Should the Graham-Cassidy measure die, it would almost surely end the long Republican quest to repeal and replace the Affordable Care Act, Mr. Obama’s signature domestic achievement. If the Senate does not vote by Sept. 30, the drive to kill the Affordable Care Act will lose special protections under Senate rules that allow it to pass with a simple majority, rather than the 60 votes necessary to overcome a filibuster.
The Senate Finance Committee has scheduled a hearing on the measure for Monday, and proponents of the repeal bill say they are not giving up.
“The deadline is still a week away,” said Tommy Binion, who handles government relations for the Heritage Foundation, a conservative policy organization. “It is one of the last trains leaving the station, and it is a political imperative for the Republican Party. I think we are going to go through a couple more loop de loops on this roller coaster before we are all done.”
In a series of tweets early Saturday, President Trump, who has embraced the legislation in recent days, appeared to be nurturing hopes that the legislative effort could be kept alive. He voiced optimism that Mr. Paul would rethink his opposition “for the good of the party.” He also indicated that he thought Senator Lisa Murkowski, Republican of Alaska, who had wavered publicly about the measure, would support it, though her spokeswoman has said only that the senator was studying the bill.
But at the same time, the president vented his frustration with Mr. McCain, saying he had let his state down and been deceived by Democrats into abandoning a promise.
John McCain never had any intention of voting for this Bill, which his Governor loves. He campaigned on Repeal Replace. Let Arizona down!
Patient advocacy groups, who also oppose the Graham-Cassidy measure, say they will continue their fight. “We are certainly not relaxing our efforts, because the vote count is not clear,” said Sue Nelson, a vice president of the American Heart Association, which is fighting to preserve the 2010 health law. “We are going full steam ahead with advertising, lobbying and grass-roots efforts to contact members of Congress.”
And in an unusual joint statement on Saturday, groups representing doctors, hospitals and health plans urged the Senate to reject the bill.
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“While we sometimes disagree on important issues in health care, we are in total agreement that Americans deserve a stable health care market that provides access to high-quality care and affordable coverage for all,” the groups, which included the American Medical Association and America’s Health Insurance Plans, said. The bill, they added, “does not move us closer to that goal.”
Still, the pressure on Republicans to fulfill their promise has been intense — not only from the voters who helped elect them, but also from conservative donors. Doug Deason, a wealthy Dallas businessman who manages money for his billionaire father, said he had formed a loose-knit coalition of donors who warned senior Republicans — including Senator Mitch McConnell of Kentucky, the majority leader — that contributions would dry up if Congress did not overhaul the tax code and repeal the Affordable Care Act.
“We said we’re not interested in meeting with him until he gets something done,” Mr. Deason said, recounting a telephone conversation he had with Mr. McConnell over the summer. “He needs to lead.”
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Senator John McCain of Arizona in Washington on Tuesday. Mr. McCain announced on Friday that he could not “in good conscience” vote for the bill. Credit
Al Drago for The New York Times
The drive for repeal of the Affordable Care Act appeared to be dead at the end of July, after Mr. McCain’s “no” vote on a “skinny repeal” measure that was designed purely as a vehicle to permit negotiations with the House, which had passed a much more ambitious bill. That measure also had critics who called it unworkable and potentially disastrous for the insurance market, but Republican leaders could argue that they never intended to actually enact it. They were prepared to discard their handiwork as soon as House-Senate negotiations could start.
The talks never did.
“It is time to move on,” a dejected Mr. McConnell declared at the time.
But behind the scenes, Mr. Graham, whose main expertise is in military affairs, and Mr. Cassidy, a gastroenterologist, had already been working with Rick Santorum, a Republican former senator from Pennsylvania, on a measure that morphed into the Graham-Cassidy bill.
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Their collaboration, Mr. Santorum said, grew out of a chance meeting between him and Mr. Graham in the Senate barbershop last spring. Mr. Santorum had already been working with members of the conservative House Freedom Caucus on a bill to take much of the money spent under the Affordable Care Act and send it to states, with vast discretion over how to use it for health care.
“I thought maybe I should bounce this idea off Lindsey and see what he thinks,” Mr. Santorum said, adding that he thought the measure could attract the votes of Senate Republican moderates.
Mr. Santorum argues that giving governors control over how to spend health care dollars will create efficiencies in the system, and disputes as a “false narrative” the idea that states will get less money under the bill.
The bill would require states to organize their own health care systems by 2020 — a time frame that many health care experts say is unworkable — and would also give states a way to roll back protections for people with pre-existing conditions.
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If enacted, the measure would constitute “the largest transfer of financial risk from the federal government to the states in our country’s history,” said the National Association of Medicaid Directors, whose members run the program for more than 70 million Americans.
Beyond that fast time frame, the bill faces other hurdles, said Mr. Fiedler of the Brookings Institution. Politically, it almost appears designed to fail, because many more states would lose money under it than would gain. Many of those losing states are represented by Republican senators whose votes are vital: Rob Portman of Ohio, Shelley Moore Capito of West Virginia, Cory Gardner of Colorado, Mr. McCain and Ms. Collins, to name a few.
And the legislation would set a cap on how much federal support states would receive per person enrolled in the Medicaid program, while health care costs are rising more quickly than the scheduled growth rate for the cap.
“One of the objectives that Republicans have come to this debate with is to reduce federal spending on health care, and it is very difficult to do that, ultimately, without reducing the people covered,” Mr. Fiedler said. “If you’re not making the underlying health care delivery system more efficient, all you’re doing is shifting around the costs.”
The bill would take money spent under the Affordable Care Act and give it to states in the form of block grants. State officials, including some who initially supported the Graham-Cassidy bill, were dismayed when they saw how much money their states could lose.
“We equalize how much each American receives toward her care, irrespective of where she lives,” Mr. Cassidy said. “I don’t see why a lower-income American in Mississippi should receive so much less than a lower-income American in Massachusetts.”
The bill would, in effect, penalize states that have expanded coverage through Medicaid and the public marketplaces created by the Affordable Care Act. An analysis by the consulting firm Avalere Health found the measure would reduce overall federal funding to states by $215 billion through 2026, and by more than $4 trillion over a 20-year period.
Mr. Graham and Mr. Cassidy, unlike some Republicans, have tried to explain and defend their proposal. But they have been overwhelmed by a tidal wave of criticism from doctors, hospitals, insurers, governors and patients — and even the late-night comedian Jimmy Kimmel. Critics object to these provisions:
The bill could weaken consumer protections in the Affordable Care Act. It envisions waivers of federal law that would allow insurers to charge higher premiums to sick people or omit some of the benefits that are now guaranteed, such as maternity care, mental health services or treatment for drug addiction.
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It would eliminate the federal tax credits and other subsidies that make health insurance more affordable for people with low and moderate incomes, letting states decide how to use the money.
It would end the expansion of Medicaid, which has provided insurance to low-income people in 31 states of all political hues. The states include Alaska, Arizona, Arkansas, Colorado, Indiana, Louisiana, New York and West Virginia.
“People are scared,” said Senator Sherrod Brown, Democrat of Ohio. “They read in the paper, they see on TV, they see online that their insurance might be taken away. There’s a lot of fear in this society injected by government, and they should be ashamed of themselves.”
SAN JUAN, PUERTO RICO — In the northern Puerto Rican town of Vega Baja, the floodwaters reached more than 10 feet. Stranded residents screamed “save me, save me,” using the lights in their cellphones to help rescue teams find them in the darkness, the town’s mayor said.
In Loiza, a north coastal town that already had been ravaged by Hurricane Irma, 90 percent of homes — 3,000 — were destroyed by Hurricane Maria just days later. In communities across the island, bridges collapsed and highways were severely damaged, isolating many residents. In Rio Grande, officials had yet to access a number of families stuck in their homes, three days after the powerful storm made landfall.
When speaking about his town’s destruction, Ramon Hernandez Torres, mayor of the southern city of Juana Diaz, took a long pause, his voice catching and his eyes filling with tears.
Hurricane Maria pounded the entire island of Puerto Rico on Wednesday, but the scope of the damage had been speculative and unclear since, in large part because towns across the U.S. territory have been completely off the grid. Though images from the air showed incredible destruction, mayors were unable to reach central government for leadership and help because communication was impossible. No telephones, cellphones, or Internet. No power. No passage through roads that had been washed away or blocked with trees and power lines.
The Ocean Park community in San Juan was underwater Friday. (Dennis M. Rivera Pichardo/For The Washington Post)
But on Saturday, for the first time in days, mayors and representatives from more than 50 municipalities across Puerto Rico met with government officials at the emergency operations command center here in the island’s capital city. Many of the mayors learned about the meeting through media reports over satellite radio the night before. One mayor said his staff was informed after a man ran to his offices with a note telling him to make his way to San Juan.
Approximately 20 other mayors across the island still have not been able to make contact with government officials, leaving major gaps in the broader understanding of the damage Maria left behind.
The mayors greeted each other with hugs and tears, and they pleaded with their governor for some of the things their communities need most: drinking water, prescription drugs, gasoline, oxygen tanks and satellite phones. The entire population remains without electricity. Families everywhere are unable to buy food or medical treatment. Roads remain waterlogged, and looting has begun to take place at night.
“Whenever I walk through San Juan,” Cruz said, she sees the “sheer pain in people’s eyes. . . . They’re kind of glazed, not because of what has happened but because of the difficulty of what will come,” she said. “I know we’re not going to get to everybody in time. . . . Two days ago I said I was concerned about that. Now I know we won’t get to everybody in time.”
Oscar Santiago, mayor of the northern coastal city of Vega Alta, said many of his community’s families refused to evacuate their flooded homes. One little girl was standing barefoot with her family on a roof, which was littered with nails, he said. When he asked her to put on some sandals, she told him: “The hurricane took them.”
Marcos Cruz Molina, mayor of Vega Baja, said even his own wooden home was destroyed, and he has since sought shelter with his parents. Jose Rodriguez, mayor of Hatillo, in the northwest, said “hundreds and hundreds” of homes in his town were obliterated. “It’s catastrophic,” he said.
The meeting in San Juan came a day after the governor urged residents downstream from Lake Guajataca — a population of nearly 70,000 — to evacuate amid fears that a dam holding the lake back might fail because of damage from Hurricane Maria’s floodwaters. Officials said the dam’s structural damage was caused by a “fissure,” a crack that had grown to a significant “rupture” by Saturday. The dam’s failure could lead to massive amounts of water flowing through coastal communities along a river’s path to the ocean, and authorities believed evacuation was the only option.
Local authorities said the actual number of residents remaining in those towns at risk of destruction was most likely much lower because of early overestimates, officials said. Evacuations continued on Saturday.
The official death toll on the island from Hurricane Maria has risen to 10. One died when he was struck in the head by a panel, another died in an accident with an excavating machine, three died in landslides, two in flooding in Toa Baja, and two police officers in Aguada drowned when the Culebrinas River overflowed. One person in Arecibo died after being swept away by rising water. Officials believe there are probably others they haven’t yet been able to confirm.
A man describes the devastation caused by the passage of Hurricane Maria in Arecibo, northwestern Puerto Rico. (Hector Retamal/AFP/Getty Images)
At the intersection of Routes 2 and 10 in Arecibo, employees of the Gulf Express gas station and their families — about 20 people in all — were hard at work Saturday. Their boots and sneakers were caked with mud because there is mud everywhere: On their pants and shirts, in their cars and on the walls of their homes. The makeshift cleanup crew was using brooms to sweep out the grayish brown slop that lay two or three inches thick inside.
After Maria blew threw the city, taking down trees and power lines, the flash floods came.
“The water had to be at least six, maybe seven feet high,” said Nelson Rodriguez, a Gulf Express employee. “It took everything. All the medicine in the pharmacy, all the food, it’s gone.”
Every home and business in this part of Arecibo was affected by the flooding. Two blocks away from the gas station, Eduardo Carraquillo, 45, helped his father, Ismael Freytes, 69, clean the mud out of their yellow, first-floor apartment. Inside, a film, rising six feet high on the walls, marked where water stagnated for much of a full day.
“The water just pushed through the door, as if it had been left open,” Carraquillo said. “We all evacuated the day after the storm, because we were warned about the flash flood that might come. Everyone left, just to be safe, except for two older men that lived a few houses away. They just didn’t want to leave. When we came back, we found out the flood had killed them right there in that apartment.”
Some Puerto Rico officials believe it could be months before the island recovers and that it will be at least a year before some sense of normalcy returns.
Officials estimate it will take three weeks for hospitals to regain power, and about six months for the rest of the island to have electricity. By Saturday, 25 percent of the population had telecommunications connections.
Gov. Ricardo Rosselló announced efforts to centralize medical care and shelters for the elderly. He also plans to distribute 250 satellite phones among mayors to facilitate communication. He said he urged the mayors to develop a “buddy system” with other local officials.
Cruz, San Juan’s mayor, said she has never seen such devastation, but she also said she has never seen such determination to make it. She described a phrase she keeps hearing from residents: “Yo soy Boricua. I am from Puerto Rico.”
“That has become the very courageous way of saying we are going to overcome anything that comes our way,” she said.
A janitor stopped Cruz with a request on Friday: “Tell the world we’re here,” he said, Cruz recounted. “Tell everyone we’re fighting. Tell everyone that can listen that we are going to make it.”
With her voice faltering, Cruz echoed that cry: “If anyone can hear us . . . help.”
“Those are words that no society should have to endure alone or ever,” Cruz said. “What I would ask is not only for Puerto Rico, but for the entire Caribbean that has been hit so hard by this: Do not forget us and do not let us feel alone.”
Cassady reported from Arecibo, Puerto Rico.
Hurricane Maria passed through Puerto Rico leaving behind a path of destruction. In Levittown, dozens were evacuated but others had to wait for the help to come. (Dennis M. Rivera Pichardo/For The Washington Post)
