A significant deadline is approaching. The federal fiscal year ends on Sept. 30 and with it this year’s opportunity to use reconciliation to reform and replace ObamaCare. Time is running out to make changes that will devolve any power back to the people and the states, a component of federalism. For Republicans, it may be the last chance to fulfill any aspect of the promise that they have campaigned on for over eight years. Hesitant politicians in Congress should support this effort through the Graham-Cassidy bill, despite its shortcomings.

Senator Rand Paul, a physician, has argued for a complete repeal and replacement with large private associations to eliminate the penalty of pre-existing conditions. A dedicated purist, he is presently against this rendition of reform as he considers it “ObamaCare-lite” since it does not eliminate all the funding nor the regulatory mandates under the existing laws. This is correct (though block-granting funds will reduce spending by 5-10%), but it misses an essential point. The longer the ACA law remains in effect, the harder it is to replace it with an improvement, as the entrenched and dependent constituency grows. An addition to the bill which might garner Paul’s support could include cross-state insurance purchasing or more regulatory flexibility at the state level.

Already, the most progressive wing of the Democratic party (led by Senator Bernie Sanders, a registered Independent) has unveiled a version of a national single-payer system. This version supported by 16 Democratic senators, according to their estimates (which are always below the real costs) will require expenditures of $32 trillion while funding is only $16 trillion over ten years. Clearly this deficit dwarfs the cost of ObamaCare and will bankrupt this nation. All efforts at socialism successfully rob a nation of its wealth. The ACA is not sustainable without tremendous infusions of federal dollars, so significant changes must occur. Will we miss this last chance to end the individual and employer mandates?

The 2012 Supreme Court ruling essentially concluded that the ACA was a tax scheme. Chief Justice Roberts, voting with the four liberal judges, legitimized the effort to nationalize healthcare. This is now settled law and one only needs to consider the 1937 ruling giving Social Security its legitimacy (under the same concept) and turning that program into the “third rail” of politics (as it is deadly to tinker with its benefits). History has taught the open-minded that programs rarely shrink with time.

Bipartisan attempts to reform ObamaCare in the Senate have failed since the divide is too wide. Democrats led by Senator Patty Murray sought to expand the federal subsidies to stabilize the private insurance health care markets. She wanted several years of financing with the Congress bypassing President Trump. Going down this road ensures the expansion of Obamacare which is not supported by the chairman, Senator Lamar Alexander, who supports one year of subsidies voted by the Congress. Under present law, the president has great latitude to manage these subsidies (including one for Congress itself).

The failed Senate attempt in August to repeal and replace ObamaCare mustered only 49 Republican votes. Senators Susan Collins, John McCain and Lisa Murkowski opposed the “skinny repeal,” fearing the impact upon their states. This version of repair provides some relief for their states. In fact, the losers will be the more liberal states with mostly Democrat senators that receive a disproportionate amount of Medicaid dollars. Already, Governor Christy of New Jersey has voiced objections as it cuts $4 billion from state funding. Most Republican governors support this bill. The distribution of funds will become more equitable on a population basis. This may help secure sufficient votes.

Senator Collins, who has consistently voted against repeal of ACA, has some concerns about the impact of block-granting Medicaid funds. Uncertainty scares some people, but the present system is unsustainable. Rural hospitals and clinics depend upon Medicaid funding for their survival. These institutions have few options for alternate sources of financing healthcare delivery. Under the proposed bill, states could improvise. Previously I suggested that those with limited funds could purchase Medicaid coverage on a sliding scale based upon income. This legislation could give this freedom to the states, as an alternate to unaffordable private insurance.

Senator Murkowski has not identified specific objections to the “skinny repeal.” Her position could be influenced by sweeteners (the way of the swamp) for Alaska. The enormous pressure upon her (since she previous voted for repeal) may induce a positive vote next week for Graham-Cassidy.

Senator McCain, who voted against the August bill, has stated that he will do the same in the next vote.

For a century, the Democrats have sought national health care. First proposed by Woodrow Wilson, the progressives have used incrementalism to move toward complete socialized medicine. In Canada, the final process took 20-40 years. Obama sought to accomplish this in half the time. Senator Graham states that the choice is between socialism or federalism.

Funding determines who makes the rules. A single source of funding will limit creativity, efficiency, and excellence. The ultimate national plan would be a Medicaid organized medical payment program as Medicare costs could not be sustained. The deficit under the Sanders proposal is evidence for this. In all of this, people have missed the substantial proportion of health care dollars the private insurance system underwrites. If this system disappears then the pressures upon the institutions accelerates. Senator Collins must understand this issue.

Attempts to roll back ObamaCare have been unsuccessful. The entire health care financing system is under pressure. The quality of our services depends upon the financing, innovation, dedication of providers, research efforts, and regulatory pressures (to name a few issues). Democrats argue to improve Obamacare, which means adding more federal government control of our health care.

This bill is the compromise that our governing elite have wrought. We seize it or fail to improve the dying system. When you are drowning, it is not time to question the color of the rope thrown your way. Voltaire said “perfect is the enemy of the good.” If this bill passes, further improvements are possible. If it fails, then we are dead in the water and progressives will determine our future.