Shannon Firth, Washington correspondent for MedPage recently discussed the present situation with Repeal and Replace, that is, the Better Care Reconciliation Act/BCRA. Revision after revision and one yanked vote after another, the long-held Republican dream to repeal-and-replace the Affordable Care Act (ACA) appeared to be evaporating last Tuesday.

On the previous Monday night, following the announcement that two more Republican senators would vote down the Senate’s Better Care Reconciliation Act (BCRA), bringing the total defections to a total of four — Republicans could only afford to lose two — Senate majority leader Mitch McConnell (R-Ky.) issued a statement, saying plans to “repeal and immediately replace” the ACA would not succeed.

While pulling the BCRA from a vote, he pledged to vote on a straightforward repeal with a 2-year transition, or “repeal-and-delay” as some have called it.

McConnell both conceded the failure of the BCRA and pushed for a new vote on the House-passed bill, which could lead, through amendment, to a “clean repeal” with a 2-year delay. During that time, Republicans could allegedly reach consensus on a suitable replacement, The Washington Post reported.

McConnell cited the ACA repeal bill of 2015, which Congress passed and then President Obama vetoed, as an example.

But even that plan fell flat: three moderate senators, Sen. Shelley Moore Capito (R-W.Va.), Sen. Lisa Murkowski (R-Alaska), and Sen. Susan Collins (R-Maine) panned the push for repeal-and-delay, according to The New York Times.

“I did not come to Washington to hurt people,” Capito said in a statement, explaining that she couldn’t eliminate Obamacare without a replacement.

Despite the opposition, McConnell said Tuesday afternoon that he would hold a vote “in the near future,” according to The Atlantic.

Meanwhile, President Trump urged a repeal-and-delay strategy. He tweeted, please someone take the President’s Blackberry away from him, Tuesday morning that one way to achieve that goal would be by amending Senate rules: “The Senate must go to a 51 vote majority instead of current 60 votes. Even parts of full Repeal need 60. 8 Dems control Senate.” Crazy!?!

But overhauling Senate rules “for a short-term gain isn’t worth it, no matter what bill we’re voting on,” said Charles Sauer, a policy fellow at the Goodman Institute.

What was the Senate’s Next Move?

“Put up or shut up,” is how Tom Miller, a resident fellow at the conservative American Enterprise Institute, translated McConnell’s message to his Republican colleagues.

He said he believes McConnell intended to force a vote on the repeal-and-delay idea in order to prove to conservative proponents of “repeal-only” just how few votes they’d get. The New York Times has already confirmed such a plan is unpopular with enough moderates to sink any such vote.

The bottom line is that Republicans failed, he said. “They are not going to be able to mark up a bill that changes current law.”

Miller suggested that, while many Republicans say they want a repeal, “when it comes to the voting, they don’t want to do it.” They aren’t ready to face the consequences of a repeal, he added.

“The normal adage is when you’re in a hole, stop digging. Eventually, they will stop digging,” Miller said.

Maybe not: some conservative stakeholders continue to dig in on repeal.

“Every single Senate Republican should vote to begin debate. They owe it to their constituents and the nation,” said Michael Needham, CEO of Heritage Action for America, the policy arm of the Heritage Foundation, a conservative think tank, in a press statement on Tuesday.

Needham went onto say that Republicans should vote to approve the 2015 ACA repeal bill, noting that because it is a partial repeal, “it will mark just the first step in a long process toward unraveling the damage caused by Obamacare.”

Asked whether the 2015 bill had the votes to pass, the Heritage Action team was uncertain.

“Given the number of senators flip-flopping on their 2015 votes, the exact count is unclear. But regardless of what passes — if anything passes at this point — there will still need to be an incredible amount of work restoring choice and competition in the individual marketplace,” added Dan Holler, vice president for Heritage Action, in a follow-up email.

On the question of a possible bipartisan compromise, Kavita Patel, MD, a nonresident fellow at the Brookings Institution, a liberal think tank, was skeptical.

“You can’t get [Sen.] Murkowski and [Sen.] Lee on the same page,” said Patel, who is also a primary care internist at Johns Hopkins in Baltimore.

If Republicans can’t find agreement in their own party, they’re unlikely to find consensus with Democrats, she noted. “But Republicans will be forced to take action to stabilize the market”, she said.

“I know Trump would like to let [the ACA] implode, but these are all congressional Republicans. They have to go back home, and they’ve got to face people, and that’s hard,” she said.

Robert Laszewski, president of Health Policy and Strategy Associates, characterized the concept of a “bipartisan solution” as a “smokescreen.”

“What is the compromise? How do you compromise rolling back Medicaid or not rolling back Medicaid? … What have the Democrats offered that comes close to what Republicans want?” he asked, noting that Republicans are opposed to an “Obamacare bailout” of insurers and certainly wouldn’t support single-payer health insurance.

Even if there were enough moderate Republicans willing to team up with Democrats, McConnell would have to be willing to introduce that bill for a vote, which he would be very unlikely to do, Laszewski said.

He argued that a bipartisan fix isn’t urgently needed because he predicts the individual insurance markets will stabilize, as he outlined in a recent blog post on his website, and even be profitable in 2018.

Others like Michael Cannon, director of health policy studies at the Cato Institute, took the unusual tack of arguing that bipartisanship wasn’t necessary, because of the BRCA, despite McConnell’s statement to the contrary, is not in fact dead.

“You can certainly read it, as ‘This bill we were trying to put together is not going to happen,'” he said. He opined that McConnell’s suggestion to put forward a repeal-only bill could be a “power play.”

While both Lee and Moran said they would not vote to agree to a motion to proceed, they were willing to negotiate, Cannon pointed out.

After McConnell proves that repeal-only is unpopular, then he can renegotiate the BCRA and say to the members and both ends of the ideological spectrum, “you gotta work with me … you’ve gotta give up something to get what you want,” Cannon said.

If nothing else, it’s clear that Republicans “own” health care, and will be held responsible for what comes next.

“If people start losing coverage and having massive premium increases as a result of [the Republicans] failure to come together on a good policy, I think they’ll be held accountable for that,” said Sabrina Corlette, JD, a research professor at the Center on Health Insurance Reform at Georgetown University here.

She said the decision to pull the BCRA was a good one, but, unlike Laszewski, her concerns about the insurance markets have not diminished. “The ACA depends on the voluntary participation of private insurance companies that have to set premiums based on what they know the rules of the road to be … Without leadership from Washington as to what those [rules] are I’m very concerned that people may lack affordable coverage options this fall.”

Corlette argued that McConnell’s best move right now would be to gather his committee chairmen and ranking members together to find a bipartisan solution to shore up the insurance markets. But she acknowledged such an approach requires walking “a very narrow path” that could be even more challenging in the House, “assuming Paul Ryan wants to keep his speakership.”

Major healthcare societies didn’t hold back in their criticism of repeal-and-delay, or the ongoing debate.

“Repeal-and-delay creates a high likelihood of lost coverage, poorer health, and financial instability for millions of Americans and their families. We urge the Senate to return to the drawing board and consider more limited, targeted solutions to our healthcare challenges,” wrote Bruce Siegel, MD, MPH, president and CEO of America’s Essential Hospitals in a press statement.

“The health reform debate is by no means over. Congress must begin a collaborative process that produces a bipartisan approach to improve healthcare in our country,” said David Barber, MD, president of the American Medical Association in a press release. “The status quo is unacceptable. A near-term action is needed to stabilize the individual/nongroup health insurance marketplace. In the long term, stakeholders and policymakers need to address the unsustainable trends in healthcare costs while achieving meaningful, affordable coverage for all Americans. The American Medical Association is ready to work on short- and long-term solutions.”

McCain’s health problems arise at a crucial time for Senate Majority Leader Mitch McConnell (R-Ky), who had hoped to bring the Better Care and Reconciliation Act, the GOP’s latest bill to repeal and replace the Affordable Care Act, to the Senate floor for a vote this week. Without McCain, it is possible that McConnell would lack the needed votes and as a result, further action on the bill will be delayed until McCain returns to the Senate.

Republican senators attempting to save their stalled effort to repeal and replace Obamacare in a late-night meeting Wednesday were interrupted with news of Sen. John McCain’s brain cancer diagnosis.

Sen. John Hoeven, R-N.D., told reporters that the senators learned of McCain’s brain cancer diagnosis during the meeting and asked Sen. James Lankford, R-Okla., to say a prayer for McCain.

“It was very emotional, almost kind of stunned disbelief for a minute, then we asked James Lankford to lead us in prayer,” Hoeven said.

“It was a sobering moment,” Sen. Ted Cruz, R-Texas, said.

Sen. Lindsey Graham, R-S.C., called McCain, who said he wanted to get back to work as quickly as possible.

“I’m going stay here a little bit longer, take some treatments and I’ll be back,” McCain said, according to Graham. Read on because as of Friday that seems to have changed.

McCain’s office announced Wednesday that the senator had an aggressive brain tumor surgically removed and was reviewing future treatment options, including chemotherapy. McCain, a war hero and the chair of the Senate Armed Services Committee, is a key figure in the conference.

The health care meeting included skeptics of Sen. Mitch McConnell’s repeal and replace bills, such as Sen. Lisa Murkowski, R-Alaska, Sen. Shelley Moore Capito, R-W.Va., and Dean Heller, R-Nev., as well as administration officials Health and Human Services Secretary Tom Price and Medicaid chief Seema Verma. Senate leadership billed the meeting as Republicans giving a replace plan “one more shot” after talks stalled earlier this week.

Senators streaming out of the late-night meeting said some progress had been made, but conceded McCain’s likely absence from the chamber during treatment made an already tricky process even harder. “Obviously it makes things difficult,” Sen Bob Corker, R-Tenn. said.

The 52-person Republican caucus has failed to get 50 votes to support a replacement plan so far, and McCain’s absence reduces their numbers further. McConnell scheduled a vote on a repeal-only bill on Tuesday but encouraged Republicans to try to agree on a replacement plan before that date. Right now, senators aren’t sure what they’ll be voting on this Tuesday — a motion to proceed on an updated version of repeal and replace they would then amend, or straight repeal. And it seems unlikely they have enough votes to start the debate on either measure at this point.

Friday it was announced that Senator McCain would be taking time off to undergo radiation and chemotherapy for his brain tumor. What will that do to the goals, progress or lack of progress in the Senate? Now add the names of Senator Jeff Flake from Arizona and Nevada’s Dean Heller, who has harshly criticized the Senate plan, who are in serious trouble for re-election. The tables could easily turn against the GOP getting anything done at all.

The Congressional Budget Office predicted a straight repeal would lead to 32 million fewer Americans having health insurance over 10 years if Congress does not replace it with an alternative plan. McConnell says Congress would come up with a replacement plan during the two-year delay before repeal goes into effect.

Before leaving the Capitol last week, McCain urged his party to start over on health care and come up with a new plan through an open committee process, instead of behind closed doors. A few of his Republican colleagues agree, but McConnell hasn’t given up yet.

Senators were still “throwing out ideas” in the meeting, according to Hoeven, but no breakthroughs were made. Asked whether they were close to a deal, Sen. Pat Toomey, R-Penn., said it’s “hard to say.”

Murkowski said she wasn’t sure how she would vote Tuesday because she doesn’t know what she’d be asked to vote on. “It’s difficult for me to say yes or no on whether to proceed because it’s not certain what we would be proceeding to,” she said. When asked what senators would be voting on, Cruz said those conversations were ongoing.

And the White House has already started on their next strategy to bring the ACA down. President Donald Trump’s administration has ended Affordable Care Act contracts that brought assistance into libraries, businesses and urban neighborhoods in 18 cities, meaning shoppers on the insurance exchanges will have fewer places to turn for help signing up for coverage.

Community groups say the move, announced to them by contractors last week, will make it even more difficult to enroll the uninsured and help people already covered re-enroll or shop for a new policy. That’s already a concern because of consumer confusion stemming from the political wrangling in Washington and a shorter enrollment period. People will have 45 days to shop for 2018 coverage, starting Nov. 1 and ending Dec. 15. In previous years, they had twice that much time.

Some see it as another attempt to undermine the health law’s marketplaces by a president who has suggested he should let “Obamacare” fail. The administration, earlier this year, pulled paid advertising for the sign-up website HealthCare.gov, prompting an inquiry by a federal inspector general into that decision and whether it hurt sign-ups.

Now insurers and advocates are concerned that the administration could further destabilize the marketplaces where people shop for coverage by not promoting them or not enforcing the mandate compelling people to get coverage. The administration has already threatened to withhold payments to insurers to help people afford care, which would prompt insurers to sharply increase prices.

I think that more and more of the voters are getting sick and tired of both parties playing games. Consider this article written by Andy Slavitt, Opinion columnist, who commented that the health care roller coaster ride has left Americans feeling increasingly sick to their stomachs. It has been ugliness at every turn.                                                                     In just the past week, Sen. Ted Cruz, R-Texas, insisted on a backroom amendment to undermine insurance markets. Vice President Pence was called on the carpet for stretching the truth in belittling the Medicaid program he aimed to cut in Ohio. Senate Majority Leader Mitch McConnell offered payoffs to fellow Republicans, trying to buy their loyalty for a bill that hurt their states. And to top it off, McConnell was caught red-handed by Sen. Ron Johnson, R-Wis., telling moderate Republicans not to worry about voting for Medicaid cuts because they would never actually happen.

What kind of games are our elected officials playing????

But the rushed deals, the untruths, the payoffs, the threats and the double-dealing were all only a precursor to President Trump’s response to the chaos. Apparently caught off guard, he first insisted on a vote to repeal the Affordable Care Act with no replacement, and then blamed the Democrats and anyone who voted against him, and finally implied that he would both allow the ACA to fail and take no responsibility for its failure. “The Dems scream death as Obamacare dies!” he tweeted Wednesday and then summoned senators to the White House to pressure them with statements that couldn’t withstand fact checking.

You can’t blame ordinary Americans for being exhausted by the whole ordeal. As one reporter met this week with cancer patients in Nevada, out in front of Republican Sen. Dean Heller’s office, there was no relief, only continued fear of Trump. As one woman put it to that reported, what’s he going to try to do next?

It’s time for the grown-ups in Washington to make themselves known. If we’ve learned anything, it’s to take Trump at his word when he claims he will take vengeful action if he doesn’t “win.” If he can’t get a health bill through Congress, he has plenty of ability to damage the Affordable Care Act through pure mismanagement. He can drive premium hikes and insurer pullouts by stopping cost-sharing payments that keep coverage affordable for low-income Americans. Already, Trump has destabilized the markets by refusing to enforce the law, which has increased prices and reduced competition. More games are not what Americans are looking for from the president.

The ACA is far from perfect, but it is also far from broken, yet! Most Americans live in areas that are quite stable, and according to a new report on 2017 exchange results, insurance companies have stemmed losses and are on solid financial ground. And this is not true. Quite a number of exchanges in severe trouble have folded. But, insurers are indicating that what they need now is enough certainty from Washington for them to be able to stay in the market, expand, and make their premiums more competitive. This statement and others from the insurance companies tell the real tale; the insurance companies are the principal forces really in charge.

If the administration refuses to provide that certainty by making cost-sharing payments, Congress should authorize the payments. If the administration refuses to enforce the law, Congress should hold oversight hearings to hold the White House to it. If the administration spends its resources making propaganda videos to scare people from enrolling instead of helping Americans enroll, the General Accounting Office needs to investigate.

And if Trump’s actions violate the law and cause Americans harm, he will end up in territory familiar to him — in court. At this point in his presidency, he has well trained his opposition. Each provocative, harmful action by Trump creates an opposite and forceful reaction of anger, fear, and resistance. People with disabilities and parents of medically fragile children have made it clear they can and will not surrender without a fight. In an echo of his immigration battles, legal experts, advocates and policy experts are already amassing to help.

Accepting the ACA as the law of the land after all that has transpired might not be in Trump’s DNA. As a result, he is unlikely to achieve what great presidents have a knack for, reading a situation well enough to turn a loss into a win.

Americans seem ready to see the politics of health care die down and crave the leadership that will put their concerns ahead of party loyalty. There are some in Washington who are not mired in subterfuge and games, notably three Republican women: Sens. Susan Collins of Maine, Shelley Moore Capito of West Virginia and Lisa Murkowski of Alaska.

The strongest message is coming from a group of governors, among them Republicans Brian Sandoval of Nevada, John Kasich of Ohio and Charlie Baker of Massachusetts, and Democrats Steve Bullock of Montana, John Bel Edwards of Louisiana and John Hickenlooper of Colorado. They are giving us a sorely needed vision of bipartisan statesmanship. But they also realize that if this Better Care Act gets passed, much of the Medicaid woes will be passed on to the states to finance and administer with efficiency and attention to the huge fraud.

Trump and McConnell are planning yet more arm-twisting followed by another vote next week to either repeal the ACA or jam through some tragically inadequate replacement. Anything can happen. More than ever, America is looking for grown-ups in Washington to stand up, make themselves known, and move us somewhere constructive. Mark my word, if they don’t grow up and act, or better yet perform like the Senators and Congressmen and women that we voted for, 2018 will be a sorry message to all elected officials!!