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Alaska Sen. Lisa Murkowski voted against GOP health care bill this summer and is once again a key vote

Republicans face a Sept. 30 deadline to get 50 votes in the Senate

CNN  — 

Sen. Lisa Murkowski could determine the fate of the Republican Party’s last-ditch effort to repeal Obamacare.

Sound familiar? The Alaska Republican has been here before.

It was less than two months ago that Murkowski was one of three GOP senators to vote against legislation to gut the Affordable Care Act, effectively killing her Republican colleagues’ campaign to repeal the health care law – at least until this week.

Now, her colleagues are looking to her again.

What was viewed as a long-shot proposal even until last week from GOP Sens. Lindsey Graham and Bill Cassidy suddenly gained new life this week, with Senate Majority Leader Mitch McConnell making it clear that he will bring the proposal up for a vote – if and when he has secured the 50 votes. That means Murkowski once again stands to potentially be a third “no” – Sen. Rand Paul has come out in opposition already, while Sen. Susan Collins has been publicly critical.

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For Murkowski, her decision has everything to do with Alaska, a state that has encountered some of the most serious challenges of the country’s current health care system.

Alaska has the nation’s highest health insurance premiums – thanks largely to its remote location and sparse population. There’s only one provider left on the Obamacare exchange.

This led the state to stabilize the marketplace by levying a tax on all insurers last year. It recently received approval to use federal funds for this reinsurance program, which helps cover the bills of high-cost patients, reducing premiums for everyone. It’s expected to reduce premiums by up to 25% next year, according to the state insurance director.

Murkowski told reporters Monday that she could not say how she is leaning because she doesn’t have any hard numbers. The Congressional Budget Office said it will only provide a preliminary assessment next week to determine whether the legislation complies with the budget reconciliation process.

“I will use the governor’s words,” she said, referring to Alaska Gov. Bill Walker. “He said, ‘I understand that a block grant gives me increased flexibility, but if I don’t have the dollars to help implement the flexibility, that doesn’t help us much.’ So, we are both trying to figure out how those dollars fall.”

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Alaska would likely lose out under the Graham-Cassidy bill, which calls for eliminating federal funding for Medicaid expansion and the subsidies that help many enrollees pay for premiums. Instead, the bill would provide a lump sum of money to states to help residents pay for health care through 2026.

The state has benefited greatly from both of these Obamacare provisions. It is one of 31 states to expand Medicaid to low-income residents, and its health insurance premiums are among the highest in the nation because of its remote, rural location.

Some 14,000 residents were enrolled in Obamacare policies at the end of February, with 93% of them qualifying for federal premium subsidies, according to federal data. Meanwhile, nearly 34,000 adults have Medicaid coverage because of expansion, according to the state’s Department of Health and Social Services. The state’s uninsured rate dropped to 14% last year, down from 18.5% in 2013, before Obamacare was enacted, according to US Census Bureau data.

Alaska would lose $844 million in federal funding in 2027 under the Graham-Cassidy bill, according to estimates by the left-leaning Center on Budget and Policy Priorities.

These factors, along with the fact that the bill would defund Planned Parenthood for a year, are why getting Murkowski on board will be a tough sell.

CNN’s Ted Barrett and Phil Mattingly contributed to this report.