Tag Archives: Health Policy

The real losers of Republicans’ latest repeal plan

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https://www.vox.com/policy-and-politics/2017/7/26/16028584/skinny-repeal-obamacare-losers

Senate Republicans have struggled for months now to find a plan to repeal and replace Obamacare that their 52-member caucus can get behind. Their latest plan, which began taking shape early Tuesday, is to simply repeal the individual mandate and a few other regulations — a strategy since dubbed “skinny repeal.”

It would hurt some American health care consumers in a very different way than previous GOP bills would have.

The losers of a skinny repeal bill, should it pass, are the middle-income Americans who purchase coverage on the individual market. Many of the Obamacare enrollees I’ve interviewed in Southeastern Kentucky, an area that predominantly voted for Trump, fall into this category.

Repealing the requirement that all Americans purchase insurance would cause premiums to rise 20 percent, the Congressional Budget Office estimates. The nonpartisan office projected that 15 million fewer Americans would have coverage when it analyzed a bill very similar to skinny repeal in 2015.

“Eliminating the mandate would likely result in lower coverage rates in the individual market and a deterioration of the risk pool,” the American Academy of Actuaries projects. “Premiums would increase as a result.”

This has the potential to wreak havoc on the individual market. Insurance plans would be reticent to sell on a marketplace where they have to offer coverage to all applicants, but healthy people have no requirement or incentive to purchase.

Premiums would likely rise as only the sickest patients continue to purchase coverage. This could put health insurance out of reach for many who would like to buy, but feel the ever-increasing premiums are a bad deal.

Skinny repeal would, somewhat surprisingly, keep the Medicaid program safe. This is a sharp departure from the other Republican health care plans, such as the House-passed American Health Care Act, which cut hundreds of billions of dollars from the program.

The losers of skinny repeal are middle- to even high-income Obamacare enrollees. Some supported Trump. Some didn’t. All would face a less-functional health insurance market should skinny repeal become law.

Skinny repeal hits those who rely on the Obamacare marketplaces

When I think of who skinny repeal disadvantages, I think of someone like Debbie Mills. She’s an Obamacare enrollee who owns a furniture store in Kentucky, and who supported Trump in the 2016 election.

Mills likes her health coverage. This year, she pays a $280 monthly premium for a plan that covers herself, her husband (who was on a waiting list for a liver transplant when we spoke), and her 19-year-old son. She heard the president talk about Affordable Care Act repeal but didn’t think he would actually follow through on taking away health insurance.

Mills has a high enough income that she does not qualify for Medicaid expansion. She is somewhat shielded from premium increases because of her tax credit, which only requires her to spend a certain percentage of her income to purchase a mid-level health plan. Once she kicks in that amount, the federal government pays the rest.

But Mills relies on a functional health insurance market, one where plans want to sell coverage — and skinny repeal makes it a lot harder for a market like that to exist. Health insurance plans are not enthusiastic about selling coverage in a market where only sick people buy coverage.

The result of skinny repeal, then, could be health plans quitting the marketplaces — or premiums rising dramatically. If Mills ever wanted to upgrade to a more robust plan, for example, she would have to pay a good chunk of that premium increase. The subsidies only limit her premium for a mid-level plan (known as a silver plan on the marketplace, which covers 70 percent of an average enrollee’s costs).

Skinny repeal would hit some of Mills’s neighbors in Southeastern Kentucky. This includes Clifford Hoskins, a 62-year-old retired coal miner who buys coverage on the marketplace, or Bobbi Smith, also 62, who owns an antique store and has used her plan for breast cancer treatment. All rely on the marketplace, not Medicaid expansion. So if insurers leave the marketplaces, scared off by the expected exodus of healthy enrollees, they’re going to be left with no options to purchase coverage.

The people who stand to lose a lot in skinny repeal are also people like Juliana Pieknik, a PhD student in Maryland who I interviewed last fall. When we spoke, Pieknik was earning $42,000, which is just slightly too much to qualify for tax credits where she lives.

Pieknik is by no means getting wealthy on a graduate student salary. But her income makes her just slightly too high-earning to qualify for a tax credit to purchase insurance. This means she’s responsible for her entire premium regardless of how much it goes up.

Under skinny repeal, Pieknik could decide to skip coverage and there would be no penalty. But there would be plenty of risk should some kind of medical emergency arise when she didn’t have coverage.

The surprise winners of skinny repeal would be Medicaid enrollees

Medicaid has never been thought to be a program with much political clout. It has a less-connected, lower-income enrollee population than Medicare, which covers the old.

But Medicaid has proved to be a shockingly resilient program throughout the Obamacare repeal and replace process. Notably, moderate Republican senators have vociferously protested cuts to Medicaid — refusing to support the Senate health bill over it, in some cases — while barely speaking about the cuts to subsidies in the individual market.

This has led to the somewhat surprising outcome where the Senate Republican’s latest attempt at repeal is one that doesn’t touch Medicaid at all, but instead focuses its sights on the individual market. It makes changes that will disadvantage higher-income Obamacare enrollees the most, especially those who earn too much to qualify for subsidies, and hurts the lowest-income patients the least.

Skinny repeal would let Medicaid expansion continue untouched in the 30 states that currently participate in program. For a party that has often pushed big cuts to large welfare programs, the “compromise” position in the Senate is one that leaves Medicaid off the table — but one that has clear losers among Obamacare’s higher-income enrollees.

The Senate’s Skinny ACA Repeal Shell Game

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https://www.americanprogress.org/issues/healthcare/news/2017/07/26/436740/senates-skinny-aca-repeal-shell-game/

As the Senate continues to hold votes on repeal of the Affordable Care Act (ACA), it appears more and more likely that Senate leadership plans to offer a “skinny” version of ACA repeal as the final version that senators must vote on. This version would reportedly repeal the individual and employer mandates and the medical device tax.

This plan is simply a feigned retreat; the Republican leadership’s end game most certainly includes cutting financial assistance for people buying insurance in the individual market, ending the ACA’s Medicaid expansion, and capping federal support for the remaining Medicaid program. Both the House-passed American Health Care Act (AHCA) and the Senate-introduced Better Care Reconciliation Act (BCRA) include these draconian changes.

If senators fall for this maneuver and pass the skinny ACA repeal bill, a limited number of senior senators and their counterparts in the House of Representatives would then meet in a conference committee, during which they would make changes to the House and Senate-passed versions of the ACA repeal legislation so that both versions are identical. At that point, Republican congressional leaders could execute their plan to re-insert provisions that lower financial assistance, end the Medicaid expansion, and cap support for the program. The version approved by the conference committee would then be voted on by both the House and the Senate, with no opportunity for further changes or amendments. If the bill passes, it would then go to the president for signature into law.

But the skinny repeal bill alone—without the reinsertion of provisions from the AHCA and the BCRA—would still have devastating effects on health insurance coverage if it became law. It would jeopardize consumer choice in the individual market by creating chaos and uncertainty for issuers in the marketplace and increasing premiums.

Based on a Congressional Budget Office (CBO) analysis, the Center for American Progress estimates that the so-called skinny bill would raise premiums $1,238 higher than it would otherwise be under current law. The benchmark premium for a 60-year-old, for example, would be about $2,014 higher in 2018 under mandate repeal. Among states, these increases would be highest in Alaska because of its already-high premium levels.

Consumers who were not subsidized, including those who buy their coverage outside the marketplaces, would pay the full premium increase from mandate repeal. For consumers eligible for subsidies, any 2018 premium increase would largely be mitigated by increased premium tax credits, and therefore borne by taxpayers.

Because insurers must finalize their 2018 rates in just a few weeks, any further changes to the market rules for 2018 could force some to withdraw altogether. The repeal bill poses an even greater risk in states with fewer insurers offering plans in the individual market. In 2017, for example, there was just one insurer offering marketplace plans each county throughout Alaska and Arizona. Many counties in other states, including Colorado, Nevada, Utah, and West Virginia, also have just one insurer. Given the uncertainty created by congressional action on repealing the ACA and the administration’s repeated actions to sabotage the law, insurers remain very nervous about participating in the marketplaces next year. As of July 26, 2017, four counties in Indiana, 14 counties in Nevada, and 22 counties in Ohio were at risk of having no insurer in the marketplace in 2018.

Voting for the skinny repeal bill authorizes Senate Majority Leader Mitch McConnell (R-KY) and other opponents of the ACA to finalize in secret an ACA repeal bill that will harm millions of Americans. Senators should not fall for this political maneuvering.

Methodology

To estimate what average premiums would be next year, we used information on the 2017 average premium and inflated it to 2018 rates. Among states that reported average 2017 premiums to the Centers for Medicare and Medicaid Services, the average was $471 per month, or $5,652 annually. To estimate premiums for a 60-year-old, we started with the U.S. Department of Health and Human Services report on state average benchmark silver plan premiums and then adjusted those averages to reflect premiums for a 60-year-old. Average premium and benchmark premium data were not available for all states.

Under implementation of the ACA, including continued payment of cost-sharing reductions and enforcement of the individual mandate, premium increases next year would reflect mostly increases in medical trend. The consultancy Oliver Wyman predictsthat premiums should rise about 8 to 11 percent in 2018. We used the midpoint of this prediction, 9.5 percent, to estimate 2018 average and benchmark premiums. To apply the CBO’s estimate that premiums would increase by 20 percent relative to current law, we applied that increase to expected 2018 premiums under the ACA implementation. We estimate that without the mandate, the national average marketplace premium would be $7,427 next year, $1,238 higher than it would otherwise be.

Senate debate day 2: A resounding no for Affordable Care Act ‘repeal and delay’

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http://www.fiercehealthcare.com/healthcare/senate-debate-day-2-a-resounding-no-for-affordable-care-act-repeal-and-delay?mkt_tok=eyJpIjoiTVRnMU1UVTNORGsxTVdReSIsInQiOiJZV0xxNFBCM3VtMkF3NitxR2tUNCthXC84cnZUdmxMenQyblJVYUNQZFljZmEzN29qV1wvSDhnZVloeFhjdDZONXQwXC9lRFRacHBqeTZZMEcrSDhHQTBMOWNoNnZFZytqUlk4NGs4MUFNU0FPNHh5Z09TT0RpYStqWFdocUdMczFvWCJ9&mrkid=959610&utm_medium=nl&utm_source=internal

Congress

During the second day of debate over plans to replace the Affordable Care Act, the Senate voted down a motion to repeal President Barack Obama’s signature legislation in two years while lawmakers worked on a replacement plan.

The 45-55 vote, originally scheduled for 11:30 a.m., was delayed to 3:30 p.m. following approximately six hours of debate Wednesday on the Senate floor. A majority vote was needed to move forward with the plan.

The repeal-and-delay plan, sponsored by Sen. Rand Paul, R-Ky., was modeled after legislation that both the House and Senate approved in 2015 before it was vetoed by President Obama. It would have kept the ACA in place for two years, after which time it would have removed Medicaid expansion, the individual and employer mandates, marketplace subsidies and the marketplace exchanges, as well as taxes on the wealthy and the healthcare industry, but it kept pre-existing conditions protections. It also included an amendment (PDF) by Sen. Mike Enzi, R-Wyo., which would have banned people from using subsidies to buy insurance plans that cover abortions.

Other amendments up for consideration

The Senate has approximately 12 hours left to debate proposals over the next two days. Shortly after the repeal-and-delay motion failed, they took up a vote on an amendment sponsored by Democrats to send the bill back to committee so that both parties would be able to work together on a replacement plan. That motion failed on a 48-52 vote. The Washington Post reports that senators will likely next take up bills for a “skinny” repeal and the Graham-Cassidy amendment. Hundreds of other amendments could be presented to stall a vote, Business Insider reports.

The “skinny” repeal would roll back the ACA’s individual mandate, the employer mandate and a tax on medical devices. Although they are among the healthcare reform law’s least popular mandates, the American Academy of Actuaries warns that repeal would lead to increased premiums, increased federal government costs for premium subsidies and insurance losses and solvency issues.

The Graham-Cassidy amendment proposes to repeal the individual and employer mandates and medical devices taxes under the ACA and keep requirements for pre-existing conditions. It would also keep the ACA’s taxes on the wealthy but give those funds in the form of block grants to states to administer their own health insurance programs.

Democratic senators, including Senate Minority Leader Chuck Schumer, D-N.Y., warned during the debate Wednesday that the skinny or scaled-back version of repeal is the Republican senators’ attempt to pass some sort of legislation that would lead to a full repeal. “Make no mistake about it,” Schumer said, “the skinny repeal is equal to a full repeal. It’s a Trojan horse designed to get the House and Senate into conference where the hard-right flank of the Republican caucus, the Freedom Caucus, will demand full repeal or something very close to it.”

He likened the idea for a conference with the House to a game of “hot potato” where the Republican leader in the Senate would pass the potato to the House, and the House leader would hand it back to the senate leader. “Neither wants to be responsible for what is inevitable, the demise of TrumpCare,” Schumer said.

But at the beginning of the debate on Wednesday, Senate Majority Leader Mitch McConnell said he expects the Senate to consider many different proposals and ultimately agree on legislation that will effectively end the ACA. “This certainly won’t be easy,” he said; “hardly anything in this process has been. But we know that moving beyond the failures of Obamacare is the right thing to do.”

Why There’s No Substitute for the Individual Mandate

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http://www.commonwealthfund.org/publications/blog/2017/jul/no-substitute-for-the-individual-mandate?omnicid=EALERT1248041&mid=henrykotula@yahoo.com

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Republicans seeking to replace the Affordable Care Act (ACA) are finding it difficult to eliminate its individual mandate while maintaining protections for people with preexisting conditions. The mandate has succeeded in keeping young, healthy people in the insurance market. The alternatives under consideration won’t accomplish that and would cause some people harm.

Protections for people with preexisting health conditions can destabilize health insurance markets because these protections encourage people to sign up for coverage only when they need care. The ACA addresses this by requiring those who can afford it to buy insurance even if they’re not sick and imposing a penalty on those who fail to make timely coverage purchases. The mandate has been quite effective because people may or may not believe they will need health insurance, but they can be sure they will have to pay a penalty at tax time if they don’t purchase it.

The ACA’s mandate worked. Although some have argued the law’s penalties are insufficient, the evidence indicates that they did lead young, healthy people who could afford coverage to buy insurance. In 2013, just before implementation of the ACA reforms, the uninsured rate among college-educated men ages 26 to 34—the group most likely to be able to afford coverage but not see it as a priority—was 6.9 percent. By 2015, during the first full year of the mandate, that rate had dropped to 3.8 percent, a decline of 45 percent (Exhibit 1).

Republican proposals would replace the individual mandate with provisions that penalize people who don’t maintain continuous coverage, either by forcing them to pay a premium surcharge when they do sign up for coverage (House plan), or forcing them to wait six months for coverage (Senate plan). These proposals would therefore replace the ACA’s modest but predictable assessment with larger but far-off, uncertain penalties for not buying coverage.

Studies over more than half a century consistently show that in most situations people are more responsive to immediate and certain consequences than they are to far-off, uncertain ones.1 That result is even stronger in the context of our fragmented health care system. For the Republican penalties to encourage continuous coverage, people must believe there’s a good chance they’ll face consequences if they delay purchasing insurance. But in our health care system, they know they probably won’t.

In the individual insurance market, prior to the ACA’s reforms, penalties for delaying insurance were large, far-off, and uncertain—as in the current Republican proposals. Just as in the current Republican proposals, coverage in the nongroup market before the ACA was guaranteed renewable, meaning that once in the market, people could continue to obtain coverage at prices that did not reflect changes in their health status. But before the ACA, when people first entered the nongroup market after being uninsured, insurers could lock out those with health conditions, exclude preexisting conditions, or charge any level of premiums they wanted. Those very costly consequences ought to have provided a strong inducement to avoid breaks in coverage. But the reality is that very few people actually faced those consequences. Over a seven-year period, just 15 percent of those who lost their health insurance coverage ultimately made their way to the individual market (Exhibit 2). Instead, most people who switched coverage eventually moved to employer plans (as policyholders or dependents) or to Medicaid or Medicare, which have few penalties for delaying the purchase of insurance.

This is especially true for young people. Not only are these “young invincibles” less likely to believe they need health coverage, they assume that if they do eventually want it, they will be able to get it outside of the individual market. From 2003 to 2009, about 23 percent of those ages 55 to 63 with a change in coverage eventually entered the individual market. Just 12 percent of those ages 25 to 34 did so. Most young adults who had been uninsured eventually gained coverage through an employer plan. That’s a big reason why the large, but far-off and uncertain, penalties in the pre-ACA market were never enough to encourage many young, healthy people to sign up for individual coverage—and why the ACA mandate, by contrast, prompted so many of them to sign up.

The Republican penalties are not just likely to be ineffective in encouraging people to make timely insurance purchases. As with any arbitrary penalty, their burden would disproportionately fall on some people. Before the ACA, some unlucky people who lost coverage assumed they’d regain it through a job or public program, but guessed wrong. While uninsured, they became ill or got injured. Some may then have paid exceptionally high premiums for individual coverage, many went without care, and still others paid their health care costs out of pocket. In that last group were nearly 150,000 people who became uninsured each year and incurred more than $20,000 in out-of-pocket medical expenses; 20,000 of them incurred over $50,000 in expenses. That’s a hefty price to pay for an unlucky choice.

The Republican proposals to replace the individual mandate with large but uncertain penalties would leave us in the worst of both worlds: high prices for those who do participate in the market and hefty punishments for those who are unlucky. The proposals won’t persuade young, healthy people to enter, and help to stabilize, the individual market. And they will leave some unlucky people who gambled wrong, held off buying coverage, and got sick to face exorbitant costs.

 

Which health-care plans the Senate is voting on (and who to watch) – The Devils in the Details

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https://www.washingtonpost.com/graphics/2017/politics/health-care-senate-amendment-votes/?_hsenc=p2ANqtz-9dWlaC8TtZzkZPj6QCpBHm1Tyb397C6DlKWalIJoa9zuOb40kntqoSSZfy9SzbZdkgNo_-N7Mx-yHItRglqD2QPbFT4A&_hsmi=54638652&utm_campaign=KHN%3A%20First%20Edition&utm_content=54638652&utm_medium=email&utm_source=hs_email&utm_term=.1cc57d27b7d8

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Senate Republicans opened debate on their health-care bill on Tuesday, but the devil’s in the details.

The Senate is considering a series of amendments to the House’s health-care bill. But don’t let the name fool you; many of these amendments would actually replace the entire House bill with an alternative plan. If the amended bill does pass, it will either be reconciled with the House bill in a conference committee or return to the House for an up-or-down vote.

Here are some of the most significant amendments we expect to come up:

‘Skinny repeal’ could be the Senate’s health-care bill of last resort

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https://www.washingtonpost.com/news/powerpost/wp/2017/07/25/skinny-repeal-could-be-the-senates-health-care-bill-of-last-resort/?tid=hybrid_collaborative_1_na&utm_term=.0d728e0d1595

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As the Senate prepared Tuesday to take a first-step vote on ill-defined Republican plans to go after the Affordable Care Act, a new phrase entered the lexicon of the debate: “skinny repeal.”

In substance, this plan would repeal just three parts of the ACA, according to several sources familiar with the approach. It would eliminate the requirement that most Americans carry health insurance as well as the requirement that employers with at least 50 full-time employees offer coverage to their workers. Both are central elements of the 2010 health-care law and its least popular aspects with the public.

The “skinny” plan also would rescind the tax on medical devices, one of several taxes the ACA created to help pay for other elements of the law.

A close variant of this surfaced two years ago in the House, as part of the GOP’s strategy back then to lower federal deficits. Congressional budget analysts estimated at the time that 15 million fewer Americans would have insurance coverage “most years” as a result.

For Republicans now in the Senate, the purpose is as much tactics as policy: A slimmed-down repeal plan would essentially be a placeholder bill. The idea would likely surface on the Senate floor as an amendment later this week if the chamber has been unable to pass a fuller demolition of the law. It would buy the Senate’s GOP leaders more time because any bill they successfully push through their chamber would lead to a conference committee with the House, which this spring passed its own anti-ACA legislation.

Negotiations between lawmakers of the two chambers could then continue past Congress’s August recess, preserving the ability of Senate Majority Leader Mitch McConnell (R-Ky.) and other GOP leaders to continue searching for a health-policy formulation that could garner the support of enough members of their caucus.

Key ACA Insurer Urges Gov’t to Keep Customer Subsidies

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https://www.nytimes.com/aponline/2017/07/25/business/ap-us-aca-exchange-future.html?utm_campaign=KHN%3A%20First%20Edition&utm_source=hs_email&utm_medium=email&utm_content=54638652&_hsenc=p2ANqtz–eAN-_JrsPxvnowpY3QX9kVEamYR1GA2aSVSqWWmEKE0DlaDC9kqZ9Mwg5FWysQGaGA358Th4IOMGqfHw–p1v5lHXeA&_hsmi=54638652

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One of the biggest insurers in the Affordable Care Act’s marketplaces is warning the federal government that it must preserve cost-sharing payments for low-income customers to avoid hurting millions of people.

Centene Corp. said Tuesday that a better-than-expected performance in those individual insurance markets prompted it to beat Wall Street expectations in the second quarter and raise its forecast for 2017.

But Chairman and CEO Michael Neidorff, like other insurance executives, is worried about the fate of cost-sharing reduction payments that ease expenses like deductibles for people with low incomes. Money for those payments has made it into Congressional bills that aim to dismantle the Obama-era law, but the fate of that legislation is uncertain.

Republicans have challenged those payments in court, and President Donald Trump has offered no guarantees that they will continue beyond this month.

Neidorff said those payments and some other government support will be crucial to stabilize the exchanges, which have been marred by dwindling choices and soaring prices.

“Any intentional act to stop these … payments does not advance the debate on how to fix our health care delivery system,” he said. “It only hurts the millions of Americans who currently have affordable health care insurance in the marketplace.

“The leadership in Washington bears the responsibility to ensure that is not happening.”

Centene covers more than 1 million people through the law’s state-based health insurance exchanges, which let people shop for coverage and then buy a plan with help from an income-based tax credit. While big national carriers like UnitedHealth and Aetna have retreated from this market, Centene has switched to growth mode.

The St. Louis-based insurer plans to expand next year into exchanges in Nevada, Kansas and Missouri, with growth in its home state filling a void in 25 counties that had no exchange choices for shoppers.

Analysts have said Centene does well on the exchanges because it sticks with customers it knows. The insurer specializes in managing the state and federally funded Medicaid program for the poor. On the exchanges, it markets to low-income customers in areas where it has a Medicaid presence.

“They came at the exchanges from a core Medicaid business and built (care) networks around largely the same providers,” said Jefferies analyst David Windley.

People with low incomes are eligible for large tax credits that help keep their premiums affordable and shield them from big tax hikes. That makes it more likely they keep up with their insurance payments and renew their coverage.

Neidorff didn’t spell out on Tuesday what his company would do if the cost-sharing reduction payments end. But other insurers have said premiums will soar in many markets.

Leerink analyst Ana Gupte said in recent note that she expects more insurers to leave the markets if the future of payments isn’t clarified by September, and that could include Centene reducing its presence. But both she and Neidorff think the funding ultimately will be preserved.

Neidorff said that he thinks congressional leaders won’t have the appetite to leave the “most vulnerable populations” without coverage.

“I am personally, and I think corporately we are, convinced that when all the dust settles there will be subsidies in some form,” he said.

Senator McCain Delivers a Key Health Care Vote, Scolding Message

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https://www.nytimes.com/aponline/2017/07/26/us/politics/ap-us-mccain.html?utm_campaign=KHN%3A%20First%20Edition&utm_source=hs_email&utm_medium=email&utm_content=54638652&_hsenc=p2ANqtz–yCfUQ97UcjjbwPzRm6wrGo6e7rVbl20dli0Sqh-ZaiPPjMpOXJjM9kAkSpedzNtG7DL6oAyP0qfB05akd0OMSf02x3g&_hsmi=54638652

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The maverick stood with his party on Tuesday, casting a crucial vote in the Republican drive to repeal “Obamacare.” But then, like an angry prophet, Sen. John McCain condemned the tribal politics besetting the nation.

Confronting an aggressive brain cancer, the 80-year-old Arizonan served notice he would not vote for the GOP legislation as it stands now. McCain’s impassioned speech held the rapt attention of his colleagues in the Senate chamber.

“Stop listening to the bombastic loudmouths on the radio, television and the internet,” he intoned. “To hell with them! They don’t want anything done for the public good. Our incapacity is their livelihood.”

A few minutes earlier, McCain dramatically entered the chamber for the pivotal vote, his first since surgery and his cancer diagnosis in Arizona. Unified for once, Republicans and Democrats applauded and whooped for the six-term lawmaker. “Aye,” he said, thumbs up with both hands, for the GOP vote to move ahead on debate.

After he voted, McCain stood at his seat and accepted hugs and handshakes from senators in both parties, drawing laughter from the spectators’ gallery when he and Vermont Sen. Bernie Sanders exchanged an awkward embrace.

McCain then spoke his mind. His face was pale, cheek bruised, a red scar and stitches above his left eye where doctors had removed a blood clot. But his voice was strong. He offered a bit of self-deprecation, saying he was “looking a little worse for wear.”

He bemoaned the lack of legislative accomplishments in the current Congress and the GOP’s secretive process in working on repealing Obamacare. He issued a plea for Democrats and Republicans to work together.

Obama and the Democrats shouldn’t have pushed the Affordable Care Act through on party-line votes when they controlled Washington back in 2010, McCain said, “and we shouldn’t do the same with ours. Why don’t we try the old way of legislating in the Senate?”

That would involve committee hearings and testimony from experts and interested parties, an incremental process that could take months.

He blasted the path taken by Republican leaders “coming up with a proposal behind closed doors in consultation with the administration, then springing it on skeptical members, trying to convince them that it was better than nothing.

“I don’t think that’s going to work in the end, and it probably shouldn’t,” he said.

Debates in the Senate have become “more partisan, more tribal, more of the time than at any time I can remember,” he lamented.

With President Donald Trump threatening electoral retribution for Republicans who don’t toe the line, McCain urged senators to stand up for their own constitutional status.

“Whether or not we are of the same party, we are not the president’s subordinates,” he said. “We are his equal!”

People with health care problems had speculated on social media how McCain would vote, and his decision disappointed many. Addressing concerns that tens of millions will lose coverage if the Republican bill becomes law, McCain said the process is far from over.

“I voted for the motion to proceed to allow debate to continue,” he said. “I will not vote for this bill as it is today. It’s a shell of a bill right now.”

Arizona is one of 31 states that expanded Medicaid under President Barack Obama’s health care law, and Republican Gov. Doug Ducey is worried about tens of thousands losing their health insurance. That has to be addressed, said McCain.

The Arizona senator has emerged as one of Trump’s most outspoken GOP critics. During the presidential campaign Trump had mocked McCain for his capture by the Vietnamese.

The speech Tuesday received a standing ovation.

“He’s tough as a boot,” said Republican Sen. John Kennedy of Louisiana. “Many people understandably would be curled up in bed in the fetal position.”

McCain’s return was reminiscent of a similar scenario involving McCain’s good friend, the late Democratic Sen. Ted Kennedy of Massachusetts, who returned to the Senate in July 2008 while battling brain cancer to vote on Medicare legislation, his dramatic entry in the chamber eliciting cheers and applause. Kennedy died in August 2009. (The current Sen. Kennedy is no relation.)

McCain himself campaigned heavily on the “Obamacare” repeal issue last year as he won re-election to a sixth and almost certainly final Senate term. But he has not been a booster of the GOP health bill.

His best friend in the Senate, Lindsey Graham of South Carolina, said he’s been impatient to get back to work.

“Is it surprising that he would get out of a hospital bed and go to work? No,” Graham said. “It’s surprising he’s been in the hospital this long.”

Obamacare’s History Littered With Near-Death Experiences

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Few laws have defied as many existential threats as the Affordable Care Act. In seven years, it has been to the brink of elimination nearly a dozen times, only to rally back from seemingly impossible odds. Efforts to kill it have come from Congress (including one in 2015 that made it all the way to President Barack Obama’s desk before being vetoed), the White House and the courts. So far, the law continues.

As the Senate continues its latest effort to remake the law, here is a timeline of the ACA’s “near-death” experiences, which occurred before the bill passed, during its implementation and after benefits began to flow.

Tough road ahead for McConnell on ObamaCare

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Tough road ahead for McConnell on ObamaCare

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Republicans on Tuesday cleared a crucial hurdle to begin the Senate healthcare debate, but now face the danger of a circular firing squad if they are unable to unify around a single proposal.

The successful procedural vote sets up 20 hours of floor debate and votes on a virtually unlimited number of amendments, known as a vote-a-rama.

Many of these amendments will fail, and some will pit centrists in the GOP conference against conservatives, a division that has made it exceedingly difficult for Republicans to move forward on ObamaCare repeal.

At press time, votes were expected Tuesday night on an amendment to repeal ObamaCare in two years, and one to repeal and replace ObamaCare with a substitute that Senate Republicans have been working on behind closed doors for months.

Both of those amendments are widely expected to fail, but GOP leaders think it will help them to determine how much support exists for both measures.

That information could be used to craft another compromise before the underlying healthcare bill comes up for a final vote.

Another possibility that seemed to have growing momentum on Tuesday is a so-called “skinny” ObamaCare repeal bill that would only eliminate the healthcare law’s insurance mandates on individuals and businesses and an unpopular tax on medical devices.

If that legislation can pass the Senate, it could be brought to a conference negotiation with the House, when lawmakers from both chambers would try to reconcile their differing products.

Yet it is far from clear that even the “skinny” measure could win support.

Sen. Susan Collins (R-Maine), long a holdout from her party in the healthcare debate, expressed skepticism about the approach on Tuesday. Sen. John McCain (R-Ariz.) predicted in a dramatic floor speech after his return to the Senate following a brain cancer diagnosis that the entire effort was likely to fail, and that Republicans should start over with an open process and committee hearings.

Democrats plan to make the process as painful as possible for Republicans by dragging out proceedings. No Democrats backed the measure to begin debate, and they withheld their “no” votes until the end to highlight the contrast to the GOP.

On Tuesday evening, Democrats forced the Senate clerk to read the entire first proposed amendment to the bill, which was expected to take a couple of hours.

“The aim of our amendment strategy is to defeat the various versions of repeal they proposed and to make it as hard as possible to get to 50,” said a senior Democratic aide.

Republicans control 52 seats, meaning they can survive only two defections with Democrats unified and Vice President Pence breaking a tie.

Several moderates, including Collins and Sens. Shelley Moore Capito(W.Va.) and Lisa Murkowski (Alaska), say they will not support a repeal measure that leaves the question of replacement unanswered.

Republicans are likely to face a rollicking debate over as many as 100 different healthcare proposals.

GOP leaders describe the “skinny” option as a fallback proposal.

“Who knows what the final bill will look like. I’d be happy to have a comprehensive bill that 50-plus senators agree to, but if we can’t, then the idea would be to come up with a core of pieces that 50 of us agree on,” Senate Majority Whip John Cornyn (R-Texas) told reporters.

Even Republican leaders admitted they don’t fully know what to expect.

“There will be a lot of different amendments offered by different members trying to craft the bill. It’s really entirely impossible to predict, in a reconciliation debate, exactly what amendments will be offered or what amendments will succeed. It’s wide open,” Senate Majority Leader Mitch McConnell (R-Ky.) told reporters.

Cornyn predicted that as many as 100 different healthcare proposals could receive votes.

“Under the budget process, everybody is entitled to get a vote on an amendment if they want one. So it’s impossible to predict the sequence,” he said. “We’re going to be doing a lot of voting this week. I hope you all have eaten your Cheerios.”

Democratic Sen. Chris Murphy (Conn.) told reporters that he alone has prepared more than 100 amendments for floor consideration.

The Budget Committee will vet the various amendments to make sure they comply with Senate rules.

The advantage of passing healthcare legislation under special budgetary rules is that GOP leaders can pass it with a simple majority, instead of 60 votes as is usually required for controversial legislation in the Senate.

But legislative provisions must pass a six-part test known as the Byrd Rule. The most stringent requirement is that the budgetary impact of the proposals must be more than incidental compared to the policy impact.

In other words, policymaking that does not have a significant impact on spending, revenues or the deficit is not allowed.