With Friday's decision by Sen. John McCain (R-AZ) to oppose a last-ditch GOP proposal to overhaul the Obama health law, Republicans have almost run out of time to make substantive changes to Obamacare by a September 30 deadline for action under a special expedited procedure that did not allow for a Senate filibuster, again dealing the President and GOP leaders a bitter defeat on an issue they've campaigned on for the last seven years.
Here's what can still happen over the next week - and in coming months on Capitol Hill.
1. There could still be a vote on Graham-Cassidy. While Sen. McCain has made clear that he won't vote for the plan from Sen. Lindsey Graham (R-SC) and Sen. Bill Cassidy (R-LA), it's possible that the Senate could still go on the record on the matter. Aides to Senate Majority Leader Mitch McConnell said earlier this week that he planned to force a vote, and that could still happen, to clearly show who was for the plan, and who was not. But for now, it seems like the GOP will fail to get anything done on this signature campaign issue, with McCain, Sen. Rand Paul (R-KY) definitely against the plan - and two others, Sen. Lisa Murkowski (R-AK) and Sen. Susan Collins (R-ME) leaning against.
2. It could re-start bipartisan health talks. Up until last week, when GOP interest suddenly surged in the Graham-Cassidy plan, there had been increasing efforts to find some kind of agreement between Senators in both parties on ways to make some short term improvements in the Obama health care system for those in the individual and non-group insurance market. Those efforts were put on the shelf in recent days, but now this development leaves an opening for Sen. Lamar Alexander (R-TN) and Sen. Patty Murray (D-WA).
3. GOP health care efforts are certainly not dead. Just because the Graham-Cassidy plan has seemingly fallen short, that doesn't mean Republicans will give up on their plans to change the Obama health law. For the next fiscal year, the GOP wants to use the budget reconciliation process to pass something on tax cuts and tax reform. Well - there is no reason that they can't also try to add a health care bill onto that measure as well. One Senate official told me exactly that a few weeks ago. So, this battle is not over.
4. Republicans just weren't ready for this process. Maybe the biggest lesson from the after-action report on GOP health care bills over the last nine months is a simple one - Republicans were not ready with their own plan to replace the Obama health law, even though they had been talking about this for seven straight years. Ever since the law was signed by President Obama, Republicans had promised to repeal it, and do something different. As a slogan it sounded great - but as we saw in recent weeks, getting the exact details was something different.
5. Democrats have also had 7 years to make improvements. Just as the GOP failed in rallying around a single plan, Democrats also didn't exactly ring the bell in recent years on how best to improve the Obamacare system. Yes, they admit, things aren't working perfectly, but they certainly haven't been talking about what exactly should change, or might be changed. Could we see something different now that Graham-Cassidy seems to be dead? Or will Democrats still just sort of circle the wagons to protect President Obama's top legislative accomplishment? This is the time for bipartisan action - but that's easier said than done.