Posted with permission from Lifezette

The fate of the latest legislative repeal of Obamacare seems likely to fail in the Senate, especially after the Friday announcement of Sen. John McCain (R-Ariz.) that he would vote against the bill known as Graham-Cassidy.

Then on Monday night, Sen. Susan Collins (R-Maine) said she would vote against the bill too.

There are only 52 Senate Republicans. Vice President Mike Pence can break a tie, and now a tie seems, at best, likely. The bill's troubled situation has Republicans and conservatives wondering what is next in the battle to repeal the Affordable Care Act.

It's an odd place for the GOP-led Congress to be, as the Republicans promised for seven years to repeal Obamacare. But according to one critic of Graham-Cassidy, there is still plenty of time.

Sen. Rand Paul (R-Kentucky) told reporters on Monday that he is not worried about the Sept. 30 deadline, which will end the possibility, this year, of using budget reconciliation to pass a partial Obamacare repeal. Budget reconciliation forbids the Democrats from using the Senate filibuster.

In response to a question from LifeZette in the Capitol, Paul suggested the deadline is artificial.

"Every year, there's a budget reconciliation," said Paul. "You can do it every year ... There are [also] things you can do in a bipartisan way. One of the things I think we can do in a bipartisan way are health associations, letting people buy health insurance across state lines."

Paul's biggest complaint on Monday was that the repeal bill keeps $1 trillion of Obamacare spending. Paul also said he wants more Obamacare regulations cut, and he wants "health associations" -- private associations wherein members can buy health coverage, even across state lines.

Paul was not alone in his criticism of Graham-Cassidy, whose main feature would be to send "block grants" to the states and let them manage health care.

Sen. Ted Cruz (R-Texas) said, so far, he is a no. And even a health-insurance executive spoke out about how the bill fails to go all the way.

"This bill is a good starting point with its federalist approach, but more legislation will be needed," said J. Marshall Dye, CEO of EssentialStaffCARE, a major provider of insurance to the staffing industry, in a statement sent to LifeZette. "Health care is a local concept with prices and services varying by community. An individual's healthcare is best-served at the state and local level. However, Graham-Cassidy does not address the 'broken math.' This bill does not fully eliminate the mandates, restrictions and controls placed on private insurance underwriters. Government-imposed mandates that limit the ability of private insurers to predictably manage risk, breaks the math that the insurance industry was built upon."

But the plan to carry on the repeal effort is far from clear within the Senate GOP's caucus. Collins, a liberal Republican, did not even vote for repeal in 2015, the only senator or House member to vote against that year's complete repeal vote.

Sen. Lisa Murkowski (R-Alaska), a liberal-to-moderate Republican much like Collins, objects to cutting subsidies to Planned Parenthood and also wants more money for Alaska, which has the nation's highest health care costs.

There is little room for error now, as senators tug the bill's final version in different directions. The Senate GOP must keep 50 members with the two defections, meaning Murkowski must join with three conservative skeptics, Paul and Cruz, and Sen. Mike Lee of Utah.

It appears to be too tall an order to fill. Some scholars believe the government standard is too high -- that health care cannot be "fixed" and will always be costly.

"Obamacare's great failing is in its faith in the federal government's ability to 'fix' health care," wrote Robert Graboyes of the libertarian-leaning Mercatus Center, in a statement emailed to LifeZette. "Graham-Cassidy may similarly overestimate the willingness and ability of states to affect positive change. The states -- red and blue -- have been notoriously retrograde in health care, and I'm not terribly hopeful that this bill would drastically change that."

Graboyes said even if some state really wished to unleash technological and managerial innovation, federal institutions such as Medicare and the FDA would severely limit that state's leeway. Meanwhile, state governments are fairly lazy about changing things they have the power to.

"On the other hand, with no changes in federal law, states could already do a great deal by relaxing regulations on telemedicine, direct primary care, scope of practice, licensing, corporate practice of medicine, and more," Graboyes wrote. "And yet, many or most hesitate to make these changes that are already at their disposal."

So change in health-care policy, for now, is best made in Congress.

Paul noted on Monday that the House's bill, the American Health Care Act, already allowed expansion of his prized health-care associations. For now, the House victory in passing Obamacare repeal and expansion of health-care associations is a hollow one, made hollow by just three Republicans in the Senate.

(photo credit, homepage and article images: iStock / Gage Skidmore, Flickr)