Given what has been going on this year there are not the votes for what Rand would consider a replacement. The result of his stance is the status quo with ObamaCare with what appears to be bailouts of the insurance being proposed by Sen Alexander (R-TN). Whether that is right or wrong is a different question.
States get to keep there money. As long as the federal government doesn’t mandate everything that’s called Federalism. This should be seen as a tax cut to the States if you ask me. You can fight it locally which is the way the government is supposed to work. Yes, ultimately this is a federal budget line item still but it’s a good step. Ultimately I’d like to see the money not get to Washington in the first place but this is a step in he right direction (as I understand the plan)