Senate Republicans are poised to take an unprecedented leap into the dark as they prepare to vote on legislation that would affect health protections for tens of millions Americans yet has been subject to virtually no analysis or public scrutiny.
The proposal goes far beyond previous bills to repeal the 2010 healthcare law, often called Obamacare, and would fundamentally restructure the nation's half-century-old healthcare safety net.
With a vote expected as soon as Wednesday, according to the White House, and backers still talking about potentially major changes, the legislation will get its first and only congressional hearing Monday afternoon. The independent Congressional Budget Office, which lawmakers rely on to assess major legislation, already has said it won't have time to analyze the bill's effect on health coverage and insurance premiums.
"This is like legislating blind," said University of North Carolina political scientist Jonathan Oberlander, who has written extensively on the history of major healthcare legislation."It is really hard to find an example of something where Congress was this reckless."
On Sunday, several key Republican senators expressed strong doubts about the bill, which appears to remain at least a vote or two short of what GOP leaders need for passage. Sen. Susan Collins of Maine said in an interview on CNN that "it's very difficult for me to envision a scenario where I would end up voting for this bill." Sen. John McCain of Arizona previously said he would oppose the bill, and Sen. Lisa Murkowski of Alaska has said she remains undecided.
On the right, Sen. Rand Paul of Kentucky, who has previously said several times that he opposes the bill, kept up his criticism in interview on NBC's "Meet the Press." And Sen. Ted Cruz, speaking in his home state of Texas, said that "right now they don't have my vote." Cruz said he did not think Sen. Mike Lee (R-Utah) was supporting the bill either.
With 52 Republicans in the Senate and no Democrats supporting the repeal effort, sponsors of the bill, including Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.), can afford to lose only two GOP votes.
Faced with the resistance within his own caucus, Cassidy suggested Sunday that he plans to introduce a new version Monday.
Graham and Cassidy have insisted their proposal would protect Americans' access to healthcare while making coverage more affordable.
"President Trump has said he will not sign a bill which does not protect those with preexisting conditions," Cassidy said Sunday on ABC's "This Week." "I'm a physician who worked in a public hospital for 25 years caring for those with preexisting conditions."
But the key language in the bill that Cassidy points to as guaranteeing coverage has never been defined or tested, leading to widespread doubts that it would actually do what he says. Cassidy's claims have been disputed by independent analyses of his proposal, which have concluded that major funding cuts and loosened insurance regulations in the bill will likely erode coverage for many vulnerable Americans.
Leading patient advocates — including the American Heart Assn., the American Diabetes Assn., the March of Dimes and the advocacy arm of the American Cancer Society — have issued similar warnings, based on their assessment of the GOP proposal.
Over the weekend, an unusual consortium of groups representing physicians, hospitals and health insurers issued a joint statement strongly condemning the legislation.
"The bill will cause patients to lose important protections as well as undermine safeguards for those with pre-existing conditions," the groups said, warning additionally that hundreds of billions of dollars in Medicaid funding cuts mean "millions of patients will lose their coverage and go without much-needed care."
"Healthcare is too important to get wrong," concluded the groups, which included the American Medical Assn., the American Hospital Assn. and the Blue Cross Blue Shield Assn. "Let's take the time to get it right."
Under normal circumstances, Congress takes years to develop complex legislation that involves large sums of money and affects millions of Americans.
The legislation creating Medicare, for example, which was signed by President Lyndon Johnson in 1965, was first introduced eight years earlier and studied and debated extensively.
Similarly, bills creating the Children's Health Insurance Program, which President Clinton signed in 1997, and the Medicare Part D prescription drug program, which President George W. Bush signed in 2003, underwent years of committee hearings and study.
Even the Affordable Care Act, which President Obama signed on March 23, 2010, after a last-minute scramble by Democratic leaders to get the votes, had been debated and analyzed for more than 15 months.
By one tally, between January 2009 and March 2010, the House of Representatives held 79 hearings on what would become the Affordable Care Act, heard from 181 witnesses and debated scores of amendments.
Similarly, the Senate held approximately 100 hearings and for nine months engaged in a bipartisan effort in the Senate Finance Committee in a bid by Democratic leaders to solicit Republican support.
The Graham-Cassidy proposal in important respects is more far-reaching than the 2010 law.
The GOP proposal would not only roll back the government programs created by the current law to guarantee Americans' health coverage, it would completely restructure the 52-year-old system of federal support for state Medicaid programs that currently cover approximately 70 million people. It would also dramatically cut future Medicaid funding that supports coverage for poor children, mothers, seniors and the disabled.
At the same time, the bill would give states broad new authority to remake their healthcare systems and waive many protections in the current law, including the ban on insurers charging sick people more for coverage.
"For something this big, you need to be deliberative, and you need to think it through," said Matt Salo, head of the National Assn. of Medicaid Directors, whose bipartisan board of directors also urged the Senate last week to slow down.
"Maybe this turns out great," Salo said. "But there are so many core questions that we don't know the answer to. Voting now is like turning off your headlights and driving into the tunnel."
One key provision of the bill, for example, would require a state to show how it "intends to maintain adequate and affordable health insurance coverage for individuals with preexisting conditions." But there's no agreement on what "adequate and affordable" would mean or what rights patients would have if a state "intends" one thing but enacts something else.
Although the Senate Finance Committee plans a hearing Monday on the Graham-Cassidy bill, the legislation will not go through the customary mark-up process in which lawmakers debate bills, offer amendments and develop a record indicating how a law should be interpreted.
"I don't see anything comparable," Don Ritchie, the Senate's former official historian, said of the process Senate Republicans are using.
Senate Republicans are scrambling to pass the Graham-Cassidy legislation before a Sept. 30 deadline, after which they can no longer use a special rule that allows them to advance repeal legislation with only 50 votes instead of the 60 normally required to pass controversial bills in the Senate.
By contrast, the Senate health committee just spent two weeks taking testimony from governors, state insurance regulators and healthcare officials from across the country in a bipartisan bid to craft a much more limited bill aimed at stabilizing health insurance markets.
Several Republican senators who have voiced reservations about the Graham-Cassidy bill, including McCain and Collins, urged GOP leaders to return to that more deliberative process.
"What I would like to see happen is for us to return to the very good work that the Senate health committee was doing," Collins said Sunday. "That's the avenue that we should take."
President Trump, for his part, sounded a downbeat note Sunday afternoon, telling reporters who asked about the healthcare bill that "eventually we will win on that" but that his "primary focus" was on tax legislation.
Staff Writer Laura King contributed to this article.