WASHINGTON (WASHINGTON POST) - The Senate Bill to repeal the Affordable Care Act was edging towards collapse on Monday (June 26) after the nonpartisan Congressional Budget Office (CBO) said it would increase the number of people without health insurance by 22 million by 2026.

Two Republicans, Senators Susan Collins of Maine and Rand Paul of Kentucky, said on Monday that they would vote against even debating the healthcare Bill, joining Senator Dean Heller of Nevada, who made the same pledge on Friday. Senator Ron Johnson of Wisconsin hinted he, too, would probably oppose taking up the Bill on an expected procedural vote as early as Tuesday, meaning a collapse could be imminent.

"It's worse to pass a bad Bill than to pass no Bill," Paul told reporters.

Collins wrote on Twitter on Monday evening that she wanted to work with her colleagues from both parties to fix flaws in the Affordable Care Act spearheaded by former president Barack Obama, but that the budget office's report showed that the "Senate Bill won't do it".

The report left Senator Mitch McConnell of Kentucky, the majority leader, with the unenviable choices of changing senators' stated positions, withdrawing the Bill from consideration while he renegotiates or letting it go down to defeat - a remarkable conclusion to the Republicans' seven-year push to repeal Obama's signature domestic achievement.

But the budget office put Republicans in an untenable position. It found that next year, 15 million more people would be uninsured compared with the situation under the current law. Premiums and out-of-pocket expenses could shoot skyward for some low-income people and for people nearing retirement, it said.

The legislation would decrease federal deficits US$321 billion (S$445 billion) over a decade, the budget office said.

McConnell, chief author of the Republican Bill, wanted the Senate to approve it before a planned recess for the Fourth of July, but that looks increasingly doubtful. Misgivings in the Republican conference extend beyond just a few of the most moderate and conservative members, and McConnell can afford to lose only two Republicans.

The loss of Collins could bring along Senators Lisa Murkowski of Alaska and Shelley Moore Capito of West Virginia, whose rural states would face effects similar to those in Maine.

"If you were on the fence, you were looking at this as a political vote, this CBO score didn't help you," said Republican Senator Lindsey Graham.

"So I think it's going to be harder to get to 50, not easier." He added: "I don't know if you delayed it for six weeks if anything changes."

Under the Bill, the budget office said, subsidies to help people buy health insurance would be "substantially smaller than under current law". And deductibles would, in many cases, be higher.

Starting in 2020, the budget office said, premiums and deductibles for a mid-level silver plan would be so onerous for a person with modest income that "few low-income people would purchase any plan".

Moreover, the report said, premiums for older people would be much higher under the Senate Bill than under current law. As an example, it said, for a typical 64-year-old with an annual income of US$26,500, the net premium in 2026 for a mid-level silver plan - after subsidies - would average US$6,500, compared with US$1,700 under the Affordable Care Act. And the insurance would cover less of the consumer's medical costs.

Likewise, the report said, for a 64-year-old with an annual income of $56,800, the premium in 2026 would average $20,500 a year, or three times the amount expected under the Affordable Care Act.

Senator John Thune of South Dakota, a member of the Senate Republican leadership, suggested that leaders would press forward with the Bill. He said an argument could be made for delaying the Bill "if you thought you were going to get a better policy" but that was not the case.

"This is the best we can do to try and satisfy all the different perspectives in our conference," Thune said, adding that he did not think the politics would improve by waiting.

"We need to move," he said. "And so we got a product, and it's time to fish or cut bait." The White House discounted the report, saying the CBO "has consistently proven it cannot accurately predict how healthcare legislation will impact insurance coverage".

The Trump administration says the Senate Republican Bill would not cut Medicaid because spending would still grow from year to year. But the budget office said the Bill would reduce projected Medicaid spending by US$772 billion in the coming decade, and it said the number of people covered by Medicaid in 2026 would be 15 million lower than under current law.

In 2026, it said, Medicaid spending would be 26 per cent lower than under current law, and enrolment of people under 65 would be 16 per cent lower. And beyond 2026, Medicaid enrolment would continue to decline, compared with what would happen under current law.

The Senate Bill would make it much easier for states to obtain waivers exempting them from certain federal insurance standards, like those that require insurers to provide a minimum set of health benefits.

The budget office said nearly half of all Americans could be affected by these cutbacks in "essential benefits", with the result that coverage for maternity care, mental healthcare, rehabilitation services and certain very expensive drugs "could be at risk".

Before the budget office released its report on Monday, the American Medical Association announced its opposition to the Bill, and the National Governors Association cautioned the Senate against moving too quickly.

The budget office's findings immediately gave fodder to Democrats who were already assailing the Bill as cruel. Senator Chuck Schumer of New York, the Democratic leader, said Senate Republicans had been saying for weeks that their Bill would be an improvement over the House Bill, which President Donald Trump had described as "mean".

"CBO's report today makes clear that this Bill is every bit as mean as the House Bill," Schumer said.

"This CBO report should be the end of the road for Trumpcare. Republicans would be wise to read it like a giant stop sign, urging them to turn back from this path that would be disastrous for the country, for middle-class Americans and for their party."

By Monday night, the chorus of criticism over how McConnell was handling the healthcare legislation had become bipartisan. Johnson, who was among those who came out against the Bill last week, told a radio host that Senate leaders were "trying to jam this thing through". He too suggested he would not vote even to begin debating the Bill.

"I have a hard time believing I'll have enough information for me to support a motion to proceed this week," Johnson said.