Robert Califf’s second confirmation as FDA commissioner appears to be in jeopardy, with support appearing uncertain or waning on both sides of the aisle in the evenly split Senate.

As more Democrats take exception to President Biden’s nominee over his ties to the pharma industry, and with Republicans displeased with the administration’s decision to make the abortion pill easier to get, it has become clear that there aren’t enough votes on Capitol Hill to confirm Califf.

Mark McClellan, director of the Duke Margolis Center for Health Policy and a former FDA commissioner, noted that there “doesn’t appear to be a Plan B” in place if Califf fails to get confirmed.

“I do think there is some recognition — on both sides — that a much longer delay in confirmed leadership at the FDA is not helpful,” he said.

Wayne Pines, an FDA veteran and president of healthcare at APCO Worldwide, said Califf faces a formidable support problem.

“The Senate leadership will not bring the nomination to the Senate floor unless they believe they have the votes to confirm,” Pines said. “I’m afraid this could go on for some time because the Senate does have other priorities. Never before has a nomination for FDA commissioner been delayed like this.”

The White House did not respond to a request for comment.

Califf, who previously served as head of the FDA from 2016 to 2017, sailed through his last Senate confirmation process with a vote of 89-to-4 in his favor.

But this time around, five Democrats in the Senate have indicated they would vote no, and several others are saying they have not decided. Meantime, a mere four Republicans have said they’d vote for him.

Sen. Elizabeth Warren (D-Mass.), along with a handful of other Democrats, has been vocal about her concerns over Califf’s ties to industry.

In a letter last week, Califf made ethics concessions to Warren, agreeing to not look for a job or compensation from any company in the pharma or medical device industries that he interacts with for four years following his second time in the commissioner’s chair.

Califf also agreed to recuse himself from decisions at the FDA related to companies with which he had ties, saying he’ll do so for four years instead of the expected two years.

Meanwhile, Janet Woodcock continues in her role as acting commissioner. As long as there’s a nomination under consideration, she can legally remain in that role.

“It is fortunate that the agency is in good hands with Dr. Woodcock, and I think that in some quarters that may be lowering the sense of urgency,” said Pines.

Read Califf’s letter to Sen. Warren here: https://bit.ly/3HAzxm4.