John McCain is an American war hero with many political accomplishments. That legacy, though will be diminished by not one but two decisions to kill Republican health-care reform. And no one should let Senator Rand Paul off the hook, either.

Mr. McCain said in a Friday statement that he “cannot in good conscience” vote for a proposal from Lindsey Graham and Bill Cassidy that would devolve ObamaCare funding to the states, as well as repeal the medical-device tax and the employer and individual mandates. The deadline to pass the bill with 51 votes is Sept. 30 thanks to arcane Senate budget procedures. Mr. McCain’s no vote almost certainly dooms the project, as Mr. Paul has already declared his opposition and Susan Collins of Maine is thought to be a reliable no vote as well.

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The last train is leaving Reconciliation Station. Republican efforts to repeal and replace Obamacare — derailed just weeks ago — now seem back on track. GOP senators Lindsey Graham of South Carolina, Bill Cassidy M.D., of Louisiana, Dean Heller of Nevada, and Ron Johnson of Wisconsin seek 47 more votes (including, if necessary, that of Vice President Mike Pence, to break a 50–50 tie) to pass their legislation within the Senate’s filibuster-proof reconciliation window. It closes September 30. Having snored through August, Republicans are scrambling to keep the repeal/replacement pledges that secured them the House, Senate, and White House.

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Sen. John McCain (R-Ariz.) on Friday announced that he will vote against the latest proposal to repeal ObamaCare, potentially dooming the legislation and, with it, the GOP’s last shot at passing a health care overhaul this year.

“I cannot in good conscience vote for the Graham-Cassidy proposal. I believe we could do better working together, Republicans and Democrats, and have not yet really tried,” he said in a statement, referring to the legislation spearheaded by GOP Sens. Lindsey Graham (S.C) and Bill Cassidy (La.).
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Based on estimates, overall federal funding for coverage expansions and Medicaid would be $160 billion less than current law under the Graham-Cassidy bill over the period 2020-2026. Thirty-five states plus the District of Columbia would face a loss of funding. Federal funding under the new block grants would be $107 billion less than what the federal government would have spent over the period 2020-2026 for ACA coverage. A typical Medicaid expansion state would see an 11% reduction in federal funds for coverage compared to an increase of 12% in a typical non-expansion state.

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Two GOP senators are likely “no” votes: Kentucky’s Rand Paul and Maine’s Susan Collins. But Arizona’s John McCain, who spoiled this summer’s attempt at ObamaCare repeal, seems unlikely to repeat his performance and sandbag his good friend Lindsey Graham. That means the 50th vote will come down to Alaska’s Lisa Murkowski, who says she’s still trying to decide how the bill will affect her state. If Ms. Murkowski is honest with her constituents—and about her numbers—Alaska needs a “yes” vote.

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As the Graham-Cassidy (Heller-Johnson) health care bill appears to achieve a rapid intensification of support, so too have lies and exaggerations about its contents. Some people are very mistrustful about the states’ willingness and ability to provide a regulatory environment in which broad segments of society will have decent health care. The competency and motivation of the states needs to be compared not to some fantasy federal government with unlimited resources, constant benevolence and technical competence, but to a federal government that in fact is deeply in debt and that has proven itself inept at creating stable health insurance markets.

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The ACA spends more than twice as much on expanding Medicaid as it does on premium tax credits for the exchange. By consolidating funding for both entitlements, Graham-Cassidy allows states to pool resources to increase the attractiveness and stability of the individual market. In doing this, it meets a clear need, but it also facilitates more thorough reform by repealing the individual mandate and potentially allowing fairly priced, fully competitive insurance to be offered outside of the exchanges. It also greatly expands the flexibility and potential uses of Health Savings Accounts. France presses Trump to reconsider climate deal
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The idea of turning more power over to the states has long been advocated by conservatives, but there are compelling reasons for liberals to get behind devolving power from the federal government.

When Congress passed the Affordable Care Act in 2010, it left many of the details to the discretion of the Department of Health and Human Services, giving vast powers to the secretary to determine everything from fast-food menu labeling requirements to when individuals could purchase insurance. During the Obama years, the administration used its regulatory discretion — pushing and arguably exceeding the limits of the law — to prop up the president’s signature legislative accomplishment as the program ran into implementation problems.

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Cassidy-Graham has an important, albeit fixable, flaw—what we might call “asymmetric federalism.” The core idea in the bill is to take the money Obamacare spends on expanding coverage to the uninsured and give it to state governments in the form of block grants. States, in turn, could use these block grants to address the health-care needs of their populations. It’s an attractive idea, in theory. But the bill would put a heavy Washington hand on the federalism steering wheel. It would make it relatively easy for blue states to expand the role of single-payer health care, while making it rather difficult for red states to achieve market-oriented reforms.

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Senate Republicans’ last-ditch attempt to repeal and replace Obamacare rests on the unlikely collaboration of a veteran senator who can’t stand health policy, a wonky freshman who has never passed major legislation and a former senator who lost his seat a decade ago.

Together, Sens. Lindsey Graham (R-S.C.), Bill Cassidy (R-La.) and former Pennsylvania Sen. Rick Santorum crafted the latest GOP repeal bill in hopes of delivering on the party’s seven-year-old campaign promise to repeal Obamacare.

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