Provisions shoehorned into the Republican health care bill dangle extra money for Alaska and Wisconsin, home states of one GOP senator whose vote party leaders desperately need and another who co-sponsored the legislation, according to analysts who've studied the legislation.
The 140-page measure, which top Republicans hope to push through the Senate next week, is stuffed with language making some states winners and others losers. Aides say the legislation is still changing as leaders hunt the 50 GOP "yes" votes they'll need to turn this summer's jarring Senate rejection of the party's crusade to erase President Barack Obama's law into an eleventh-hour triumph.
Alaska is home to GOP Sen. Lisa Murkowski, who's among a handful of Republicans who've not said how they'll vote. Sen. Ron Johnson, R-Wis., is one of the bill's co-sponsors and his support is not in question, but the episode suggests the value of helping craft of legislation.
The bill was chiefly written by GOP Sens. Bill Cassidy of Louisiana and South Carolina's Lindsey Graham. It would end Obama's Medicaid expansion and subsidies for people buying private insurance and combine the money into new block grants for states.
With all Democrats opposed, Republicans controlling the Senate 52-48 can lose only two votes if they are to succeed, leaving the bill's fate uncertain. Generally, it would shift money from states that expanded their Medicaid programs for the poor under Obama's statute, which tend to be run by Democrats, to the largely Republican-run states that shunned that expansion.
The measure would shield Alaska from some cuts it imposes on Medicaid, according to analysts, including from the nonpartisan Kaiser Family Foundation, by limiting spending to a maximum amount per beneficiary starting in 2020. The federal-state program for low earners has always automatically provided whatever money is needed for eligible recipients. Montana would also qualify for the exemption.
It would also increase federal Medicaid funds for states with high American Indian populations, including Alaska, according to health care consultant April Grady.
Analysts offered no figures about how much money the provisions would mean for Alaska.
The provisions hardly ensure support from Murkowski, who's said she's studying how the measure would affect her state. The administration was pushing for her support, with Vice President Mike Pence calling into an Anchorage talk-radio show Thursday and urging listeners to contact Murkowski and ask her to "stand with President Trump" and support the bill.
According to studies released this week by Kaiser and the consulting firm Avalere Health, Alaska is among many states that would lose money overall under the bill. Alaska has unusually high health care costs because of the remoteness of many communities.
The provisions do not mention Alaska or Wisconsin by name.
But the bill allows a state that turned down extra federal funds to expand Medicaid under Obama's statute to count the rejected money in determining how large its block grant will be, analysts say.
Grady, Avalere analyst Chris Sloan and others said they were unaware of states other than Wisconsin that would benefit from the provision. This language could mean "potentially hundreds of millions" of extra dollars for Wisconsin, said Grady.
In a written statement provided by aides, Johnson said funding formulas to correct "the grossly unfair" distribution of money under Obama's law needed to be changed "to reflect the unique circumstances of many states, including recognizing the innovative reforms of Wisconsin."
Wisconsin is among 19 states that declined to fully expand Medicaid under Obama's law, which also provided generous federal reimbursements. Under Gov. Scott Walker, a GOP 2016 presidential contender, Wisconsin just partially expanded Medicaid and agreed to accept smaller federal subsidies.
The provision in the health care bill applies to states that expanded Medicaid only up to 100 percent of the federal poverty level and had that expansion in effect this past Sept. 1.
Since the bill's details emerged, health industry and other groups have been lining up against it.
The National Association of Medicaid Directors, representing state officials who administer Medicaid, said it is concerned the measure would have damaging consequences on state budgets. Also announcing opposition recently was America's Health Insurance Plans, a huge health insurers' trade group, the American Hospital Association and the American Medical Association.