Eiliperin Sullivan of the Washington Post reported that last Wednesday, President Trump seemed “to distance himself further from a bipartisan Senate health-care effort,” and he warned, “against ‘bailing out’ insurance companies.”

President Trump seems to be playing both sides as he qualifies his backing of the bill. He “appeared to give his blessing” to the deal, but on Wednesday, he “qualified his endorsement.” Indeed, the article says Trump “appeared to send a different message,” although that “may have been more of a caveat than a rejection.” Alexander explained that Trump wants to review the deal “carefully to see if he wants to add anything to it,” and he “wants to reserve his options.” The Times adds that Alexander and Murray “have already moved to address concerns that restoring the payments to insurers could be viewed as providing them with a ‘bailout.’” They explained on Tuesday that their agreement “would contain ‘the strongest possible language’ to ensure that the money provided for the subsidies would go to the benefit of consumers, not insurers.”

However, despite the confusion amongst lawmakers senators seem to be moving ahead with the bipartisan deal to fund ACA subsidy payments to insurers. Sen. Lamar Alexander (R-TN) said, “We are having the strongest possible language in the Alexander-Murray agreement to make sure the cost-sharing reduction payments for 2018 and 2019 benefit the low-income Americans to help them pay for their insurance and don’t benefit the insurance companies.”

This proposal in the Senate to help stabilize Affordable Care Act marketplaces would ensure that subsidies paid to insurance companies benefit consumers rather than padding the companies’ profits.

A draft of the bill, obtained by NPR, requires health plans to offer the subsidies as one-time or monthly rebates to consumers or they will be repaid to the federal government. The subsidies, known as cost-sharing reduction payments, are designed to reimburse insurance companies for discounts they are required to offer their customers on copayments and deductibles. President Trump has criticized the payments as a “bailout” and said last week he would cut them off.

The bipartisan bill, proposed by Sens. Lamar Alexander, R-Tenn., and Patty Murray, D-Wash., restores the payments for the rest of this year and the next two years. But the lawmakers are seeking to reassure the president that the payments will benefit consumers and not insurance companies.

Trump told reporters at the White House Wednesday morning that he was looking forward to seeing the bill. White House press secretary Sarah Huckabee Sanders told reporters on Wednesday afternoon that Trump does not support the deal in its current form.

“If something can happen, that’s fine. But I won’t do anything to enrich the insurance companies because right now the insurance companies are being enriched. They’ve been enriched by Obamacare like nothing anybody has ever seen before. I am not going to do anything to enrich the insurance companies,” Trump said.

He had tweeted such concerns earlier on Wednesday.

I am supportive of Lamar as a person & also of the process, but I can never support bailing out insurance companies who have made a fortune with Obamacare.

Alexander told NPR’s Susan Davis that he had spoken to the president three times in the past 12 days, including Wednesday morning before the president’s tweet. He also reiterated that the effort to repeal and replace the Affordable Care Act would not end because of this bill. They just can’t accept defeat.

“We would like to replace Obamacare, that’s almost unanimous in the Republican caucus. But I think it will become increasingly unanimous in the Republican caucus that we understand that between today and the time we can replace Obamacare is two to three years,” Alexander told NPR. “And that if we do nothing we’ll create chaos, and chaos will lead to a birthday present for Bernie Sanders, which is a single-payer solution — which none of us want.”

Murray and Alexander are expected to officially release the bill with a list of bipartisan co-sponsors on Thursday. Republicans are working a number of influential senators from the moderate and conservative wings to sign on to the bill can pass the Senate.

Republican Senate leaders have indicated they will not waste limited floor time on another failed health care bill, which means the bill must be ensured 60 votes to pass.

Senate Minority Leader Chuck Schumer, D-N.Y., criticized the president at length for tempering his initial support for the deal. “This president keeps zigging and zagging so it’s impossible to govern,” Schumer said on the Senate floor Wednesday morning. “He’s totally inconsistent. For it, one day, against it the next day. You can’t govern — Mr. President, you cannot govern a country, you cannot keep America great if you don’t know what’s in the bills and you don’t have a consistent policy about them.”

Schumer said he’d had private conversations with the president in recent weeks in which they both agreed to encourage their respective senators to reach a deal.

The bill also allows states to seek waivers to create variations on the Affordable Care Act in their own states. That’s been a priority of Republican lawmakers, who argue that state-level legislators and governors better understand the needs of their citizens.

“This will give states meaningful flexibility,” Alexander said Tuesday in discussing the forthcoming bill.

The ACA allows states to apply for waivers to set up systems such as reinsurance programs that protect insurance companies from large and unexpected losses, or high-risk pools to provide coverage to the sickest patients.

But many of the state applications have been delayed or denied because of all the requirements laid out in the law.

For example, the ACA requires state legislatures to pass a law approving the waiver provisions. The new proposal would simply allow a state governor to sign off on the plan. The bill also restores some of the federal budgets for advertising and outreach for open enrollment in ACA health plans, which starts on Nov. 1. The Trump administration slashed that budget by 90 percent.

Alexander says he will seek Senate co-sponsors for the bill and then bring it to Majority Leader Mitch McConnell later this week for consideration. Last Thursday, the bipartisan bill, which seeks to stabilize ACA marketplaces “gained momentum…when enough lawmakers rallied behind it to give it potentially unstoppable Senate support.” The measure’s sponsors, Sens. Lamar Alexander (R-TN) and Patty Murray (D-WA), “appeared together on the Senate floor to announce 24 sponsors, divided evenly between both parties, for resuming federal subsidies to insurers that [President] Trump has blocked.” The article says Senate Minority Leader Chuck Schumer (D-NY) indicated all 48 Senate Democrats would vote for the bill, and that number, combined with 12 GOP sponsors, would give the measure 60 votes, enough to defeat a filibuster. So, now the Democrats in the Senate “pressed…to advance a bipartisan bill that would preserve subsidies for low-income Americans under the Affordable Care Act amid a new show of cooperation, even as Republican leaders suggested that they would need greater concessions before bringing it up for a vote.” Alexander warned that conservatives who refuse to support the bill “were ignoring the ‘chaos’ that could ensue if the federal government did not provide the cost-sharing reduction payments that Trump cut off this month.” Meanwhile, Murray insisted “Congress would ultimately pass the measure because Americans are beginning to grasp that the impasse in Washington has translated into higher insurance rates for 2018.”

It was the Friday before a Monday deadline, and federal health officials in Washington, D.C., were working feverishly with their counterparts in Oklahoma to finalize the details of a new state reinsurance program.

Emails flew between the Centers for Medicare and Medicaid Services in Washington and Oklahoma’s Department of Health. Blue Cross Blue Shield of Oklahoma, the only ACA insurer in the state, was on board. Everything had to be done by Monday, Sept. 25 so the insurance company could set new, presumably lower, health insurance rates for 2018.

Just before 6 p.m. on Friday, Sept. 22, CMS sent along a draft approval letter saying it expected an approval to be released the following Monday.

Instead, Sept. 25 brought more questions from the agency and more reassurances. “We don’t necessarily see this issue as a barrier to approving the application today,” reads one email from a CMS employee and provided to NPR by Oklahoma officials.

But the approval never came and the deadline to cut insurance premiums for 2018 passed. Oklahoma withdrew its application.

“While we appreciate the work of your staff, the lack of a timely waiver approval will prevent thousands of Oklahomans from realizing the benefits of significantly lower insurance premiums in 2018,” Oklahoma Health Secretary Terry Cline wrote in a Sept. 29 letter to former Health and Human Services Secretary Tom Price and Treasury Secretary Steven Mnuchin explaining why the state was withdrawing the application.

That angry letter lit up Twitter with speculation that the Trump administration was so intent on undermining the ACA to force Congress to pass a repeal bill that it would even cross a Republican state.

Oklahoma’s situation isn’t unique. Of the eight states that have applied for waivers under the Affordable Care Act to strengthen their health insurance markets, only two have been granted in full — one before Trump took office and one just days after he was sworn in and before his Health and Human Services secretary was confirmed.

Two other applications remain incomplete, but several have been plagued by delays and partial approvals. Some health care analysts say the delays and denials are part of a pattern of actions by the Trump administration to undermine the ACA insurance markets.

“The Trump administration has been promising state flexibility,” says Andy Slavitt, former acting director of CMS. “But in the case of Oklahoma, rather than respond in a timely way, by not responding, they chose instead to drive up premiums for millions of Oklahomans, presumably to sabotage the ACA.”

But Larry Levitt, senior vice president at the Kaiser Family Foundation, says waiver applications can be complicated.

“On the one hand, there are legitimate issues about whether these waivers meet the requirements of the law, so taking time to review that is not unreasonable,” he says. “On the other hand, it does appear that the states have been getting mixed signals from the administration.”

CMS declined to answer questions about the waiver decisions and email exchanges.

Former Secretary Price, who resigned last month, and CMS Administrator Seema Verma encouraged states to apply for the waivers. Just weeks after he was sworn in in February, Price wrote a letter to every governor in the country to urge them to consider creating reinsurance programs and high-risk pools through what’s known as a 1332 waiver, named for the section of the Affordable Care Act that authorizes them.

HHS “invites states to pursue approval of waiver proposals that include high-risk pool/state-operated reinsurance programs,” the letter says. “The Departments will work with states to review all applications within the timeframe provided … and do our best to work with state to review their applications on an expedited basis.” But that’s not how it appears to have played out.

The Washington Post reports that President Trump personally intervened to delay approval of Iowa’s waiver application. The state asked to create a reinsurance program to protect insurance companies from losses when patients suffer unusually expensive illnesses. The state also wanted to create a separate set of insurance plans outside the ACA marketplace. Together the measures would cut premiums by as much as 80 percent and stabilize that state’s market, Insurance Commissioner Doug Ommen told Morning Edition.

“I don’t speak to the president, so I really don’t know what the story is behind this,” he said. “It does seem that we are having some difficulty getting to a solution.”

The state is running out of time to implement its program, called the Iowa Stopgap Measure, for next year, Ommen said. “The closer it gets to open enrollment, the harder it is for the stopgap to work,” he said.

Another state, Minnesota, did get an answer to its request. But it wasn’t the answer state officials expected. CMS granted half of Minnesota’s waiver request, allowing the state to create a reinsurance system. But at the same time, CMS denied a request from the state to leave funding for its basic health program for the working poor intact.

Minnesota Commissioner of Human Services Emily Piper says the state was shocked by the rejection.

“We bounced the language off them about how to make reinsurance work and how to hold our basic health plan harmless,” Piper says. “We worked really closely with various experts at CMS. We wrote our legislation a certain way, we wrote our waiver application a certain way. And we followed all of the directions and guidelines that CMS put in place along the way.”

Emails between CMS and state officials bear that out. One note from a CMS staffer describes exactly what language should be included in Minnesota’s state law authorizing the reinsurance program.

“To be clear, the BHP (basic health plan) funding *will* go down. However, the pass-through will go up an extra amount to account for that,” the CMS staffer says in the email to Minnesota state Sen. Michelle Benson. The staffer adds that he edited the language in the state’s draft legislation to ensure Minnesota achieved that result.

Piper, the health commissioner, says they not only worked on the language with CMS but also told the agency multiple times that the state needed the waiver approval in August so it could prepare its markets for open enrollment, which starts in November.

Minnesota didn’t get an answer until late September.

“We were trying to reach out during that time period. The governor was seeking to get a hold of [HHS] Secretary Price and [CMS Administrator Seema] Verma,” Piper recalls. “There was a period of several days where at the highest levels we were unable to make contact with Secretary Price and Admin Verma.”

She says the state was stunned that the answer took so long and even more shocked when CMS rejected their request to protect the state’s Basic Health Plan, which now stands to lose $369 million in federal funding over two years.

“I’m not sure why this has been states’ experience,” Piper says. She acknowledges the process of getting a waiver is complex but says the results seem politically motivated.

“With regard to the ACA, when the president makes comments on Twitter that express an intent to compromising intentionally the ACA, it certainly feels like one potential is that there is an intentional political calculation here,” Piper says.

Despite these experiences, states could find relief soon.

A proposal to stabilize insurance markets by Sens. Lamar Alexander, R-Tenn., and Patty Murray, D-Wash., would add flexibility to the state waiver process.

Several paragraphs of the draft legislation appear to be geared specifically to the Minnesota situation by adding protections for basic health program funding from the federal government.

And more generally, the bill would cut the wait time for waivers to be approved, allow states to go ahead with just the approval of the governor rather than a vote from the legislature, and it would make it easier for states to get copycat waivers once a program has been approved elsewhere.

However, the bill has yet to be scheduled for a committee hearing or a floor vote. And it is unclear whether it would pass the House or get the support of the president.

A bipartisan coalition of 24 senators — 12 Republicans and 12 Democrats — has signed on to health care legislation to prop up the individual insurance market and keep premiums down. With the expected support of all Senate Democrats, it could have the votes to pass the chamber. But questions remain over when it might actually get a vote, as well as whether President Trump and House Republicans would bring the bill over the finish line.

“This is a first step: Improve it, and pass it sooner rather than later. Our purpose is to stabilize and then lower the cost of premiums in the individual insurance market for the year 2018 and 2019,” said Sen. Lamar Alexander, R-Tenn., on the Senate floor. Alexander and Sen. Patty Murray, D-Wash., crafted the compromise bill.

Alexander and Murray have been working on this legislation for months. Negotiations initially began after the Senate failed to pass legislation to repeal and replace Obamacare back in July.

Most Americans get health insurance through their employer or from the government. About 18 million Americans get their insurance through the individual market established by the Affordable Care Act. “They’re the ones we’re worried about; they’re the ones we’re seeking to help,” Alexander said, noting that includes about 350,000 people in his home state.

“I have to say that after seven years of intense partisanship on these issues, which would lead everyone to believe there was no hope for Republicans and Democrats to come together and work to strengthen our health care, I’m really pleased with this common ground we’ve been able to find,” Murray said on the Senate floor.

President Trump’s decision last week to end subsidies to insurance companies that were allowed under the ACA revived congressional talks. The Trump administration argued — and initial court rulings backed it up — that the payments were illegal because they had not been appropriated by Congress, which has the constitutional authority to spend the government’s money. Although the 2010 health care law required insurers to provide discounts to some low-income consumers and said the government would reimburse them, without authorizing the spending.

The Alexander-Murray proposal would appropriate those subsidies for two years and tie them to permanent changes to the law that give states more flexibility to seek waivers from the Health and Human Services Department from the ACA’s requirements. It would also allow insurances companies to sell less comprehensive plans to all customers, not just those under age 29 as is the case under current law.

The nonpartisan Congressional Budget Office estimates that without the subsidies, premiums will go up, the deficit will rise and up to 16 million Americans could live in counties with no insurance providers at all.

“Unless they are replaced with something else temporarily, there will be chaos in this country and millions of Americans will be hurt,” Alexander warned.

Alexander said Trump has been privately encouraging of the talks, but the president cast doubts on the legislation this week by suggesting it was a “bailout” for insurance companies that he could not support. However, the bill’s sponsors counter that the legislation requires that the subsidies go directly to the consumer to keep premiums down.

The bipartisan bill has potentially critical GOP support from Sens. Susan Collins of Maine, Lisa Murkowski of Alaska and John McCain of Arizona. The trio played a defining role in the defeat of previous GOP health care bills this year. It also has the backing of Sens. Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, who have competing legislation to dismantle the ACA and replace it with a block grant system to the states.

Again the GOP backers say the bill does not pre-empt the party’s ongoing effort to end Obamacare but rather buys time to keep working on legislation that can muster enough support to pass Congress. Conservatives have balked at Alexander-Murray as a tacit admission that Obamacare will remain the law of the land. House Speaker Paul Ryan said through a spokesman Wednesday that the speaker believes the Senate should remain focused on legislation to end Obamacare, not prop it up.

The proposal puts the GOP in a bind between the policy necessary to act to protect millions of Americans from premium hikes and the political necessity to continue to keep up its effort to dismantle the current system. An August poll from the Kaiser Family Foundation found that 60 percent of Americans think Trump and Republicans in Congress are responsible for what happens to the ACA in the future.

Senate Majority Leader Mitch McConnell has not taken a position on the bill, but he is unlikely to bring something to the floor unless it has Trump’s support and the 60 votes needed to clear a potential filibuster, which it should if all 48 Senate Democrats support it along with the 12 Republicans who have signed on. The legislation crowds an already limited legislative calendar. It would need to become law before the end of the year when Congress needs to pass a spending bill package to keep the government running. That spending bill would be the vehicle to fund the insurance subsidies.

Along with Alexander, Collins, Murkowski, McCain, Graham and Cassidy, the additional GOP co-sponsors include Sens. Mike Rounds of South Dakota, Joni Ernst and Chuck Grassley of Iowa, Bob Corker of Tennessee, Richard Burr of North Carolina and Johnny Isakson of Georgia.

The Democratic co-sponsors joining Murray include Sens. Angus King, independent of Maine, Jeanne Shaheen and Maggie Hassan of New Hampshire, Joe Donnelly of Indiana, Amy Klobuchar and Al Franken of Minnesota, Heidi Heitkamp of North Dakota, Joe Manchin of West Virginia, Tom Carper of Delaware, Tammy Baldwin of Wisconsin and Claire McCaskill of Missouri.

I keep on saying, but no one listens- there are good aspects to the ACA/Obamacare and all we/they need to do is modify or fix the problems, such as the sustainability aspect of the equation. But I really believe that Trump really knows what he is doing in that if he starts working with the Democrats the Republicans will rally and join the Democrats to fix the system that he is attempting to sabotage. Smart? Not sure.

I next, want to investigate the idea of a Single Payer system as promoted by Bernie Sanders. Is a single-payer system really ever true single-payer system of healthcare delivery and whom does it benefit or penalize?

What a momentous occasion, our book is in production- The Search for Excellence in Clinical Practice. A Handbook for Clinical Process Improvement for Providers, published by Sentia Publishers.