Sept. 25 ended up being a rough day for supporters of the Graham-Cassidy legislation to repeal the Affordable Care Act (ACA), beginning with the bill’s only scheduled hearing being interrupted by protesters shouting, “No cuts to Medicaid, save our liberty.”

The hearing eventually did get underway after dozens of protesters—some in wheelchairs—were removed from the hearing of the Senate Finance Committee. One of the namesakes of the bill, Sen. Bill Cassidy, MD, R-Louisiana, told the committee he believes it continues his work as a physician when he treated Medicaid beneficiaries in Louisiana’s public hospital systems. He also rejected criticisms that the bill’s transformation of ACA funding into block grants for states would benefit Republican-run states and make insurance unaffordable for people with pre-existing conditions.

“Many on the left are threatened that we give states and patients the power Obamacare usurped. Under this narrative, states are inept, corrupt Governors scheme to deprive his or her state’s residents of protections, and patients only get better if told what to do. This amendment rejects that narrative,” Cassidy said.

Cassidy’s claims were countered by Cindy Mann, former CMS deputy administrator and director of the Center for Medicaid and CHIP Services under President Barack Obama. Having led the administration of Medicaid as the ACA expanded the program, she argued the Graham-Cassidy bill would “pose life-threatening harm” to the program’s beneficiaries and shift the “full risk” of healthcare cost growth onto states.

“By contrast, under current law, states and the federal government share the risk of unanticipated costs due, for example, to higher drug costs, new cancer treatments, or health emergencies like the opioid crises,” Mann said. “States that are not able to shoulder significant new costs will need to reduce provider payment rates and benefits, increase beneficiary costs, or reduce eligibility.”

The tumultuous hearing for the bill was followed later by the Congressional Budget Office’s preliminary analysis of its impact. The CBO said it didn’t have time to do its usual analysis before the Sept. 30 deadline for the bill to pass with a simple majority in the Senate, but it did estimate “millions” would lose insurance which “covers high-cost medical events” compared to the ACA. Many fewer people would be covered by Medicaid, the report said, countering Cassidy’s assertion that the bill doesn’t reduce Medicaid funding or truly eliminate its expansion under the ACA.

“All told, federal spending on Medicaid would be reduced by about $1 trillion over the 2017–2026 period under this legislation,” the report said.

The results of the CBO led Sen. Susan Collins, R-Maine, to announce she wouldn’t support the bill, calling it “as deeply as the previous iterations.” She appeared to reject any attempts at changing the bill to send more federal funding toward Maine to gain her support.

“If Senators can adjust a funding formula over a weekend to help a single state, they could just as easily adjust that formula in the future to hurt that state,” Collins said in a statement. “This is simply not the way that we should be approaching an important and complex issue that must be handled thoughtfully and fairly for all Americans.”

Collins joins Sens. Rand Paul, R-Kentucky, Ted Cruz, R-Texas, and John McCain, R-Arizona, as “no” votes. Sen Lisa Murkowski, R-Alaska, who opposed the last attempt at ACA repeal along with McCain and Collins, is still officially undecided.

Republicans could afford to lose only three votes from their caucus, but bill sponsor Sen. Lindsey Graham, R-South Carolina, indicated to CNN he still wants the legislation to come to the Senate floor.

“We're going to press on,” he said. “And it's OK to vote. It's OK to fall short if you do for an idea you believe in.”