The bill was drafted in secret by the Senate majority leader, Mitch McConnell of Kentucky, who unveiled it on Thursday. Mr. McConnell wants a vote this week, before lawmakers take a break for the Fourth of July holiday.
But the billâs supporters were battling a dire internal threat: reluctant Republicans. Senator Ron Johnson, Republican of Wisconsin, said Sunday that âthereâs no way we should be votingâ on the legislation this week. âNo way.â
âI have a hard time believing Wisconsin constituents or even myself will have enough time to properly evaluate this for me to vote for a motion to proceedâ to the legislation, Mr. Johnson said on NBCâs âMeet the Press.â
And Senator Susan Collins, Republican of Maine, appearing on ABCâs âThis Week,â said: âItâs hard for me to see the bill passing this week, but thatâs up to the majority leader. We could well be in all night a couple of nights.â
Senate Republican leaders were trying to lock down Republican votes by funneling money to red states, engineering a special deal for Alaska and arguing that they could insure more people at a lower cost than the House, which passed a repeal bill last month.
But the forces arrayed against the Republican push to dismantle President Barack Obamaâs signature domestic achievement are formidable. Much of the nationâs $3 trillion health care industry opposes the bill. And Mr. McConnell has done little to woo the health care stakeholders who were assiduously courted by Mr. Obama from his first months in office as he fought for his legislation.
The outside forces against the bill also appear to be growing: Top lieutenants in the conservative Koch brothersâ political network sharply criticized the legislation over the weekend, saying it was insufficiently conservative and did not do enough to rein in the growth of Medicaid. And a number of Republican governors have joined doctors, hospitals and patient advocacy groups in opposing the bill, in part because of its cuts to Medicaid.
Mr. McConnell has only a few days to wheel, deal and cajole reluctant senators to get behind legislation that has grown less popular with more exposure. He has considerable firepower to win votes, by guaranteeing amendments that would address the concerns of individual Republican senators, playing on their loyalty to him and their fealty to conservative voters still demanding an end to the Affordable Care Act. At the same time, Democrats say, he has striking liabilities. Mr. Trump has endorsed the bill, and Democrats say they will take every opportunity to link the legislation to an unpopular president.
Republicans have endlessly cataloged problems with the Affordable Care Act, which they deride as âObamacare,â but party leaders face a bigger challenge now as they try to persuade wavering Republican senators and a skeptical public that they have a better plan. Democrats have met that push with withering criticism, saying âTrumpcareâ is far worse.
And the Democratic wall of opposition is backed by less partisan voices. Senators are being flooded with appeals like this from the advocacy arm of the American Cancer Society: âCancer is scary enough. Donât take away our coverage.â
The American Childhood Cancer Organization, a charitable group formed by parents, is mobilizing a small army of grass-roots lobbyists with the message that the Senate Republican bill, with its deep cuts in Medicaid, âwill threaten the lives of children battling cancer.â
The United States Conference of Catholic Bishops said the Senate bill was âunacceptable as writtenâ and would âwreak havoc on low-income families.â At the same time, the bishops said they liked two sections of the bill that seek to âprohibit the use of taxpayer funds to pay for abortion or plans that cover it.â
Meantime, Republicans are finding allies to be few and inconstant. Mr. Trump has said that âObamacare is deadâ and that he is âvery supportiveâ of the Senate bill. But that support will be of limited help to Mr. McConnell. Few senators feel loyal to Mr. Trump, whose erratic message has often weakened his influence on Capitol Hill.
After pushing for passage of the House repeal bill, he criticized it as âmeanâ a few weeks later. A spokeswoman, Sarah Huckabee Sanders, said last week that Mr. Trump did not necessarily support cuts to Medicaid, even though his budget and the Senate bill would make such cuts.
So far, five Republican senators have announced they cannot support the health care bill as drafted: Dean Heller of Nevada, who says the measure cuts coverage too deeply, and four conservatives â Rand Paul of Kentucky, Ted Cruz of Texas, Mike Lee of Utah and Mr. Johnson â who say it does not do enough to lower health costs. Other Republicans, like Ms. Collins and Senator Lisa Murkowski of Alaska, have expressed misgivings.
Republicans have assembled reams of data to show that premiums are soaring and choices are shrinking as insurers withdraw from markets in many states. They assert that Democrats have no constructive solutions. And they will use Senator Bernie Sanders of Vermont as a punching bag.
Mr. Sanders has long advocated a single-payer health care system, what he calls âMedicare for all,â and he repeated that position on âMeet the Pressââ on Sunday. The No. 2 Senate Republican, John Cornyn of Texas, said Mr. Sanders had become âthe chief spokesman for the Democrats in the Senateâ on solutions to âthe failures of Obamacare.â
But that criticism comes amid a striking shift in public opinion. Fifty-one percent of Americans now have favorable views of the Affordable Care Act, according to a monthly tracking poll by the Kaiser Family Foundation. âThatâs the first time in our 79 tracking polls over seven years that this share has topped 50 percent,ââ said Craig Palosky, a spokesman for the foundation.
Medicaid is by far the largest program of federal grants to the states, and state officials are always trying to tweak the formula for distributing that money to their advantage.
In his budget request to Congress, Mr. Trump said he wanted to âcap federal funding for the Medicaid program,â and the House and Senate bills would do just that, converting Medicaid from an open-ended entitlement program to a system of per-capita payments for beneficiaries.
A novel feature of the Senate bill would redistribute federal Medicaid money from higher spending states like New York to lower spending states like Alabama.
One noteworthy exception to this provision is tailor-made for Alaska. âThis paragraph shall not apply to any state that has a population density of less than 15 individuals per square mile,â it says.
Only five states â Alaska, Montana, North Dakota, South Dakota and Wyoming â meet that criterion, and Alaskaâs two Republican senators have expressed concern about the billâs potential effect on their state, where medical costs are exceptionally high.
Ms. Murkowski said federal legislation must recognize the stateâs high costs. Premiums on the insurance exchange in Alaska average about $1,000 a month for an individual, according to federal data. But the special provision may not be enough to win her vote. Ms. Murkowski is also concerned about two other sections of Mr. McConnellâs bill, one that would cut federal funds for the expansion of Medicaid under the Affordable Care Act and another that would block federal Medicaid payments to Planned Parenthood.
The Senate Republican bill sets Medicaid spending targets for each state. A state that exceeds its target is subject to financial penalties. But the bill would tweak these targets âto promote program equity across states.â
If a stateâs Medicaid spending per beneficiary is more than 25 percent above the national average, its spending target would be reduced by the secretary of health and human services. If a stateâs spending is more than 25 percent below the national average, its target would be increased.
These adjustments must be made in a way that does not increase federal spending, so states will, in effect, be vying with one another for a limited pot of federal money.
Democrats said the reallocations would often take money from blue states and give it to red states, because Democratic states often have more generous Medicaid programs with higher levels of spending.
Republicans said the reallocations were not only good politics, but also good policy. âSome states are fiscally conservative, and others are fiscally out of control,â said a Republican aide working on the legislation. âSome states may be overspending while others may not be spending enough.â
Senate Republicans say that other provisions of their health care bill will make it possible to insure more people at lower cost than the House bill.
Sheryl R. Skolnick, an analyst at Mizuho Securities who follows the health care industry, said this might be possible if the subsidies are smaller and the benefits are âskinnier.â Currently, she said, subsidies are tied to the price of a âsilver planâ that covers 70 percent of the medical costs for a typical consumer. Under the Senate bill, the subsidies would be linked to the price of a plan that covers 58 percent of those costs.
âSmaller subsidies on lower premiums mean lower spending and more coverage,â Ms. Skolnick said.
But those lower-price plans typically have much higher deductibles. âPeople may be paying less, but they will be getting less,â said Jeanne M. Lambrew, a health policy coordinator at the White House under Mr. Obama.