As the Republican Party's last-ditch effort to repeal Obamacare hangs by a thread, a revised version of the Graham-Cassidy bill was circulated to Senate Republicans on Sunday with the aim of winning over key votes.
Even with the changes, leadership has an uphill climb -- two senators, Rand Paul and John McCain -- have already publicly opposed the bill. Others like Lisa Murkowski and Susan Collins have deep reservations.
The newest version of the bill gives Medicaid expansion states that expanded the program after 2015 additional federal dollars.
Under the latest proposal, states that expanded Medicaid after December 2015 would be eligible for $750 million that the federal government would allocate between 2023 and 2026. According to a summary of the bill, "the administrator will distribute fund to qualifying states based on their percentage of low-income individuals in the state compared with the total number of low-income individuals for all qualifying states."
In an important nod to Murkowski, the revised bill says Native Americans and Alaska Natives enrolled in Medicaid expansion prior to 2020 could continue to be eligible after that point, according to documents circulated Sunday night to senior Senate aides and obtained by CNN. The state's sizeable native population and that group's unique health needs has been a serious concern for Murkowski.
In one new provision particularly beneficial to Alaska, the state would receive a 25% boost in federal matching funds for Medicaid due to its defined high-level of poverty.
Under the new plan, Medicaid expansion would end in 2020 and no states that haven't already expanded could opt to do so. Also beginning in 2020, funding for the program would be changed to the per-capita model.
The updated bill would also allow states to design some of their own insurance rules. This would wipe away many of Obamacare's protections not only for those with pre-existing conditions, but also for those who get medical care.
It would let states alter the essential health benefits, which require insurers to cover prescription drugs, mental health and other services. But states could also change many of Obamacare's financial protections, including limiting how much people must pay out of pocket each year and how much of the tab insurers must pick up. That means that insurers could once again offer plans with deductibles of $10,000 or more for a single person. Republicans have long criticized Obamacare for having high deductibles, which this year cannot exceed $7,150.
Also, states could allow insurers to create multiple risk pools -- meaning those who are healthy could be assigned to one risk pool with lower premiums, while those who are not could be put into another with higher rates.
The new bill would also let states change the Obamacare requirement that insurers could not charge older Americans in their 50s and early 60s more than three times the rates of younger enrollees. Under the Affordable Care Act, younger consumers essentially subsidized the premiums of older ones. All the GOP repeal bills this year have loosened this provision, which has led the influential AARP to blast Republicans for levying an "age tax" on older Americans.
And under Obamacare, many preventative services -- including annual check-ups, mammograms and colonoscopies -- were free. States could make changes to this provision too.
The new proposal also appears to attempt to shore up concerns about states adequately addressing pre-existing conditions if they opt out of certain Obamacare regulations. It appears the new plan would attempt to address that by saying states "shall" maintain access to adequate and affordable coverage, which is a shift from a state saying it "intends" to maintain them.
In one of the most notable changes from Obamacare, states would receive block grants from 2020 to 2026. In applying for such funding, states must describe how they would provide "access to adequate and affordable" coverage to people with pre-existing conditions -- a requirement that critics and experts have widely said would not ensure that people with medical histories would not see spikes in their coverage costs.
The issue became a flashpoint in recent days when late-night comic Jimmy Kimmel accused the authors of Graham-Cassidy of failing to preserve protections for people with pre-existing conditions, pointing to his own son who was born with a congenital heart defect.
As in the previous version of the bill, the new Graham-Cassidy would repeal the individual and employer mandates -- penalties imposed by the Affordable Care Act on people who don't have insurance and certain employers that don't provide coverage for employees.
This story has been updated and will continue to update with new information and analysis.