty much everyone wanted to scream at Heather Bresch, the CEO of Mylan, after she hiked the price of a life-saving EpiPen injector 500%.

But they're not the only executives running companies that raise drug prices astronomically — and the price jackers aren't the only problem with the system. The pharmaceutical industry tangled in a Gordian knot of secret deals; shadowy third parties with their hands out for a rebate; medications of questionable efficacy; doctor payouts; mind-bending CEO compensation; price collusion; financial engineering; and non-disclosure agreements. There's so many non-disclosure agreements.

Now, the standard pharmaceutical industry response to this complaint about pricing is that it spends so much on R&D that it needs to charge a lot for drugs. Also, Americans (the world's heroes) are subsidizing global health because our government hasn't put in place draconian price controls — without us, people abroad would suffer.

This is nonsense. Americans aren't just paying for big pharma's R&D with elevated drug prices — they're paying for R&D and then some. According to a study from the journal Health Affairs, the list prices of drugs in other developed countries average only 41% of the net price we pay here.

"Overall in 2015 the premium earned by US net prices exceeding other countries’ list prices generated $116 billion, while that year the companies spent just 66 percent of that amount, or $76 billion, on their global R&D."

Like I said we're paying for R&D, and then some.

"Although prices are often justified by the high cost of drug development, there is no evidence of an association between research and development costs and prices," researchers from Brigham and Women's Hospital in Boston found last year. "Rather, prescription drugs are priced in the United States primarily on the basis of what the market will bear."

We just have to want to

I'm pretty sure that it was during the second Obamacare repeal attempt this year that the Senate Health, Education, Labor, and Pensions committee had a meeting on drug pricing. Most of the Republicans weren't there because they were trying to write a secret bill in a secret room somewhere in the Capitol.

And that was really unfortunate because there was some fascinating testimony about how third-party rebates work and frankly, about how Americans are getting duped.

It was all so clear that Sen. Sheldon Whitehouse (D-RI) ended up exasperated. He said that the Senate could solve drug pricing "in a week" if it weren't for Citizens United, the Supreme Court decision that opened the door to campaign spending. The pharmaceutical industry has spent billions of dollars lobbying Congress to keep this system opaque.

And for all of President Trump's talk about drug pricing, his administration has done absolutely nothing. A few months ago the New York Times published a White House "draft executive order" on drug pricing that was so pro-industry, so offensive to everyone paying attention, that no one has spoken of it since then. We count our blessings.

That's not the only evidence we have that this administration is out of touch on the issue. Last week in an interview on CNBC Commerce Secretary Wilbur Ross expressed his concern for poor big pharma getting based by "initiatives by these European and other countries [that] are very much anti-US."

Perhaps it's needless to say, but Ross, a billionaire private equity magnate, is not known on Wall Street for being in touch with the common man's problems. It seems he's swallowed the industry's R&D story hook, line, and sinker — and it's quite possible, based on his silence, that Trump has too.

Or perhaps Trump's simply forgotten about drug pricing since he's busy fighting with 30-something basketball players and oligarch football franchise owners.

We won't know until he tweets about it.

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The Graham-Cassidy healthcare bill was dealt a fatal blow on Tuesday, but Republicans appear far from ending their quest to repeal and replace the law known as Obamacare.

Despite a setback on the latest round of repeal efforts, the GOP appears to be moving toward a new strategy, floating the idea of combining a healthcare overhaul with their soon-to-launch effort to reform the nation's tax code.

As of September 30, the ability for Republicans to repeal Obamacare and replace it with another system using the budget reconciliation process will expire. Reconciliation allows Republicans to pass a bill through the Senate on a simple majority vote without being subject to a Democratic filibuster, as long as the bill reduces the federal deficit.

The reconciliation rules that were used for the Graham-Cassidy bill, and all other recent Obamacare repeal efforts, were included as part of budget for fiscal year 2017, which ends September 30.

One idea circulating around Capitol Hill is to add instructions for a healthcare bill in a reconciliation rule for the upcoming fiscal year 2018 budget. That would allow another few bites at the apple on healthcare overhaul.

But there's one complication — Republicans also want to use 2018 reconciliation for tax reform.

Republicans can use reconciliation once per year for a single bill that affects revenues — so they chose to do Obamacare this year and tax reform under fiscal year 2018.

Combining Obamacare repeal and tax reform on one reconciliation bill is technically possible, but it would make the effort for both tax cuts and Obamacare repeal more difficult.

But delivering on an Obamacare repeal before the 2018 midterms elections remains a high priority for many Republicans.

Sens. Ron Johnson and Lindsey Graham, both authors of the latest Obamacare repeal bill, told reporters Tuesday that they would oppose any budget resolution that does not include the ability to combine repeal and tax reform via reconciliation. The two lawmakers sit on the Senate Budget Committee, where Republicans have only a one-vote majority.

Other Republicans, without going as far as Johnson and Graham, have suggested they also prefer a potential two-pronged approach on a reconciliation bill.

GOP Senate leadership has been mum on the issue and outside Republican groups have said it would be a bad idea to complicate tax reform with another issue that has proved to be divisive for the Republican conference.

"I don’t want to jeopardize tax. We’ve done this for eight months, it’s got to get fixed, let the committee keep working on it,” Sen. David Perdue told Politico. "So I really believe we’ve got to get to tax, that’s my top priority right now before we run out of time."

SEE ALSO: Susan Collins opposes Graham-Cassidy healthcare bill, dooming the Republican Obamacare repeal

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President Donald Trump tweeted his assurance Wednesday that Republicans will have enough votes to repeal Obamacare, one day after the GOP canceled its vote on the Graham-Cassidy healthcare bill due to a lack of support.

"With one Yes vote in hospital & very positive signs from Alaska and two others (McCain is out), we have the HCare Vote, but not for Friday!" Trump tweeted. 

Technically, the Senate has until midnight Saturday, September 30, to pass a healthcare bill using the process known as budget reconciliation. The reconciliation process allows the GOP to pass a bill with just 50 votes and avoid a Democratic filibuster.

Three GOP senators — Susan Collins, John McCain, and Rand Paul — publicly announced they would oppose the Graham-Cassidy bill. With only 52 Republican Senate members, the leadership and the bill's authors yanked the vote.

As for the hospitalization, Trump appears to be referring to Thad Cochran from Mississippi, who is in his home state recovering from a urological issue but not hospitalized.

Since Trump dismissed the prospect of McCain getting on board, it would appear he believes that Collins and Paul could be flipped. Paul is adamant about a full Obamacare repeal, saying Graham-Cassidy did not go far enough in dismantling the law. Collins, on the other hand, believes that the law went too far in its cuts to Medicaid and weakening of protections for sick Americans.

Sen. Lisa Murkowski did not announce her opposition prior to the bill being pulled, but released a statement soon after expressing deep concern with aspects of the bill, similar to Collins'. Murkowski and Collins had voted against every previous Republican healthcare bill in July as well.

"We will have the votes for Healthcare but not for the reconciliation deadline of Friday, after which we need 60," Trump said. "Get rid of Filibuster Rule!"

The request to get rid of the filibuster is not a new suggestion from Trump, who tweets the idea regularly. It is also one of the suggestions that most annoys Senate Majority Leader Mitch McConnell, according to reports. Given the strained relationship between Trump and McConnell — Axios' Mike Allen reports Trump has even taken to physically mocking the Kentucky senator in private — this tweet will likely not help repair that divide.

SEE ALSO: There's a way Republicans could bring back Obamacare repeal — but it could wreck their tax plan

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President Donald Trump, frustrated with Senate Majority Leader Mitch McConnell and Arizona Sen. John McCain, has begun physically mocking them in private, Axios reported on Wednesday.

The president imitates McConnell by slumping his shoulders and looking lethargic, and emulates the dramatic thumbs down McCain used to indicate his "no" vote on the GOP healthcare bill in July. 

Trump has repeatedly lashed out both at McConnell and McCain, most recently over Congress's failure to pass legislation repealing and the Affordable Care Act.

The president called McCain's recent opposition to the latest incarnation of the GOP healthcare bill a "tremendous slap in the face to the Republican Party," and placed full blame for legislative failure on McCain. 

"You can call it what you want, but that's the only reason we don't have it, because of John McCain," Trump said in a radio interview on Monday.

Trump has also repeatedly expressed his frustration with McCain on Twitter. On Monday, the president tweeted a six minute-long video montage of the senator and former presidential candidate publicly promising to get rid of Obamacare.

McConnell, another repeat Trump target, drew continued criticism from the president for his inability to deliver on the longstanding GOP promise. During the Monday radio interview, Trump brought up the majority leader's low approval rating with constituents.

"Mitch is not, polling-wise, the most popular guy in this country," Trump said.

Trump has also placed blame on McConnell's shoulders for Republican candidate Luther Strange's loss in Alabama's Senate primary to Roy Moore, an anti-establishment candidate who was backed by some of Trump's most fervent supporters.

Bob Bryan contributed to this report.

SEE ALSO: Trump says 'it's disgusting' Obamacare repeal isn't done, singles out McCain for his opposition

SEE ALSO: IT'S OVER: Republicans will not vote on Graham-Cassidy healthcare bill, will move on from Obamacare repeal for now

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The day after the latest Republican healthcare bill collapsed, President Donald Trump laid out a few potential paths forward on healthcare for the federal government.

During a question-and-answer session with reporters on the lawn of the White House, Trump suggested a few things: that Republicans have enough votes to go it alone on repealing the Affordable Care Act; that he could work with Democrats to pass a bill by early 2018; and that he could issue executive orders within weeks to make unilateral changes to the system.

Trump repeatedly claimed Wednesday that Republicans had enough votes to pass a healthcare bill, which flew in the face of what the bill's actual authors and GOP leaders said when they pulled the bill from a planned floor vote the day before. Trump blamed a Friday deadline for why it would have to be pushed back to January or February.

"We have the votes, but we can't go longer than Friday," Trump said.

Republicans' ability, at least for awhile, to use the budget reconciliation process to pass a bill without the threat of a Democratic filibuster expires September 30. They will have to pass a new budget resolution with new reconciliation rules, but the Republican pivot to tax reform would complicate any plans to move a healthcare bill.

Then Trump suggested a possible bipartisan push to solve the issue with Democrats.

"I'm also going to meet with Democrats and see if we can get a health care plan that's even better," said the president. "So I will negotiate with Democrats."

It's unclear what sort of plan Trump would seek with Democrats. It could be simply a stabilization package for the Obamacare exchanges, similar to one that was being developed by GOP Sen. Lamar Alexander and Democratic Sen. Patty Murray — before Republican leaders scrapped the plan. It could also be a broader package to help correct some of the issues with Obamacare. 

Finally, Trump said he was considering signing an executive order that he said would allow people to purchase insurance across state lines.

"I am considering an executive order on associations and that will take care of a tremendous number of people when it comes to healthcare," Trump said. "And I'll probably be signing a very major executive order where people can go out, cross state lines, do lots of things, and buy their own healthcare. And that will be probably signed next week, it's being finished now."

Allowing insurance to be sold across state lines has long been a focus for Trump. But Obamacare already allows it, no insurers use it, and it would likely do little to bring down costs.

The other idea he mentioned would allow association health plans, which would permit employees at small businesses and other individuals to pool together to buy insurance at more favorable rates.

The plans would not be subject to Obamacare regulations, and experts say they could destabilize the rest of the individual insurance market.

"Potentially quite destabilizing if these non-compliant association plans could skim of healthy individuals and small businesses," tweeted Larry Levitt, a senior vice president at the Kaiser Family Foundation, a nonpartisan health policy think tank.

Trump did not specify which of these three options he would pursue first, or if they would all work in conjunction.

SEE ALSO: There's a way Republicans could bring back Obamacare repeal — but it could wreck their tax plan

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President Donald Trump said during a gaggle with reporters at the White House on Wednesday that Republicans "have the votes for healthcare."

"We have one senator that's in the hospital. He can't vote because he’s in the hospital," Trump said.

It was one of several times he went on to make that false claim, according to the very authors of the latest version of the Republican healthcare bill that was pulled from a Senate floor vote this week.

"I’m almost certain we have the votes," Trump said of the so-called Graham-Cassidy healthcare legislation. "But with one man in the hospital, we cannot display that we have them. Plus, some people want to go through a process just to make themselves feel better, that's okay."

Trump also tweeted Wednesday that "we have the HCare Vote."

But Republicans do not have the healthcare votes.

Sen. Thad Cochran, whom Trump referred to as hospitalized, is recovering at home from a medical procedure. But even with his vote, there simply aren't the necessary 50 GOP senators supporting the Graham-Cassidy plan for it to pass.

The GOP can only afford two Senate defections. While Trump is correct that Sen. John McCain expressed misgivings about the process which Graham-Cassidy was going through — the bill was scheduled to go to a vote just two weeks after its release — he also said he wants to move forward on a bipartisan basis.

Additionally, Sens. Rand Paul and Susan Collins came out as no votes on the bill primarily over the substance.

Sen. Lisa Murkowski of Alaska also released a statement decrying the process, but her concerns centered around the details of the plan as well.

"Giving control back to the states and flexibility are ideas I can get behind,"Murkowski wrote. "But substance matters and the ability to validate data matters."

Finally, Sen. Ted Cruz suggested last weekend that he was against the latest version of the legislation. He hinted that Sen. Mike Lee was opposed, as well.

SEE ALSO: Trump laid out 3 potential paths forward after the latest Republican failure on healthcare

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Idaho's Obamacare customers will face an average 27 percent premium increase next year because of too many sick customers.

The state's insurance regulator announced the final rates Friday. The announcement comes as many states are grappling with double-digit rate increases for a variety of reasons that include a sicker-than-expected population and questions about whether the federal government will continue to pay insurer subsidies.

Idaho's silver plans, which are the most popular of Obamacare's three plan options, will rise an average 40 percent. The premiums for the lowest tier bronze plans will increase 8 percent, and gold plans 9 percent.

Idaho pegged the increase to higher medical claims for insurers on the individual market, which includes Obamacare's exchanges and is used by people who don't get insurance through work. It showed that claims for 2016 totaled $563 million, but the state's six insurers brought in only $494 million in premiums.

"Large rate increases may be needed when the prior year's premiums is not sufficient to pay for health claims and administrative costs and fees," Idaho's insurance regulator said.

The regulator does not approve the final rates. It can decide if the rate increases are reasonable, though.

Idaho is far from the only state facing double-digit premium increases. Florida's insurance regulator expects rates to increase by nearly 45 percent, and Utah 39 percent, according to the Salt Lake Tribune.

Major contributors to the rate increases have been risk pools without enough healthy people to offset high claims from sicker customers, uncertainty around whether insurer subsidies will be paid by the federal government and the looming health insurance tax being reinstated next year.

SEE ALSO: Trump laid out 3 potential paths forward after the latest Republican failure on healthcare

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On January 10, just days before his inauguration, President Donald Trump told The New York Times that Republicans would have Obamacare repealed"probably sometime next week."

Now, as September comes to a close, Obamacare is still the law of the land (though Trump is working to undermine that) and Republicans are no closer to overhauling their healthcare law than they were when Trump took office.

The expiration of the 2017 budget reconciliation rules, which allowed the GOP to pass a bill repealing and replacing Obamacare without being subject to a Democratic filibuster in the Senate, it will likely be months before the party can attempt a repeal again.

The formal process all started back in March, with the release of the American Health Care Act from the House GOP leadership. The drama featured not one, but two failed votes spanning both chambers of Congress. There were seven different plans, a slew of edits, and many more ideas thrown around.

Here's a breakdown of every major plan from Republicans to repeal the law, and the ultimate fate:

The most drama came from the Senate, as John McCain's momentous thumbs down brought down the "skinny repeal" bill and seemed to kill the Obamacare repeal effort (and, let's be honest, the Graham-Cassidy push was more of a sputtering epilogue than an honest threat to pass).

Just because McCain produced the drama, doesn't mean he was the only senator to oppose one of the various ideas put forth by Senate Majority Leader Mitch McConnell. Republican senators from across the party's ideological spectrum took issue with the plans at various points. In all, 13 of the 52 GOP senators said they would vote against a healthcare bill at some point.

Here's the breakdown of Republican defectors for each Senate bill:

This does not mean, however, that the Obamacare repeal effort is dead.

The GOP can include reconciliation instructions in upcoming budgets, meaning the next attempt to dismantle President Obama's signature achievement could come in just a few months.

SEE ALSO: There's a way Republicans could bring back Obamacare repeal — but it could wreck their tax plan

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