Senate Republicans are making a last stab at health care reform, before a looming Sept. 30 deadline. And Massachusetts could be mortally wounded if it becomes law.

The core idea in this latest bill is to give each state a pot of money and let it decide how best to provide insurance to residents. But this bill would fill those pots of money by eliminating virtually all subsidies associated with the Affordable Care Act (aka Obamacare) — including aid to help lower-income individuals purchase subsidized insurance and support for states that expand Medicaid.

It’s not a straight swap, either. The cuts are bigger than the new grants, and the shortfall isn't evenly distributed. States that have done the most to expand access, like Massachusetts, actually lose the most.


Republican are racing ahead on the legislation because the rules change when the new federal fiscal year begins Oct. 1. Right now, they can pass this bill with just 50 votes, but once the calendar turns they’ll need 60 to overcome a near-certain Democratic filibuster. That’s a tight timeframe, making it unlikely that the Congressional Budget Office will complete a full analysis of how this proposal will affect health insurance coverage and premiums.

However, the left-leaning Center on Budget and Policy Priorities, which has a strong track record when it comes to budget estimates, says that under this bill, federal aid for Massachusetts’ health care programs would be cut by over $5 billion in 2026. That’s a huge amount, equivalent to roughly half what we currently receive in federal aid for health insurance.

It's hard to see how Massachusetts could make up for those lost funds, not without substantial reductions to state health programs or an unprecedented increase in taxes.

The key senators behind this last-ditch effort are Lindsay Graham and Bill Cassidy, who claim to have 48 or 49 votes in the Senate. But finding a 50th is far from guaranteed, and there isn’t much time either.


Comparing the pieces of the Cassidy-Graham bill with earlier efforts, it’s not clear why it should fare better than previous Republican failures: nearly all of the most contentious elements are still in place.

■  Funding for Medicaid is slashed, making it difficult for states to provide necessary support for poor, disabled, and elderly residents in need of care.

■  Popular regulations are loosened, potentially allowing insurance companies to charge people more when they get sick, if states consent. States can also allow for “skinny” insurance plans, dropping requirements for coverage of mental health or prescription drugs, for examples.

■  Subsidies designed to help lower-incomes Americans purchase individual health plans may be eliminated altogether. Under Cassidy-Graham, states can redirect their federal aid towards other health-related areas, such as hospital payments or high-risk pools.

Atop these fractious concerns — which were already enough to derail earlier Senate efforts — the Cassidy-Graham bill adds a new bone of contention: It picks favorites among the states. The new bill gradually shifts to a funding formula that favors the largely red, largely rural states that refused to join the Medicaid expansion program under Obamacare.

This is what makes Massachusetts especially vulnerable.

We’ve long been a leader in health care reform, having put in place the forerunner to Obamacare. We’ve continued that tradition by expanding Medicaid, seeking additional federal funds for health care, and generally pursuing creative ways to cover more people.


But under Cassidy-Graham, our innovative efforts would slowly be drained of funding. By 2026, block grants will be based solely on the number of poor people in the state — not what we’ve been doing for them. And compared to most states, we don’t have that many poor residents.

To be sure, there’s a certain equitable logic to this. It makes sense for federal funds to be distributed based on objective measures of need, rather than the commitment and creativity of state leaders.

But this is sort of a false choice. Under current Obamacare rules, there are piles of money still sitting on the table, waiting to be picked up by states that have so far refused to expand their Medicaid programs. They could get more without Massachusetts getting any less.

Cassidy-Graham transforms this into a zero-sum game in which Massachusetts has to lose for Texas to gain. And not just Massachusetts; others that will lose out include California, Connecticut, New Hampshire, Kentucky, D.C., and New York among 36 states, collectively home to the vast majority of American citizens.

You may be thinking that with losers like this, there must be some huge winners in this funding shift. But not really. Because remember, Cassidy-Graham also cuts the overall amount of federal aid, by a total of $300 billion between 2020 and 2026.

This could prove an insuperable problem politically, because there are red states that stand to lose massively under this bill, including two with key senators in this debate: Lisa Murkowski in Alaska and Rand Paul in Kentucky, both of whom have opposed earlier bills.


None of this even accounts for what may be the two most disruptive features of Cassidy-Graham. First, that it would set off a sudden, patchwork rewriting of life-changing insurance rules across all 50 states. Second, that the block grants upon which the whole bill is premised disappear in 2027, as if states will have solved the problem of affordable health insurance in one short decade.

In the end, it’s hard to see how this bill can pass, given that it carries many of the risks of its predecessors, and some new ones besides.

Having 48 or 49 senators behind it is no guarantee of eventual triumph. In July, Republicans came within one vote of repealing Obamacare, and that could happen again. The real problem is getting number 50, and with Cassidy-Graham, it’s still unclear where that deciding vote will come from.

Except there is one important difference this time: the Sept. 30 deadline. It may be now or never for Senate Republicans, and that can be a powerful motivator.

So residents of Massachusetts had better keep their eyes on that ticking clock, because if Republicans succeed, we’re going to lose billions in health care funds.

Evan Horowitz digs through data to find information that illuminates the policy issues facing Massachusetts and the US. He can be reached at evan.horowitz@globe.com. Follow him on Twitter @GlobeHorowitz.