Senate Republicans are closing in on the 50 votes needed to pass the repeal of the Affordable Care Act (ACA, or Obamacare) proposed by Senators Bill Cassidy (R-LA), Lindsey Graham (R-SC), Ron Johnson (R-WI), and Dean Heller (R-NV). As of Tuesday morning, the sponsors were touting between 47 and 49 Senate supporters, as well as about 15 Republican state governors backing the bill.

Although each of the Republican health care bills so far has had solid but insufficient support ranging from 43 and 49 votes, the Graham-Cassidy bill has been more hurriedly scheduled for a hearing in the Senate Finance Committee, demonstrating the strong political will of the Republicans to pass the bill in the Senate. Because Republican Senators are trying to rush a vote before reconciliation rules expire on September 30 (requiring only 50 votes for passage as opposed to the usual 60), the Congressional Budget Office (CBO) will not be able to conduct a full analysis of the effects of the proposal for their consideration. Elected officials and Americans alike won’t know the human costs of the bill, like how many millions of Americans will lose coverage or have premiums raised, before its possible passage.

As noted by Kaiser Health News, the Graham-Cassidy bill proposes to change the American health care system in three major ways: block grants, per capita-capped Medicaid, and protections waivers. While the proposal shares some attributes with the previous Republican repeal plans (like the Better Care Reconciliation Act of July and the American Health Care Act from March, both of which kept some parts of the ACA, though significantly reduced), experts are saying that Graham-Cassidy is even worse because of these three changes.

Block Grants

Under the ACA, both the federal government and individual state governments pay a portion of public health care coverage in that state. The Graham-Cassidy proposal would take the money spent on the two major funding mechanisms of the ACA—Medicaid expansion and insurance subsidies—and create block grants, or lump sums of money, that would be given to each state, determined primarily by if the state in question had chosen to expand Medicaid under the ACA or not; if the state did expand Medicaid, funding previously used to pay for that expanded coverage would be redistributed to states that did not, punishing those states that made concerted efforts to get more of their citizens insured.

Thirty-one states so far have chosen to expand Medicaid. Graham-Cassidy would cut billions of dollars of funding from liberal states like California and Massachusetts, as well as conservative ones like Louisiana and Kentucky. The Center for Budget and Policy Priorities (CBPP) estimates that Graham-Cassidy would cut federal health care spending 34 percent by 2026 compared to what the ACA would spend if left in place, with 20 states seeing funding cuts of anywhere between 35 percent and 60 percent during that time period.

Caps on Medicaid

No matter how much funding is gained or lost by each state, individuals in every state—especially people living with HIV—still lose. The Graham-Cassidy proposal would significantly restructure traditional Medicaid. As it is now, Medicaid is an entitlement program, meaning that anyone who qualifies is guaranteed the benefits of the program. Under Graham-Cassidy, Medicaid funding is changed to a “per capita cap” system, setting a limit for how much funding the states will receive for each person enrolled in Medicaid. A recently released analysis by the health care consulting firm Avalere showed that, under the per capita cap system proposed in Graham-Cassidy, traditional Medicaid spending would decrease by a staggering $1.08 trillion between 2020 and 2036. These cuts would be especially significant for people living with HIV, as 40 percent of people living with HIV in care today use Medicaid to help pay for that care.

The Center on Budget and Policy Priorities (CBPP) estimates that the block grant outlined in Graham-Cassidy would provide $239 billion less than the current projections for Medicaid expansion and marketplace subsidies between 2020 and 2026. Furthermore, an analysis done by The New York Times using data from the Kaiser Family Foundation, Centers for Medicare and Medicaid Services, and CBPP shows 36 out of 50 states receiving health care funding cuts in 2026, including the key states of Alaska, Arizona, Maine, Ohio and West Virginia. On Thursday, all 50 state Medicaid directors signed on to a statement condemning the Graham-Cassidy bill and describing its changes to Medicaid as, “the largest intergovernmental transfer of financial risk from the federal government to the states in our country’s history.”