The Senate is in its third day of a debate  to reshape the US healthcare system. 

Senate Minority Leader Chuck Schumer ended the day Wednesday by calling the healthcare debate a "sham," pointing to the issue that it's not clear what bill will ultimately be voted on. Schumer said Democrats won't offer up any more amendments until they see the final product.  

"We don't even have a final bill to amend," Schumer said.

The debate has begun to shift toward a "skinny repeal" bill, which would repeal certain aspects of the ACA. If passed, it could lead to the House and Senate working together to compromise on one final bill. 

The debate began earlier Tuesday, and the Senate has 20 hours of legislative time to debate, and about 10 have been used in the first two days. The time's split equally between Democrats and Republicans. Once that concludes, the Senate will then go into a "vote-a-rama" in which an unlimited number of amendments can be proposed to bed added onto the bill. 

We'll be updating this post as the debate continues.  

SEE ALSO: The 10 GOP senators who will decide the fate of the Republican healthcare bill

DON'T MISS: Americans are facing rising out-of-pocket healthcare costs — here's why

12 p.m. - Senator Bernie Sanders calls Daines amendment an 'old political trick'.

During debate on Thursday, Sanders addressed the upcoming Daines amendment, which would introduce a "Medicare for All" healthcare plan. 

"I hope that this is really a breakthrough," Sanders said of the bill, which was introduced by Republican Senator Steve Daines. But, he said, he suspects it's just an "old political trick" inserted a mid a serious debate about healthcare.

"I think this is not a time for political games," Sanders said. 

Sanders has been a proponent of "Medicare for All," but isn't buying into Daines' plan to expose which members of the Democratic caucus might be in favor of a single-payer healthcare system.

10 a.m. - Debate opens for the day, with a vote on single-payer healthcare coming this afternoon.

The plan, introduced as an amendment to the House bill by Republican Sen. Steve Daines of Montana, is titled the "Expanded & Improved Medicare For All Act."

The amendment would set up a universal healthcare system in which all Americans would be covered through Medicare, the federal government's health program that currently covers all adults who are at least 65 years old. 

But the vote, which is scheduled for 2:15 p.m. on Thursday, isn't expected to pass. Daines doesn't even support it. The intention is to try to expose which senators would vote in favor of a single-payer system. 

Sen. John McCain was one of three Republicans to vote against the GOP healthcare plan early Friday morning, and he is being credited with the decisive vote that killed the so-called Obamacare "skinny repeal."

"We should not make the mistakes of the past that has led to Obamacare's collapse, including in my home state of Arizona where premiums are skyrocketing and healthcare providers are fleeing the marketplace," McCain said in a statement.

All 48 Democrats voted no. In joining fellow Republicans Lisa Murkowski of Alaska and Susan Collins of Maine, who had previously expressed concern with the GOP's repeal strategy, McCain was seen as casting the deciding vote.

McCain had returned to Washington for the healthcare vote on Tuesday, nearly a week after his office announced he had brain cancer. The Arizona senator delivered a powerful speech from the Senate floor Tuesday, focusing on a need to return to a more bipartisan approach.

Shortly before the vote, it appeared that Senate Majority Leader Mitch McConnell and Vice President Mike Pence were attempting to persuade McCain to change his mind; the three were seen talking before the vote, but the senator stuck with his "no," effectively ending the bill.

McCain released the following statement early Friday morning:

"From the beginning, I have believed that Obamacare should be repealed and replaced with a solution that increases competition, lowers costs, and improves care for the American people. The so-called "skinny repeal" amendment the Senate voted on today would not accomplish those goals. While the amendment would have repealed some of Obamacare's most burdensome regulations, it offered no replacement to actually reform our health care system and deliver affordable, quality health care to our citizens. The Speaker's statement that the House would be "willing" to go to conference does not ease my concern that this shell of a bill could be taken up and passed at any time.

"I've stated time and time again that one of the major failures of Obamacare was that it was rammed through Congress by Democrats on a strict-party line basis without a single Republican vote. We should not make the mistakes of the past that has led to Obamacare's collapse, including in my home state of Arizona where premiums are skyrocketing and health care providers are fleeing the marketplace. We must now return to the correct way of legislating and send the bill back to committee, hold hearings, receive input from both sides of aisle, heed the recommendations of nation's governors, and produce a bill that finally delivers affordable health care for the American people. We must do the hard work our citizens expect of us and deserve."

SEE ALSO: John McCain delivers powerful speech from the Senate floor as he returns while dealing with brain cancer

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NOW WATCH: Listen to the leaked audio of Australia's prime minister mocking Trump

House Speaker Paul Ryan says he's "disappointed and frustrated" by the failure of health care legislation in the Senate.

But Ryan says "we should not give up" after promising for years to repeal and replace "Obamacare."

At the same time, the speaker says in a statement Friday that overhauling the tax code is at the top of the House's list of priorities.

Ryan is pledging to pursue "historic tax reform" in the fall.

He issued his statement as the House prepared to leave Washington for its annual August recess.

The House passed legislation repealing and replacing "Obamacare" in May. But after a failed vote early Friday in the Senate, it's not clear GOP leaders will be able to resuscitate the efforts.

SEE ALSO: John McCain saved Republicans from themselves

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Early on the morning of July 28, Republicans were dealt a surprising blow when Sen. John McCain (R-AR), along with Sen. Susan Collins (R-ME) and Sen. Lisa Murkowski (R-AK), voted against the latest installment of GOP efforts to repeal the Affordable Care Act (ACA).

In light of Republicans’ failure to undo the ACA, President Trump was quick to react on Twitter, stating that he would simply “let ObamaCare implode” and have Democrats own the consequences. With Republicans holding all positions of power in Washington, D.C., these statements are startling by themselves.

However, with Congressional efforts in limbo, the Trump Administration seems to be going a step further than “letting” Obamacare fail. Indeed, it has emphasized an alternative strategy: actively sabotaging the Affordable Care Act.

Cutting outreach … and misdirecting it

From the get-go, the Trump Administration quickly sought to impair the success of the Affordable Care Act. In one of its first moves, the Department of Health and Human Services under the direction of Secretary Tom Price pulled advertising for the federal government’s enrollment entity, healthcare.gov.

The advertising has proven important to reach 18 to 34-years-olds. Enrolling these “young invincibles” is crucial for stabilizing risk pools because they are generally healthier and seek less medical care. States running independent campaigns, like California and its insurance marketplace Covered California, have been very successful in recruiting young people.

In an ironic twist, the Trump Administration used advertising funding intended for the promotion of the Affordable Care Act for a series of social media promotions attacking the law.

Also, in mid-July, the Administration moved to end contracts for enrollment assistance in 18 major cities. Contractors helped individuals navigate the often challenging enrollment process in such places as libraries, businesses and urban neighborhoods in these cities which had been identified by the Obama Administration as high priority.

Finally, the window for the next open enrollment period has been cut in half compared to previous years, thus making it difficult for time-pressed people and those who need enrollment help to enroll.

Many of these actions have triggered calls for inquiries into potential malfeasance by Congress and the Government Accountability Office (GAO).

Spreading misinformation

Trump Administration officials have been actively traveling the country and pushing talking points that are often false, or, at the very least, highly misleading and incomplete. Prominently featured in these efforts has been Vice President Mike Pence, who blamed Medicaid expansion for the backlog of disability cases in Ohio.

A favorite focus has been on increasing insurance premiums. While it is true that premiums have risen in many places, well over 80 percent of individuals purchasing insurance in the ACA marketplaces are eligible to receive premium subsidies that shield them from these costs. Moreover, 59 percent of enrollees are also eligible to receive cost-sharing subsidies that shield consumers from rising out-of-pocket costs, another favorite Republican talking point.

Efforts to spread misinformation about the ACA has been coupled with equally misleading information about Republican repeal-and-replace efforts. For example, Republicans consistently argue that draconian reductions to the Medicaid program are not actual cuts, a position that virtually all health experts disagree with.

Republicans have repeatedly and persistently argued that the ACA is facing imminent implosion. Again, this position is in direct opposition to that of most health policy experts.

Trump Administration officials’ preferred vehicle for outreach has been social media. For example, there has been a nearly constant stream on Twitter by HHS Secretary Tom Price focusing on “collapsing exchanges”, rising premiums, and how the ACA is “wreaking havoc” on America. These claims are in direct contradiction to expert analyses or at very least incomplete and highly selective.

Spreading uncertainty

Far from providing a major overhaul of the American healthcare and insurance system, the ACA provided a mere extension of the existing system, a system that relies extensively on private businesses to implement government policy.

Arguably, one of the most crucial components of the ACA is the active cooperation of insurance companies. And unlike with previous health reform efforts, insurance companies have been on board with Obamacare from the beginning.

Yet, insurance companies, both for-profits and non-profits, are first and foremost businesses that need to generate profits to stay afloat. Crucial in this endeavor is legal and regulatory certainty, which allows for long-term planning and helps guide investment decisions.

The constant undermining talk by the Trump Administration has done much to shake the confidence of insurance companies in the ACA. Entering a new market and spending resources to seek new enrollees require significant investments. Insurers do not want to see these potential investments wasted.

One of the most prominent issues in this regard has been the Administration’s lack of commitment to paying the ACA’s cost sharing subsidies. These subsidies help low-income consumers in the insurance marketplaces to shoulder out-of-pocket costs like co-payments for prescription drugs and doctor visits. Most importantly, the ACA requires insurers to cover these costs for their low-income enrollees. Insurers are then reimbursed by the federal government. Last year, reimbursements amounted to $7 billion.

Failure to pay these subsidies would be damaging to insurance markets. Insurers would still be required to make the payments for qualified individuals. However, they would not receive federal reimbursements. This would likely lead to massive premium increases as insurers are seeking to recover their payments. It could also potentially trigger an exodus by insurers.

Not surprisingly, given these uncertainties, insurance companies have left many markets and refused to enter new ones.

The situation is made worse by the Administration’s announcement only days after taking office that it would not enforce the ACA’s individual mandate and the associated tax penalty. While the Administration has reversed that decision for the 2016 tax year, it is unclear what will happen next tax season.

A flawed law doesn’t mean it’s horrible

As Minority Leader Chuck Schumer (D-NY) reightfully pointed out on the last day of the vote-arama on the Republican health care plan, Obamacare is not without its flaws.

It does little to contain health care costs or improve the quality of health care provided in this country. Millions of Americans are left without insurance. Some parts of the country lack insurers.

Yet, undeniably, the ACA has done much good by providing coverage to more than 20 millions of Americans and added benefits to millions more.

Republican efforts in Congress to do away with the Obama Administration’s signature accomplishment have been rather bumpy. While Republicans may still be successful, they have certainly taken much longer than President Trump’s promise to repeal the ACA on Day One.

The verdict about the effectiveness of the Trump Administration’s effort to actively undermine the ACA is still out. Yet the efforts appear deliberate and they have been ongoing since the Administration took over the White House and the Department of Health and Human Services.

Actively seeking to bring hardship to millions of Americans by sabotaging their health coverage is certainly highly questionable from a moral and ethical perspective. Future inquiries may also prove that they are illegal.

Perhaps most concerning, in my opinion, when the President of the United States and his closest advisers consistently spread false and misleading information, Americans are bound to lose. They may not only lose their health care coverage. They may also lose trust in their government and their elected leaders, and, eventually, in democratic government itself.

SEE ALSO: A full breakdown of the dramatic 19 seconds when McCain killed the GOP's healthcare bill

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NOW WATCH: 'Where is Sean?': Things got awkward when April Ryan asked Sarah Sanders why Spicer didn’t attend the WH briefing

Democrats may be dancing on the grave of the Republican effort to repeal and replace the Affordable Care Act, but there’s a real danger that like the suckers in a horror movie celebrating the monster’s death a bit too soon they could be in for an unpleasant surprise.

But if President Trump manages to raise ACA repeal from the grave, he’ll be doing it in spite of himself.

The Senate’s failure last week to pass one of three different alternatives to the ACA that came up for votes was, no doubt, a major embarrassment to both President Trump and Majority Leader Mitch McConnell. And, as he does when frustrated or embarrassed, Trump took to Twitter in a rage that extended into the weekend.

Republicans in the Senate looked like “fools” he wrote. The institution of the Senate itself has become a “JOKE.”

On Saturday, still on Twitter, Trump crossed the line into public threats. He said that unless he is presented with legislation “quickly” that he would cut off what he called “BAILOUTS” of both the insurance industry and of lawmakers themselves. The twin threat was broadly viewed as a promise to do two things.

First, Trump seemed to be suggesting that he would cut off the cost-sharing payments to insurance companies that were created under the ACA. The payments compensate insurers for offering cheaper premiums to low-income Americans. Health insurance experts warn that cutting off the payments could cause the individual health insurance market to crash.

Second, Trump is apparently threatening the federal healthcare subsidy for lawmakers and their Capitol Hill staff. Prior to the ACA’s passage members of Congress and their staff, like most Americans, got their health insurance through their employer -- in this case, the federal government.

However, Republicans pushed for and passed a measure requiring lawmakers and their staff to buy their insurance from a health insurance exchange created under the ACA. After some wheeling and dealing, the Obama administration drafted a rule allowing lawmakers and staff to receive premium subsidies that covered a similar percentage of their health care expenses as the federal government had prior to the law’s passage. On Saturday, Trump appeared to be threatening to cut that off.

And just in case he hadn’t already alienated everyone on Capitol Hill, he renewed his call for the Senate GOP majority -- mentioning McConnell by name -- to do away with the legislative filibuster. There may be things that members of Congress hate more than a president telling them how to run the co-equal branch of government that they control. But not many.

But the good news for Trump is that there is yet another measure to do away with the ACA making its way through the Senate, and it might be able to gain the support necessary to pass.

So far, most of the efforts to undo Obamacare have fallen into one of two categories, either a straight repeal of all or most of the law with a promise to replace it later, or what amounts to a watering down of the law by tinkering with mandates, taxes, and insurance regulations.

However, South Carolina Sen. Lindsey Graham and Louisiana Sen. Bill Cassidy have been pushing a very different alternative that has several elements going for it that weren’t present in earlier proposals.

Announcing the plan in mid-July, Graham said, “In a nutshell, we’re keeping the [ACA] taxes in place on the wealthy, we’re repealing the individual mandate and the employer mandate, and the medical device tax that 75 senators voted to repeal. There’s about $500 billion in money, rather than trying to run health care from Washington, we’re going to block grant it to the states, and here’s what will happen.

If you like Obamacare, you can re-impose the mandates at the state level. You can repair Obamacare if you think it needs to be repaired. You can replace it if you think it needs to be replaced. It will be up to the governors. They’ve got a better handle on this than any bureaucrat in Washington.”

That’s about as much in the way of details that most people have seen of the Graham-Cassidy plan. But on its face, it has at least two major upsides for Republicans.

In the run up to last week’s votes, Congressional Budget Office scores of various ACA replacement plans had been the Republicans’ bane. Every time they produced a plan, the CBO would declare that it would save billions of dollars, but that it would also inevitably cause millions of Americans to lose their health insurance.

In terms of cost, the Graham-Cassidy plan would be relatively simple to score. The beauty of block grants is that they are nothing if not predictable. And if all it is doing is taking existing tax revenue and redirecting it to block grants, it’s not likely to have much impact on the budget. But it would be exceedingly difficult for CBO to estimate the impact on health insurance coverage. Because every state would be in charge of implementing its own health insurance system, which could run the gamut from keeping the ACA in place, to starting from scratch, and everything in between, an estimate with any degree of reliability would be virtually impossible.

Second, the proposal lifts the burden of responsibility from members of Congress. One of the biggest objections that Republican lawmakers had to the measures presented last week was that they created systems that, arguably, would hurt millions of Americans. The Graham-Cassidy bill creates no system at all, but rather passes the buck to the states.

This is not to suggest that the bill would face a smooth path to passage. The idea of retaining taxes imposed under the ACA would be a bitter pill for many Republicans, particularly members of the House Freedom Caucus. But Freedom Caucus Chairman Mark Meadows of North Carolina has been meeting with Graham and his supporters in order to try to find common ground, Politico reported Saturday.

And considering that the GOP is in full charge of the federal government, and is facing a logjam of must-pass legislation this fall, including a debt-ceiling increase and a new federal budget, passing something and declaring victory over the ACA is going to look increasingly appealing as the summer drags on.

SEE ALSO: GOP sends mixed messages on the future of American healthcare after suffering a blistering defeat in the Obamacare repeal effort

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NOW WATCH: 5 of the best memes from Trump's trip to the G20 Summit

WASHINGTON — President Donald Trump's threat to stop billions of dollars in government payments to insurers and force the collapse of the Affordable Care Act could put the government in a tricky legal situation.

Legal experts say he'd be handing insurers a solid court case while undermining his own leverage to compel Democrats to negotiate, especially if premiums jump by 20% as expected after such a move.

"Trump thinks he's holding all the cards. But Democrats know what's in his hand, and he's got a pair of twos," said University of Michigan law professor Nicholas Bagley. Democrats "aren't about to agree to dismantle the Affordable Care Act just because Trump makes a reckless bet."

For months, the president has been threatening to stop payments that reimburse insurers for providing required financial assistance to low-income consumers, reducing their copays and deductibles.

Administration officials say the decision could come any day.

The "cost-sharing" subsidies are under a legal cloud because of a dispute over whether the healthcare law, better known as Obamacare, properly approved the payments. Other parts of the healthcare law, however, clearly direct the government to reimburse insurers.

With the issue unresolved, the Trump administration has been paying insurers each month, as the Obama administration had done previously.

Trump returned to the question last week after the GOP drive to repeal the healthcare law fell apart in the Senate, tweeting: "As I said from the beginning, let ObamaCare implode, then deal. Watch!"

He elaborated in another tweet: "If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies...will end very soon!"

It's not accurate to call the cost-sharing subsidies a bailout, said Tim Jost, a professor emeritus at Washington and Lee University School of Law in Virginia.

"They are no more a bailout than payments made by the government to a private company for building a bomber," he said.

That's at the root of the Trump administration's potential legal problem if the president makes good on this threat.

The health law clearly requires insurers to help low-income consumers with their copays and deductibles. Nearly three in five HealthCare.gov customers qualify for the assistance, which can reduce a deductible of $3,500 to several hundred dollars. The cost to the government is about $7 billion a year.

The law also specifies that government "shall make periodic and timely payments" to reimburse insurers for the cost-sharing assistance that they provide.

Nonetheless, the payments remain under a cloud because of a disagreement over whether they were properly approved in the language of the health law, by providing an "appropriation."

The Constitution says the government shall not spend money without a congressional appropriation.

Think of an appropriation as an electronic instruction to your bank to pay a recurring monthly bill. You fully intend to pay, and the money you've budgeted is in your account. But the payment will not go out unless you specifically direct your bank to send it.

House Republicans trying to thwart the ACA sued the Obama administration in federal district court in Washington, arguing that the law lacked specific language appropriating the cost-sharing subsidies.

The district judge agreed with House Republicans, and now the case is on hold before the US appeals court in Washington. A group of state attorneys general are asking the appeals court to join in the case, in defense of the subsidies.

Both Bagley and Jost have followed the matter closely, and they disagree on whether the health law properly approved the payments to insurers. Bagley says it did not; Jost says it did.

But the two experts agree that insurers would have a solid lawsuit against the administration if Trump stops the payments. Insurers could sue in the US Court of Federal Claims, which hears claims for money against the government.

"The ACA promised to make these payments — that could not be clearer — and Congress has done nothing to limit that promise," Bagley said.

"I think there would very likely be litigation if the Trump administration tries to cut off the payments," Jost said.

Another way to resolve it: Congress could appropriate the money, even if temporarily, for a couple of years.

"Simply letting Obamacare collapse will cause even more pain," Rep. Kevin Brady, of Texas, the House Ways and Means Committee chairman, said recently.

Experts estimate that if the president makes good on his threat, premiums for a standard "silver" plan would increase by about 19%. Insurers could recover the cost-sharing money by raising premiums, since those are also subsidized by the ACA, and there's no question about their appropriation.

But millions of people who buy individual healthcare policies without any financial assistance from the government would face prohibitive cost increases.

And more insurers might decide to leave already shaky markets.

California Attorney General Xavier Becerra says Trump's tweets will bolster arguments from him and his counterparts in other states to intervene in the case.

"We need somebody who will stand up in court and defend the subsidies against the erratic nature of President Trump," Becerra said.

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JK Rowling has apologised for wrongly accusing Donald Trump of ignoring a disabled boy last week.

The "Harry Potter" author tweeted a clip of the US president, which appeared to show him ignoring a young boy in a wheelchair visiting the White House.

In a string of now deleted tweets, Rowling savaged Trump's "stunning" and "horrible" behaviour. Here is the thread in full, courtesy of Wayback Machine:

The problem? Rowling appeared not to have watched the entire news conference.

A video of the full event, posted on YouTube by the White House on July 24, shows the president bending down to greet three-year-old Montgomery Weer.

According to the Washington Post, Weer has Spina Bifida, a birth defect that prevents babies from developing their spine and can cause brain damage.

Trump and Vice President Mike Pence had given the news conference to urge Senate Republicans to repeal and replace the Affordable Care Act, or Obamacare.

They then stood in front of a group of families, including Weer and his mother, that Trump labelled Obamacare's "forgotten victims."

You can see the moment Trump greets Montgomery around the 2:20-minute mark here:

Rowling was corrected by Weer's family. Marjorie Kelly Weer, Montgomery's mother, wrote on Facebook that Trump "didn't snub [her] son" and that Montgomery was "showing off his newly acquired secret service patch," not trying to shake the president's hand.

"Good Morning Britain" presenter Piers Morgan tweeted Weer's Facebook post on 30 July.

He then used his MailOnline column on Monday to criticise Rowling's actions. He called her "the world's most aggressively self-righteous tweeter" and "a shameful, disgraceful hypocrite."

Later on Monday, Rowling acknowledged her error. The writer said she "very clearly projected my own sensitivities around the issue of disabled people being overlooked or ignored onto the images I saw and if that caused any distress to that boy or his family, I apologise unreservedly."

Rowling did not direct her apology toward Trump, and a spokesperson for the author declined to tell CNN whether she would do so.

She has also deleted her July 28 thread. The first in that series of July 28 tweets garnered more than 75,000 retweets by Monday, CNN noted. Chelsea Clinton originally retweeted Rowling's posts, but later undid the actions.

Rowling is not a stranger to Trump-bashing on Twitter. She has called out Trump for misquoting Mayor of London Sadiq Khan following the London Bridge terror attacks and encouraged anti-Trump protests if he ever visited Britain.

She also has a long running feud with Morgan.

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NOW WATCH: 5 of the best memes from Trump's trip to the G20 Summit

• The GOP effort to repeal Obamacare appears dead for now.
• One GOP senator says the party is "too divided" for a restart right now on healthcare.
• The Trump administration could seek to weaken Obamacare through a number of executive measures.

After numerous resurrections, false starts, and missteps, the Republican attempt to repeal and replace Obamacare on a straight party-line basis looks like it is truly dead.

The defeat of the attempted "skinny repeal" of Obamacare on Thursday appears to be enough to put the idea to rest for now. GOP lawmakers expressed doubts that another bill would come up, and the brutal stretch of must-pass legislation ahead on the calendar likely puts the GOP Obamacare effort on the back burner.

Nevertheless, the White House has attempted to revive the push by getting behind a plan advanced by Republican Sens. Bill Cassidy, Lindsey Graham, and Dean Heller. The plan would have shifted the funding for Medicaid and other healthcare needs to the states in a block-grant form.

According to reports, the trio met with President Donald Trump regarding the plan and brought in Rep. Mark Meadows, the head of the conservative House Freedom Caucus.

Trump used the bully pulpit of Twitter over the weekend to lay into Republicans for failing to pass a repeal and replace bill, even going so far as to call GOP senators "quitters" and threaten the healthcare of members of Congress.

But many Republican leaders have simply moved on.

Senate Majority Leader Mitch McConnell said it was "time to move on" after last week's healthcare bill failure and focus on other priorities before the Senate recesses in mid-August.

Seante Majority Whip john Cornyn, the second-highest ranking Republican, said in floor remarks on Tuesday that the way forward on healthcare was a bipartisan approach before pivoting to talk about tax reform.

Sen. Orrin Hatch, the head of the Finance Committee, told Reuters that the Republican conference was too far apart on the issue to sustain another attempt on repeal and replace.

"There’s just too much animosity and we’re too divided on healthcare," Hatch said.

And Sen. John Thune — the third-highest ranking GOP senator — told Politico's Burgess Everett and Jennifer Haberkorn that the healthcare effort is off the table.

"Until somebody shows us a way to get that elusive 50th vote, I think it's over," Thune told Politico. “Maybe lightning will strike and something will come together but I'm not holding my breath."

Additionally, the math makes any sort of revival for the repeal and replace bill nearly impossible. With Sen. John McCain gone through August for treatment on brain cancer, McConnell could only lose a single Republican vote to pass a bill. Sens. Susan Collins and Lisa Murkowski, who voted against every GOP healthcare measure, are enough to sink any push.

There's still work to be done

The US healthcare system could still see some adjustments throughout the rest of the year.

For instance, there have been repeated calls from both sides of the aisle to work on a bill that would stabilize the individual marketplace — in other words, what people think of as the Obamacare exchanges. Ideas include guaranteeing critical cost-sharing subsidies via congressional appropriation, setting up a stability fund for states to try to bring down premiums, and rolling back parts of the employer mandate.

Those could happen in separate legislation or as part of the Children's Health Insurance Program (CHIP) reauthorization, which must be passed by the end of September.

While the end of GOP-overhaul efforts could mean fixes to the Obamacare markets, it does not mean the law is free of danger.

The White House and the Department of Health and Human Services could use a variety of tactics to stir up trouble in the Obamacare markets and cause its "collapse," including yanking the cost-sharing payments, halting the enforcement of the individual mandate, and cutting off funding for key programs designed to get people into the markets.

Complicating all of this is a jam-packed schedule for Congress in the back half of the year. Before the end of September alone, Congress needs to pass legislation to avoid a shutdown, raise the debt ceiling, and reauthorize several government programs.

Throw on top of that the GOP's pivot to tax reform, which the White House wants done by the end of 2017.

A revived health bill would "take time," said Greg Valliere, chief strategist at Horizon Investments. "Lots and lots of time."

SEE ALSO: Trump is threatening a move that could make Obamacare implode and hurt lawmakers' coverage

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NOW WATCH: 'I'm used to dealing with friction': Trump’s new communications director reacts to Sean Spicer’s abrupt resignation

• California, Idaho, and Arizona joined a growing number of states saying Obamacare premiums could shoot up unless President Trump guarantees important cost sharing reduction (CSR) payments.
• Trump has threatened to yank these payments to get Democrats to the negotiating table on healthcare.
• These payments help offset costs for insurers to provide low out-of-pocket costs for poorer Americans. If they are pulled, insurers in those three states would be forced to jack up premiums in 2018 to offset the loss in funding.

In his push for healthcare reform, President Donald Trump has consistently pointed to the "collapse" of markets under the Affordable Care Act and rising healthcare costs as the main reason the law must be repealed and replaced.

But over the past two days, insurance groups in Idaho, California, Arizona, West Virginia, South Carolina, Wyoming, and several other states have shown that Trump's actions could be the biggest source of soaring healthcare costs in Obamacare markets next year.

The uncertainty Trump has created surrounding payments to bring down out-of-pocket costs has led insurers in those states to consider massive insurance premium increases for 2018, and it could cause costs for millions of Americans in the exchanges to skyrocket.

Perhaps the most stark example came in Idaho, which released its preliminary rate increases for 2018 in the state's individual insurance marketplace. The department projected premiums for Obamacare plans would increase by an average of 38% next year compared to 2017.

A significant portion of that increase, according to the Idaho Insurance Department, would be due to uncertainty surrounding Obamacare's cost sharing reduction (CSR) payments. The increases would hit mid-level, silver-tier plans particularly hard, the department said.

"The proposed increases for Silver level plans on the exchange are significantly higher this year, even more than the increases for Bronze or Gold level plans, due to the potential refusal by the federal government to fund the Cost Share Reduction (CSR) mechanism,"the department said in a statement.

What are CSR payments?

CSR payments are provided to low-income Americans on the exchanges to help offset out-of-pocket costs and mitigate possible losses for insurers. The payments are currently appropriated by the executive branch, but they became the subject of a lawsuit between the Republican-controlled House and the Obama administration. After a judge ruled in favor of the House in 2016, President Barack Obama launched an appeal in the case.

Trump, however, has the option to drop the appeal. Such a move would end the CSR payments immediately. In May, the two sides asked for a 90-day delay on the appeal.

Trump has repeatedly threatened these payments in tweets over the weekend, and senior administration officials have said a decision on the future of CSR payments would come this week.

Idaho Insurance Department Director Dean Cameron urged lawmakers to guarantee the payments and stabilize the markets.

"I call on Congress to either repeal the CSR requirement or fund the program," Cameron said in a statement Monday. "That action alone would reduce the proposed increase by at least 20% on the Silver plans."

A similar message came out of California on Tuesday, as Covered California — the department in charge of the state's Obamacare exchange — said a failure to provide CSR payments would lead to a drastic increase in premiums.

According to Covered California, a current average premium increase of 12.5% could be even higher, as much as an additional 27 percentage points. Covered California Director Peter Lee said a decision from the Trump administration about the state of CSRs for 2018 needs to come soon to endure lower costs.

"A decision by the federal government is needed in the next few weeks," Lee said in a statement. "Without clear confirmation from the administration that these payments are secured, we will be forced to have health insurance companies in California add a CSR surcharge to the Silver-tier rates."

'Critical for providing some sort of affordability'

Blue Cross and Blue Shield of Arizona also said that if CSR payments were cut off, premiums would increase.

Jeff Stelnik, senior vice president of strategy, sales, and marketing at BCBS Arizona told azcentral.com that premiums for benchmark silver-level plans would increase by 16% in 2018 compared to the year before. But if CSR payments were guaranteed, it would be "something like a flat increase across all plans."

"Continuing with cost-sharing reduction payments is critical for providing some sort of affordability in the future," Jeff Stelnik said. 

BCBS Arizona provides insurance on the exchanges in all but two counties in the state.

The states new statements follow along with states like Pennsylvania and North Carolina, both of which previously announced marketplace enrollees would see much larger premiums hikes in 2018 if CSR payments are yanked.

While the legal status of the payments is up in the air, there is a renewed push from members of Congress on both sides of the aisle to guarantee the payments and take the decision out of Trump's hands.

GOP Sen. Lamar Alexander, chair of the Senate Health, Education, Labor, and Pension (HELP) Committee, said Tuesday that the committee would consider a bipartisan bill that would seek to stabilize the markets, including guaranteeing CSR payments for at least the next year.

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NOW WATCH: 'I'm used to dealing with friction': Trump’s new communications director reacts to Sean Spicer’s abrupt resignation

The Senate voted down the Republican proposal to repeal parts of Obamacare last week, and according to a new oral history from The Washington Post, it was as tense inside the chamber as it was for people watching the proceedings.

The Post spoke to a handful of Democratic and Republican senators about the vote that, for the time being, crushed the GOP's hopes to overhaul the healthcare system.

Based on the lawmakers' comments, it's clear that Sen. John McCain's decision to join fellow Republican Sens. Susan Collins and Lisa Murkowski and vote against the GOP proposal was a surprise.

GOP Sen. Tim Scott described the lead-up to the vote as a "roller coaster" and said after "energy and the pressure was building

Two previous drafts of healthcare legislation — one that would repeal and replace Obamacare and one that would simply repeal the law — had already failed when McConnell introduced the so-called skinny repeal. The final bill was expected to be the closest to getting the needed 50 votes from Republicans, since it only repealed some parts of Obamacare.

With speeches going past midnight on Thursday over the bill, Vice President Mike Pence showed up to the Senate. Collins told the Post she expected Pence to be the tiebreaker to pass the bill in the event of a 50-50 tie, but realized that was not the case.

"Originally I had thought Vice President Pence had come over to break the tie and allow the bill to proceed,"Collins said."But it then became obvious that he was there to talk to Sen. McCain."

Democratic senator and former vice presidential nominee Tim Kaine said while Republicans tried to win over McCain, you could see "the tension level in their faces was increasing." Scott said there was a change in mood as it become clear McCain may kill the bill.

"All of a sudden I looked down from the roller coaster, and I started noticing that on my side, I could feel the shift in the room,"Scott told the Post."We were happy when we left, we were energetic, but the faster we got to the top, we realized the steep fall wasn’t going to be what we thought it was going to be, not a thrilling ride, but instead a really scary drop."

When the time came to cast their votes, Collins and Murkowski voted no as soon as they were called. McCain, on the other hand, approached the Senate clerk after the other two Republican defectors voted.

"The clerk was not looking at McCain, who was standing with his arm straight out," Kaine said. "It was like the scene from 'Gladiator' with Russell Crowe: Do you survive, or not?"

McCain signaled his "no" vote with a thumbs down, and the healthcare bill was dead.

Read the full oral history of the vote, and the whole week, at The Washington Post»

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• President Donald Trump has repeatedly threatened to cut off a key subsidy for health insurers, a move experts say could cause Obamacare markets to explode.
• A court ruled that states could intervene in a court case to keep the payments funded.
• This doesn't mean Trump can't end the payments, but it makes it harder for him to do so and would put blame for any fallout squarely on his shoulders, experts say.

It became harder Monday night for President Donald Trump to help engineer the collapse of the Affordable Care Act.

A federal court ruled that attorneys general in 17 states and the District of Columbia would be allowed to intervene in a case over crucial subsidies known as cost-sharing-reduction payments.

Health-policy experts and insurance companies often cite uncertainty over the payments as the biggest danger to the short-term future of the individual insurance markets established by the ACA, the healthcare law better known as Obamacare.

The CSR payments help reimburse insurers for providing plans with low deductibles and low out-of-pocket costs for poorer Americans on the exchanges. Over the past few months, a slew of insurers and state insurance commissions reported that without the payments, premiums on the exchanges would increase substantially in 2018.

Under Obamacare, the payments came through an executive-branch order. The unusual appropriation became the subject of a lawsuit between the Republican-controlled House and the Obama administration, with the health and human services secretary as the defendant.

In 2016 a judge ruled in favor of the House, saying the CSR payments were illegal because Congress did not appropriate them. The Obama administration filed an appeal of that decision.

Trump and his team can decide whether to continue that appeal; pulling it would effectively cut off CSR payments unless Congress were to appropriate the funds.

But on Monday, the court ruled that the 17 states and DC could intervene and continue the appeal. The court's ruling said ending the payments would be damaging to the states' citizens.

Nicholas Bagley, a professor of health law at the University of Michigan, wrote on the Incidental Economist blog that this decision by the court made it harder for the Trump administration to cut off the CSR payments.

"If the Trump administration wanted to stop making cost-sharing payments, the easiest way to do so would be to dismiss the appeal," Bagley said. "The lower court entered an injunction to stop those payments, but put its injunction on hold to allow for an appeal. If Trump were to order the appeal's dismissal, the injunction would spring into force, and the payments would end."

"Now the states can keep the appeal alive, even if Trump wants to get rid of it,"he added.

Bagley said a key element of the case — as with some court decisions surrounding the administration's travel ban— was Trump's own statements. Trump's tweets threatening to cut off the payments supported the idea that the states faced enough danger that they deserved to take up the case.

"The States have filed within a reasonable time from when their doubts about adequate representation arose due to accumulating public statements by high-level officials both about a potential change in position and the Department's joinder with the House in an effort to terminate the appeal," the court's decision said.

Bagley and Timothy Jost, a professor at the Washington and Lee University School of Law who supports the ACA, suggested the decision didn't mean Trump couldn't still try to end the payments. But the two agreed that ending the appeal would no longer be a definitive deathblow to the payments.

"The decision does not mean that the Trump administration is barred from ending the cost-sharing reduction payments," Jost wrote at Health Affairs. "It does mean, however, that the administration cannot unilaterally stop the CSR payments, dismiss the appeal, and claim judicial imprimatur for its doing so."

Trump could instruct the Justice Department to announce that it no longer thinks the payments are legal, according to Bagley, but any chaos caused by the move would fall squarely on his shoulders.

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Office of Management and Budget Director Mick Mulvaney and CNN anchor Chris Cuomo engaged Wednesday in a fiery exchange about the future of a key piece of the Affordable Care Act.

During an interview on "New Day," Mulvaney and Cuomo argued the merits of what are known as cost-sharing reduction payments.

The CSR payments help reimburse insurers for providing plans with low deductibles and low out-of-pocket costs for poorer Americans on the exchanges. Over the past few months, a slew of insurers and state insurance commissions reported that without the payments, premiums on the exchanges would increase substantially in 2018.

The future of the payments are embroiled in a lawsuit and whether to pay them going forward is essentially up to the Trump administration.

Mulvaney said the administration was deciding whether to pay for the CSR payments on a "month-by-month basis."

When Cuomo asked whether the administration thought it might be hurting people by "holding those payments hostage"— pointing to the comments from insurers about the dangers of cutting them off — Mulvaney argued that the payments made little difference, since the Obamacare exchanges were already in trouble.

"Yes, because I feel like you're dancing around the reality that you need those payments in order to stabilize the markets," Cuomo said. "And if you're holding them hostage, you're essentially putting people at risk."

"Chris, stop for a second," Mulvaney replied. "Stop for a second. These payments have been there for years. The markets are not stable."

Premiums on these exchanges have increased, though some evidence suggests it is due in part to insurers pricing plans too low in the early years of the law's implementation. A study by The Kaiser Family Foundation, a nonpartisan health policy think tank, showed the Obamacare markets have stabilized and would continue to do so in future years.

Cuomo and Mulvaney also argued about the White House's repeated attempts to discredit the Congressional Budget Office's analysis of the various Republican healthcare bills and the reasons Obamacare markets were not stable over the past few years.

"When has that ever worked in the insurance world?" Cuomo asked when Mulvaney suggest Obamacare prevented the market from bringing down insurance costs. "When have we ever seen that this free enterprise notion makes things cheaper for people when it comes to health insurance? People were crippled by the cost before the ACA. You know that." 

"Yes, I'd love to have a long conversation about what was broken with health insurance before Obamacare, what continues to be broken with insurance on Obamacare," Mulvaney replied.

"Certainly still problems," Cuomo said.

Watch the exchange:

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John McCain is enjoying high levels of approval from many voters — just not those in his own party.

McCain's vote, along with fellow Republicans Susan Collins and Lisa Murkowski, helped kill the Republican push to overhaul the US healthcare system last week. And it appears Democrats now appreciate the Arizona senator much more than Republicans.

A new Quinnipiac poll showed 39% of Republican voters held a positive view of McCain and 49% held a negative view. By contrast, Democratic voters hold a 74% positive view of McCain compared to 18% negative, for a plus-56 net rating.

Overall, the poll showed McCain has a net plus-25 favorability rating from all people surveyed — 57% positive to 32% negative.

McCain's return to Washington just a week after announcing a brain cancer diagnosis helped Republicans bring their various Obamacare repeal plans to the floor of the Senate for a vote. McCain voted for a bill to repeal and replace Obamacare called the Better Care Reconciliation Act, but against both a repeal-only and "skinny" repeal bill.

The vote against the "skinny" repeal bill sank the Republican hopes of getting any sort of legislation passed.

McCain argued the bill would not bring down costs or improve care for Americans. He also criticized the party-line approach the GOP used to try to pass the bill.

According to the Congressional Budget Office, the skinny repeal bill would have resulted in 16 million more uninsured Americans by 2026 than under the current baseline.

Collins and Murkowski have also gotten approval following their votes. Collins was applauded in the airport upon her return to Maine, while more than 200 people showed up for a "Thank You Lisa" rally in Alaska for Murkowski.

Lawmakers have begun considering bipartisan approaches to shoring up Obamacare marketplaces instead of trying to overhaul the law.

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Two high-profile insurers said they would make changes to their Obamacare-related business next year, adding to the uncertainty surrounding the future of the law formally known as the Affordable Care Act.

Molina Healthcare said it would exit the Obamacare individual insurance exchanges in Utah and Wisconsin due to lagging financial performance.

"Looking back on our involvement in Wisconsin and Utah, the populations in those states were probably not significant enough to move the needle for the company in a positive way," CEO Joseph White said during the company earnings call Wednesday. "The cost experience certainly moved it in a negative way. But, frankly, I think the markets there were just so small as to just not offer a lot of upside."

Molina, which has been relatively successful on the exchanges, is in the midst of a restructuring after firing its CEO and CFO in May. Both of the executives were sons of Molina founder David Molina.

White did say there were some exchanges were positive contributors to Molina's bottom line, but the company is reviewing all of its marketplace offerings to make sure it is being as efficient as possible.

"There's no doubt performance in Texas has been very nice," White said. "Performance in some of the smaller states, Michigan and New Mexico, has been nice. California has been okay. Florida, though, has not been a good market for us. We're going to have to look closely at it."

In addition to the Molina news, insurance giant Aetna said Thursday that it would not offer 2018 exchange plans in Nevada — the last market where it was considering offering Obamacare plans. The firm filed to potentially offer plans in the state back in June.

The company's CEO, Mark Bertolini, said in an earnings call that the company was terminating a Medicaid contract with the Nevada government due to low enrollment. Insurers in a state's Obamacare exchanges typically receive some breaks in the Medicaid market, so without the Medicaid contract, there was little reason to continue to offer exchange plans.

"Our 2018 participation was required based on a Medicaid contract with the state," TJ Crawford, an Aetna spokesperson, told Business Insider in an email. "As a result of terminating that contract for unrelated reasons, we will not have a presence on the individual exchange in Nevada, and will have no on-exchange presence anywhere in 2018."

Aetna was only planning to offer plans in a handful of counties in the state, none of which were the potentially bare rural counties, making the scrapped plans mostly a symbolic blow.

But the moves come as the future of Obamacare continues to be in doubt. Weak financial performance has led to many major insurers to pull out of the exchanges over the past two years, raising doubts over the future of the marketplace. However, a recent study by the Kaiser Family Foundation, a nonpartisan healthy policy think tank, found that for the insurers that remain the markets are stabilizing and that profits should begin to materialize.

Despite this, numerous insurers and state insurance commissions have cited uncertainty over future policy from the Trump administration and Congress as a reason to exit the exchanges or raise prices.

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The Republican push to overhaul the US healthcare system has taken a toll on Sen. Jeff Flake's popularity, according to a new poll.

The poll, from the Democratic firm Public Policy Polling, found that the Arizona senator's support of the GOP's healthcare push had hurt voters' opinions of him.

Overall, 52% of Arizona voters surveyed for the poll said they were less likely to vote for Flake in his 2018 reelection bid because of his vote in support of the various Republican plans. Twenty-six percent said they were more likely to vote for him because of the vote, and 20% said it made no difference.

Just 31% of those surveyed said they would vote for Flake if the election were held immediately, compared with 47% saying they would vote for a generic Democratic opponent. No Democrat has announced plans to run for the seat.

The poll also found that 62% of Arizonans disapproved of Flake's performance, while only 18% approved.

In contrast, Flake's fellow Republican Arizona senator, John McCain, voted against the latest Republican effort to repeal the Affordable Care Act, derailing the GOP healthcare efforts but drawing positive reviews from his state's voters. Fifty-four percent said they approved of McCain's vote, while 40% said they disapproved.

The poll provided some of the first concrete evidence that some GOP members could get dinged for voting in favor of the healthcare push. It may not come as much of a surprise, since the Republican healthcare bill was among the least popular pieces of legislation in decades.

Democrats are capitalizing on the public's distaste for the Republican plans. Rep. Jacky Rosen, the Democratic challenger to Sen. Dean Heller of Nevada in 2018, is already running ads about Heller's vote for the Republican healthcare bills.

Heller originally came out against Senate Republicans' first bill, the Better Care Reconciliation Act, but supported later plans laid out by Senate Republican leadership.

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George Stephanopoulos, the host of ABC's "This Week," put Kellyanne Conway on the spot Sunday morning when the senior White House adviser tried to change the subject from President Donald Trump's role in crafting a misleading statement about his son's meeting with a Russian lawyer last year.

Stephanopoulos said the White House and Trump's surrogates had given conflicting statements about how involved the president was in responding to initial reports that Donald Trump Jr. met in June 2016 with the lawyer, Natalia Veselnitskaya. Paul Manafort, then the campaign's chairman, and Jared Kushner, the president's son-in-law who is now a senior adviser, were also at that meeting.

When Stephanopoulos pressed her on the discrepancy in the statements and said the White House "didn't tell the truth," Conway pivoted to the Affordable Care Act.

"Let's talk about telling the truth," Conway said. "Let's talk about a president looking Americans in the eye, who are still suffering eight years later, who were lied to. If you like your plan, you can keep your plan. If you like your doctor, you can keep your doctor."

Conway then shifted to the Obama administration's response to the 2012 attack on the US diplomatic compound in Benghazi, Libya.

"Benghazi happened because of a video," she said. "Go tell the families of those four innocent Americans who were slaughtered in Benghazi that that lie mattered."

"Hold on a second," Stephanopoulos interjected. "You're changing the subject."

"No. No. That is a subject," Conway replied. "Let's talk about credibility that impacts people."

Stephanopoulos said Conway was "going back to President Obama and Hillary Clinton," to which she replied that "those were big lies."

When Stephanopoulos continued grilling her on the different responses offered by the Trump administration about Trump Jr.'s meeting, Conway did not address the question, and she later called the FBI's counterintelligence investigation into whether the Trump campaign colluded with Russia to influence the 2016 election "fabricated."

Watch the exchange:

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Senate Majority Leader Mitch McConnell said he thought of one person when the long-held Republican promise to repeal and replace Obamacare went up in flames: Hillary Clinton.

The Louisville, Kentucky-based NPR affiliate WFPL reported McConnell told attendees of Fancy Farm — an annual Kentucky event — that he took solace in the fact that Clinton wasn't president following the stunning defeat of the Senate plan to repeal Obamacare.

"I choose not to dwell on situations where we come up a little bit short," McConnell said, according to WFPL.

"Even on the night when we came up one vote short of our dream to repeal and replace Obamacare, here’s the first thing I thought about: Feel better, Hillary Clinton could be president."

Despite controlling the House, Senate, and White House, the GOP failed to deliver on the "dream" after months of debate on a variety of plans that formed serious divides within the party.

The final blow came from Republicans in the Senate, who came up short on various healthcare proposals. Following the defeat of a full-blown repeal-and-replace plan and a wholesale repeal-only bill, three GOP senators — Susan Collins, Lisa Murkowski, and, most dramatically, John McCain— all voted against the so-called "skinny repeal" plan that would have eliminated certain aspects of Obamacare.

The failure appears to be the death blow for the GOP's aspirations of passing a repeal-and-replace bill. Most senators have moved on discussing possible bipartisan fixes for Obamacare or shifted to other issues, like tax reform, the budget, and the debt ceiling.

Clinton had a similar failure on healthcare healthcare during her tenure as first lady, when she took the lead on reform efforts but saw her proposal was defeated by Republicans in Congress.

SEE ALSO: A vulnerable Republican senator just got brutal poll numbers after his vote on the Republican healthcare bill

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NOW WATCH: 'I'm used to dealing with friction': Trump’s new communications director reacts to Sean Spicer’s abrupt resignation

Sen. Orrin Hatch is ready to move on from the Republican healthcare debacle.

The Utah senator and chair of the Senate Finance Committee told Politico in a story published Monday that the GOP botched its chance at any repeal and replace of Obamacare for now.

And he had a colorful way of saying it is time to move on to tax reform.

"We’re not going back to health care,"Hatch told Politico. "We’re in tax now. As far as I’m concerned, they shot their wad on health care and that’s the way it is. I’m sick of it."

Hatch's sentiments have been echoed by other Republicans, who are now turning attention to tax reform and must-pass legislation like the budget and an increase in the nation's debt ceiling.

Senate Majority Leader Mitch McConnell has said it is time for Republicans to "move on" from healthcare and focus on other issues.

Hatch's remark that Republicans "shot their wad" on healthcare drew the attention of social-media users, leading to a clarification Hatch's office. His office said Hatch was referring to Civil War era nomenclature.

"As few of you were alive during the Civil War, here's a valuable jargon lesson on 'wads' and the shooting of them," Hatch's office tweeted, along with a screenshot of the dictionary definition.

Matt Whitlock, Hatch's communications director, joked that the quote was in reference to the Civil War because that's when Hatch, 83, entered the Senate. He also tweeted a link to a Washington Post article entitled "Respectable uses for 'shooting your wad.'"

Hatch's comments reveal a growing sentiment among higher-ranking members of the GOP caucus: that the divisons that plagued the debate over the Better Care Reconciliation Act (BCRA) will likely not be solved anytime soon.

Instead of toiling over differences, Republicans want to instead focus on tax reform, where there is broader agreement within the party.

But the strategy of moving on has been complicated by the fact that President Donald Trump and many in the administration are continuing to pressure Republican lawmakers to complete some sort of Obamacare repeal, to the chagrin of some GOP leaders.

SEE ALSO: A vulnerable Republican senator just got brutal poll numbers after his vote on the Republican healthcare bill

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Nevada's Division of Insurance said Monday that Anthem, the largest provider of Blue Cross Blue Shield plans in the country, would pull out of the state's 2018 individual insurance exchanges under the Affordable Care Act.

Anthem will no longer offer plans in the three counties in which it was planning to participate next year. The insurer had already announced in July plans to exit 14 rural counties in Nevada.

The newest round of departures in Clark, Washoe, and Nye counties will not leave additional Nevadans without an option on the Obamacare exchange for 2018. (The earlier exits have left those 14 counties with no options on the Obamacare marketplace next year.)

"While the Division is disappointed in Anthem’s latest decision regarding its withdrawals, we believed that it was in the interest of the Nevada public to let consumers know about the Anthem decision as soon as possible," Barbara Richardson, Nevada's insurance commissioner, said in a statement.  "The Division is continuing to work with our state partners on attracting an insurance carrier to serve the 14 bare counties and to support the stability of the market for those insurance carriers who remain."

Richardson also cited rising costs and uncertainty surrounding the Trump administration's decision regarding key payments to insurers, known as cost-sharing reduction (CSR) payments, as reasons for Anthem's exit.

"Based on the rate submissions the Division of Insurance received from Anthem, they proposed an average rate increase of 62%," Richardson said. "This proposed rate increase did not reflect the potential elimination of payments to insurance carriers for Cost Share Reductions (CSRs). Loss of the Cost Sharing Reduction payments has the potential to increase further rates in the Nevada market."

In a statement, Anthem pointed to enrollment and policy uncertainty over CSRs and the possibility the Trump administration stops enforcing the penalty for not buying insurance as reasons to leave the state.

"Today, planning and pricing for ACA-compliant health plans has become increasingly difficult due to a shrinking and deteriorating individual market, as well as continual changes and uncertainty in federal operations, rules and guidance, including cost sharing reduction subsidies and the restoration of taxes on fully insured coverage," the statement said. 

Insurers are facing an end of August deadline to lock in rates for most states next year, and contracts for 2018 exchange offerings must be locked in by the end of September.

Nevada is perhaps worst off of all states in terms of outlook for Obamacare's future. Wisconsin, Ohio, and Indiana each have a single county without an insurer, but the widespread blank spots for Nevada require a more large-scale fix.

Health policy experts have described counties with no insurers described as the "worst-case scenario" for the Obamacare markets. There is no back-up plan for empty counties, so if the state government can't convince another insurer to step in, anyone with coverage through those exchanges would likely go without it in 2018.

Anthem's moves come despite relative support from Republican Gov. Brain Sandoval for the exchanges and for more people getting covered through Obamacare. Sandoval was a staunch opponent of every proposal congressional Republicans put forward to repeal and replace Obamacare.

Perhaps most importantly, the future of Nevada's Obamacare market could also become a major sticking point during GOP Sen. Dean Heller's re-election bid in 2018. Democrats have identified Heller's seat as a possible pick up and given the map for the midterm elections, it could be one of the most hotly contested races next year.

SEE ALSO: Obamacare just got a one-two punch of bad news

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Sen. Dean Heller of Nevada's tough road to reelection was hit with a new twist Tuesday.

Danny Tarkanian, a Nevada businessman and perennial political candidate, announced on "Fox & Friends" Tuesday that he would mount a primary challenge to Heller in 2018.

Tarkanian has run for office in Nevada five different times for a variety of offices. His latest bid in 2016 for the seat in Nevada's 3rd congressional district came up just shy. Tarkanian lost by about 1 point to Rep. Jackie Rosen, who is Heller's most likely Democratic opponent for the Senate seat.

During his announcement on "Fox & Friends," Tarkanian said that he is running because Heller wavered in his support of President Donald Trump in the 2016 election, something that has continued during Trump's tenure.

"We're never going to make American great again unless we have senators in office that fully support President Trump and his America first agenda," Tarkanian said on the show, which Trump has been said to watch frequently.

"Dean Heller wasn't just one of the first 'Never Trumpers' in Nevada, he was one of the most influential. He actually helped Hillary Clinton win the state of Nevada," Tarkanian said.

Tarkanian pointed to Heller's record on the Senate Republican effort to repeal and replace Obamacare. Heller came out strongly against the GOP bill, the Better Care Reconciliation Act (BCRA), in a press conference the day after it was released.

Heller eventually voted for another Republican healthcare plan, but Tarkanian said the damage was already done.

"Even after President Trump has been elected, Dean Heller has obstructed his agenda," Tarkanian said on Fox News. "That grandstand press conference he had derailed any momentum to get the healthcare bill repealed. We need people who will support the America first agenda and I will be that person."

A pro-Trump PAC initially created ads to attack Heller for his opposition to the bill, a move that drew the ire of Senate Majority Leader Mitch McConnell, who asked the White House to get the ads pulled.

Heller already faces a stiff challenge from Rosen, his likely general election opponent, in a state won by Hillary Clinton. Tarkanian's entry could make Heller look to move to the right.

Tarkanian's announcement came on a morning when Trump retweeted clips or stories from "Fox & Friends" three times. But even as Tarkanian looks for backing from the president, he will likely face resistance from Republican congressional leadership. A super PAC associated with McConnell plans to back Heller in 2018.

Watch Tarkanian's announcement here:

SEE ALSO: A key state's Obamacare markets are facing a nightmare scenario

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