As expected, the nonpartisan Congressional Budget Office has released a preliminary analysis of the Senate Republicans’ latest bill to repeal and replace the Affordable Care Act, and while the CBO did not have the time to provide the in-depth projections about how the legislation would affect insurance coverage, it does indicate that millions of additional Americans will be without quality health insurance if the bill passes.

“The number of people with comprehensive health insurance that covers high-cost medical events would be reduced by millions,” writes the CBO in its prelim report [PDF].

The CBO acknowledges that the specific number of Americans likely to be affected by the bill will depend on which states choose to take advantage of loopholes in the law that would allow insurers to, for instance, stop covering a suite of “essential health benefits” that are currently required under the ACA. Another opening that would be created by this law could allow insurance companies to raise insurance premiums for people with pre-existing conditions, meaning they could be priced out of affording insurance altogether.

While the CBO can’t pin that number of affected people down just yet, it writes that “the direction of the effect is clear.”

The analysis gives three reasons that Graham-Cassidy would likely lead to fewer people with insurance. The bill’s cuts to federal Medicaid funding would result in a decrease in the number of Americans covered by that program. Graham-Cassidy also seeks to slash subsidies that currently go to insurance providers to reduce out-of-pocket expenses for lower-income Americans. And then of course there is the removal of the so-called “individual mandate” — the ACA’s requirement that most people must have some sort of qualifying health insurance or face a financial penalty.

Finally, as every CBO analysis of every repeal bill thus far has made clear, getting rid of the mandate will immediately result in people — particularly younger, healthier adults — defecting from the non-group insurance market, leaving behind a group of policyholders that are likely going to be older and higher risk.

The Graham-Cassidy bill would replace the ACA with massive federal block grants to the states, effectively allowing each state to determine not only how to allocate the money from those grants, but also gives each state flexibility to drop or alter many coverage requirements established by the ACA.

Because of the huge variety of potential outcomes, CBO says it would need several additional weeks to complete this more detailed score of Graham-Cassidy. However, the Senate doesn’t have that much time. The GOP is attempting to pass the bill as a budget resolution, which only requires 51 votes to pass the Senate, as opposed to a traditional piece of legislation, which would need 60 votes in the Senate to stop a Democratic filibuster. Budget resolutions must be passed by the Senate by the end of the federal fiscal year, which is Sept. 30, or wait until next year.

Senate leadership tweaked the bill over the weekend, boosting federal funding to a handful of states that just happen to be states — Arizona, Kentucky, Maine, and Alaska — where a Republican Senator had expressed concerns about, or said they would vote against, Graham-Cassidy.

Those revisions did not seem to have any effect. Sen. Rand Paul (KY), a vocal opponent of the ACA, also continues to be opposed to Graham-Cassidy as he feels it doesn’t go far enough to repeal the current law. Sen. John McCain (AZ) has said he would vote No on Graham-Cassidy because his fellow Republicans are trying to squeeze the bill through using the budget reconciliation process, rather than by working with Democrats to fashion a bill that could pass with 60 votes.

Alaska’s Sen. Lisa Murkowski and Sen. Susan Collins of Maine — both of whom voted with McCain to scuttle the Senate’s first repeal attempt in July 2017 — had been skeptical but noncommittal. However, this afternoon Sen. Collins confirmed to reporters that she had told President Trump that she would likely be a No vote if the bill came to the Senate floor this week.

Murkowski has yet to come out one way or the other publicly on Graham-Cassidy, and her vote may not be needed if Paul, McCain, and Collins vote against the bill.

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