Many of us were cheered by Senator John McCain’s announcement of his opposition to the horrible Graham-Cassidy bill that would gut Medicaid and wreck the individual insurance market. But Senate Republicans could still pass this bill, and will keep trying until the clock runs out at midnight September 30th.

Last week I explained why the bill is so damaging to public health, and Kim Krisberg rounded up opposition statements from major organizations that work on healthcare. Two items that have come out since then are also worth considering.

Senate Republicans are rushing to vote before the Congressional Budget Office can complete its analyses on how many people will lose insurance coverage or how premiums might respond to the destabilization of the individual market. In the absence of a CBO score, Matthew Fiedler and Loren Adler of the USC-Brookings Schaeffer Initiative for Innovation in Health Policy have used CBO’s estimates for prior legislation to analyze Graham-Cassidy’s likely impacts. They calculate that, compared to the status quo, the legislation would lead to 21 million more uninsured by 2026, and 32 million uninsured after 2026 (unless Congress acts before then to authorize additional funding to replace the block grants that will expire in 2026).

Another important point comes from the New York Times’s Margot Sanger-Katz, who dug into the details of how states might use the block grants that Graham-Cassidy offers. Senators Lindsey Graham and Bill Cassidy are promoting these block grants as a way to allow states rather than the federal government to decide how to assist the portions of their populations that don’t have employer-sponsored insurance — though they’re not mentioning that the total federal transfer to states will be about $160 billion less than it would have been for 2020-2026. The idea of local solutions to local issues might sound good in theory, but it also means states will have to devote a lot of resources to identifying and setting up those local solutions. Sanger-Katz writes:

In 2003, health care policy makers in Massachusetts agreed that the state should build a system to expand coverage to its uninsured residents.

It took four years before Romneycare was fully up and running.

In between, politicians had to think hard about how they wanted the system to work: how money would be raised and spent, what benefits would be offered, whether and how markets should be used to distribute coverage, whether people who didn’t buy coverage should be penalized. They had to build a computer system to help people check their eligibility and understand their options. They had to recruit insurers to participate. And they needed to find uninsured residents and persuade them to enroll.

A new health care bill before the Senate would require all the states in the country to make a similar soup-to-nuts evaluation of how they’d like their health care systems to work, to build such a system and be ready to open their doors in substantially less time — just over two years. That may not be realistic.

As the National Association of Medicaid Directors noted in a letter opposing Graham-Cassidy, the bill would “constitute the largest intergovernmental transfer of financial risk from the federal government to the states in our country’s history.” States would have to do far more than they currently do, but with far less money.

For Graham-Cassidy to fail, three Republicans would need to vote against it. So far, Senator Rand Paul of Kentucky and Senator John McCain of Arizona have come out against it. Senator Lisa Murkowski of Alaska voted against the previous GOPcare bill; this time, Graham-Cassidy would allow Alaska and up to four other states with low-density populations to put off the Medicaid rollback. Senator Susan Collins of Maine is “leaning against” it but hasn’t publicly committed to voting against it. The American Public Health Association is still urging public health supporters to ask their members of Congress to vote against Graham-Cassidy.