Republicans are paralyzed over what to do about health care, caught between a bipartisan effort to shore up Obamacare and the opportunity to take one last swing at their years-long promise to repeal the law.

Leaders of both efforts have less than three weeks to gather enough support to persuade Senate Majority Leader Mitch McConnell to either take another partisan shot at the Affordable Care Act or begin bipartisan reforms. Key procedural powers for the GOP to repeal the law expire on Sept. 30, and insurance companies desperate for certainty have until Sept. 27 to decide whether to participate in Obamacare markets next year.


A group of senators is making a last gasp effort to repeal some of the law and replace it with a block grant program to the states, though many Senate Republicans are pessimistic they will be able to get the 50 of their 52 senators needed to support it in the coming days.

“I don’t see it,” Sen. Jeff Flake (R-Ariz.), who backs the block grant proposal set to be introduced by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.), said on Wednesday. “I don’t see voting on doing it one more time.”

Shot back Sen. Ted Cruz (R-Texas), who came to prominence attacking Obamacare: “I think we are much closer to getting this done than many outside observers believe. I think we’ve got 45-46 votes in the Senate.”

But it has always been the last five votes that have stymied action on Obamacare repeal, and 46 votes isn’t close enough for GOP leaders to reopen the painful wound left by July’s failure to pass even a slimmed down Obamacare repeal bill.

The problem for McConnell is that the alternative doesn’t seem to be taking off either.

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Sen. Lamar Alexander (R-Tenn.) is trying to work with Sen. Patty Murray (D-Wash.) on a bill to shore up the insurance markets, but the two health committee leaders are already at odds over including looser regulations with the package. Without regulatory reform, many Republicans argue, the bill amounts to a giveaway to the insurance industry.

“All I see so far are suggestions for further bailouts of insurance companies and no real reform,” said Senate Majority Whip John Cornyn (R-Texas). He said it “may be” better to do nothing at all.

Alexander said Tuesday that he wants to have some kind of plan “in our minds by early next week in order to be able to hand it to Senator McConnell and [Minority Leader Chuck] Schumer in time to deal with it before the end of the month.”

So far, Alexander is looking at a bill that would fund Obamacare’s cost-sharing program for two years, allow for people to buy “catastrophic” health care plans that were restricted under Obamacare and make changes to a state waiver program. The waivers, dubbed 1332s, have proven to be the most controversial element, as Democrats say the changes shouldn’t eliminate consumer protections and Republicans say structural changes are needed to reduce costs in the health system.

McConnell on Tuesday refused to rule out votes on either a repeal or a fix of Obamacare, wary of picking sides among his caucus and aware that both proposals divide the Senate GOP.

“The way forward as of today is unclear,” he told reporters.

But doing nothing at all seems an equally bad option.

Insurance companies make final decisions on their 2018 plans at the end of the month, and inaction seems likely to cause a premium spike. Congress would also be ceding more authority to President Donald Trump, who currently threatens to withhold Obamacare subsidies on a monthly basis, a move that could cripple the insurance markets and allow Democrats to blame the GOP for high premiums.

Senate Republicans also are still stewing over the failure of their July repeal effort. Cassidy, Graham and two other senators will begin a final push for their block grant approach at a Wednesday news conference. Senators say their voters are sick of hearing excuses and need to see some action.

“My constituents want to see Obamacare repealed. But the votes aren’t there right now,” said Sen. John Kennedy (R-La.).

Cruz, Graham, Cassidy and their allies are trying to change that narrative, and they believe that stated interest by Sen. John McCain (R-Ariz.) — who with Sens. Susan Collins (R-Maine) and Lisa Murkowski (R-Alaska) killed the GOP’s “skinny” bill — could help get them to 50 votes. They also see an opening on the calendar: The Senate is likely to have a window for another repeal vote at the end of month, once the chamber passes the defense bill it is currently debating.

But some Democrats are skeptical that McCain, who opposed the previous bill in part because it was rushed to the floor, could back Graham-Cassidy, which is being introduced less than three weeks before the deadline for passage.

“Anybody that said that they want regular order can’t vote for a bill when regular order is literally playing out before your eyes,” Sen. Chris Murphy said of the health committee's process. “How on earth do you short circuit a bill and undercut Lamar Alexander?”

But with the budget reconciliation tool to evade a filibuster about to expire, pressure is increasing from the White House and among rank-and-file GOP senators to give repeal another try. Trump has repeatedly needled McConnell and his members over this summer's failure.

And that requires Republicans to keep the door cracked for another repeal vote this month.

“It’s not done. It’s still a live round out there,” said Sen. James Lankford (R-Okla.). “It’s pretty slim, but there’s a chance.”

The block grant plan would likely cut hundreds of billions of dollars in federal spending and potentially leave millions more uninsured, a problem for the more moderate Republicans. But Graham and Cassidy are running into resistance from conservatives because the bill keeps some of Obamacare’s taxes and regulations.

The main selling point to the right is that the bill is better than allowing the fast-track power to lapse with nothing to show for it.

Sen. Rand Paul (R-Ky.) says that’s not enough for him.

“Keep all the Obamacare taxes? Keep most of the Obamacare regulations? And then give some sort of pretense to giving state control? They leave all the regulations in place as far as I'm concerned. It sounds to me like a bad idea,” Paul said Monday. “I don’t think it’s going anywhere. I’ve heard nobody talking about it.”

Heritage Action spokesman Dan Holler said the conservative advocacy group is waiting to see details but prior versions of the bill were “far off the mark from what conservatives had anticipated” from the GOP Obamacare repeal effort.

“What they proposed in the summer had some pretty big downfalls — keeping most of the taxes,” Holler said. “But there were elements of good things in there too [such as] allowing states to be flexible.”

Conservatives are even less likely to support the Alexander-Murray effort, but the bipartisan duo was never going to get the most conservative members of the Republican Conference. Instead, the bill would likely pass with a mix of Democratic votes and centrist Republicans, if McConnell decides to bring it to the floor.

“We need cost-sharing. We need it soon,” Schumer said. “Sens. Alexander and Murray are working on a compromise proposal, which we hope will be ready very soon. And we can move that, not some effort to repeal.”