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Enrollment in the state-based marketplaces – where about 11 million Americans buy insurance – starts in just three months, and hundreds of counties will have just one or no plan options under present conditions. They'll be looking at the first full sign-up season with Republicans holding both the White House and Congress, putting them under heavy pressure to ensure Americans have insurance options – or otherwise bear the blame if they don’t.

Then there’s the question of who will actually sign up. How Republicans approach enforcing the individual mandate and funding extra cost-sharing subsidies will have significant influence on the resiliency of the marketplaces – that is, who enrolls and whether insurers are able to start breaking even.

Right after enrollment season ends, there's another ACA element that will be implemented under the law -- a tax on health insurers is set to start up again in January after Congress suspended it for 2017. Bombarded by opposition from the insurance industry, which argues the tax will force it to hike premiums, it’s up to Republicans to either delay the levy again, repeal it or let it take effect.

Regardless of President Trump's insistence that he won't be blamed for problems with a system he is charged with implementing, polling suggests otherwise. Sixty-one percent of respondents to an April Kaiser Family Foundation poll said Republicans are responsible for any ACA problems going forward compared to 31 percent who said such issues would still be Democrats' fault.

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The bottom line is this: Ignoring health care after the party’s embarrassing meltdown on an Obamacare replacement isn’t an option for the GOP. Here’s a quick run-down of their decision list:

1. Whether to fund cost-sharing subsidies

Depending on how a court case plays out, congressional Republicans will likely have to decide whether marketplace insurers will continue receiving an extra bucket of payments to cover cost-sharing discounts they’re required to give the lowest-income enrollees.

Called cost-sharing reductions, or CSR’s, these payments represent about 18 percent of the total subsidy payments marketplace insurers get from the federal government in order to lower costs for poorer Americans.

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The problem is that while the premium subsidies are funded by the ACA, the CSRs require an appropriation from Congress, a federal judge has ruled. The Trump administration has been making the payments month-to-month for now, but if the ruling stands, Congress would have to shell out.

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The CSR’s are a hefty chunk of change, so if insurers don’t get certainty about the payments, more are likely to withdraw from the marketplaces next year and beyond, worsening the situation for millions of Americans shopping there.

“I think everyone involved in this -- state regulators and insurers and consumer groups and provider groups – agree they need to do something about the cost-sharing reduction payments,” Tim Jost, a health law professor at Washington and Lee University, told me. “That’s the single threat by far to the individual market.”

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And the marketplace situation is already tenuous in parts of the country. Unless more insurers join last-minute (they have until Sept. 27 to submit final plans to the feds), 40 counties will have no plan options and some 1,300 counties will have only one option in 2018, according to data released Wednesday by the Centers for Medicare and Medicaid Services.

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2. Whether to enforce the individual mandate

Insurers have warned Congress that healthy people must have incentives to buy coverage if the marketplace are going to work as intended. The IRS still accepted tax returns this year that failed to indicate whether a person had health coverage – but it hasn’t indicated whether it will crack down for next year.

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How strictly the federal government enforces the mandate and other rules around when people can enroll all plays into the overall environment of the marketplaces and insurers’ calculations. Several major insurers have already withdrawn entirely, and more are warning they’ll exit too if the marketplaces don’t eventually become self-sustaining.

“Clarity around the rule set,” Cigna CEO David Cordani told me in an interview last week, when asked what his company is seeking from policy-makers. Cigna sold plans in seven states this year, but hasn’t yet announced its plans for 2018.

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Cordani said that encompasses a range of policies – from the individual mandate to CSR's to how enrollment will be handled.

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“The marketplace is a basket of rules and a basket of standards and a basket of approaches,” Cordani said. “How that basket gets refreshed, changed or solidified is what’s most important.”

3. Whether to repeal – or keep – Obamacare’s sales tax on insurance plans

Dubbed the “HIT” by the insurance industry, plans are arguing that the tax will force them to hike premiums and undermine the overall goal of bringing down health-care costs. America’s Health Insurance Plans cites a study by Oliver Wyman that found the tax would cause employers to pay $210 more per employee and families to pay $530 more per year on average.

This argument has gained traction with Democrats and Republicans alike, who agreed to suspend the tax for one year in a budget bill they passed at the end of 2015. Insurers are pressing for Congress to either suspend the tax again or repeal it entirely. They paid $11.3 billion in 2016, but that’s expected to be 26 percent higher – around $14.3 billion – next year. If Republicans allow the tax to go into effect under their watch, they could suffer industry backlash.

UnitedHealth Group CEO Steve Hemsley raised the issue on an earnings call on Tuesday, saying it would hurt marketplace stability.

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“The return of the tax…would further destabilize the market, which is already fragile,” Hemsley said. “And make that market less affordable.”

AHH, OOF and OUCH

AHH: Sen. John McCain used his signature snark yesterday to warn colleagues that he will be returning soon to Washington — and chastised the Trump administration for ending assistance to moderate Syrian rebels battling the government of Bashar al-Assad. The Arizona Republican has been diagnosed with a brain tumor called a glioblastoma, and underwent surgery to remove a blood clot above his left eye last week -- prompting McConnell to postpone a previously planned health-care vote.

Yesterday, McConnell said, “We look forward to seeing our friend again soon and we hope he’ll be back in the very near future.”

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"When McCain might return to Washington, however, remains in doubt," my colleagues Ed O'Keefe, Sean Sullivan and Karoun Demirjian report. "The Mayo Clinic in Phoenix, which diagnosed McCain, said that the senator and his family are considering treatment options, including a combination of chemotherapy and radiation. His office has not indicated when he might return to the Senate."

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"The tumor McCain is fighting, glioblastoma, is an aggressive type of brain cancer, and the prognosis for this kind of cancer is generally poor," they write. "Sen. Edward M. Kennedy (D-Mass.) survived less than 15 months after his was found in 2008. Beau Biden, the son of former vice president Joe Biden, died of the same cancer in 2015."

--Read what McCain learned from Kennedy, per The Post's Paul Kane.

Trump's daughter Ivanka tweeted support:

McCain called his buddy Sen. Lindsay Graham (R-S.C.) several times yesterday, per the Guardian's Sabrina Siddiqui:

OOF: The Trump administration has ended ACA contracts that enabled Healthcare.gov enrollment in libraries, businesses and urban neighborhoods in 18 cities, the AP reports. Community groups say the move, announced to them by contractors last week, will make it even more difficult to enroll the uninsured and help people already covered re-enroll or shop for a new policy during the 2018 sign-up season, which is already half as long as last year.

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"Some see it as another attempt to undermine the health law's marketplaces by a president who has suggested he should let 'Obamacare' fail," the AP writes. "The administration, earlier this year, pulled paid advertising for the sign-up website HealthCare.gov, prompting an inquiry by a federal inspector general into that decision and whether it hurt sign-ups....Now insurers and advocates are concerned that the administration could further destabilize the marketplaces where people shop for coverage by not promoting them or not enforcing the mandate compelling people to get coverage."

"There's a clear pattern of the administration trying to undermine and sabotage the Affordable Care Act," said Elizabeth Hagan, associate director of coverage initiatives for the liberal advocacy group Families USA. "It's not letting the law fail, it's making the law fail."

OUCH: The revised health-care plan Senate Republicans had planned to vote on this week (before it became clear McCain couldn't make it to Washington) would increase the ranks of the uninsured by 22 million people a decade from now -- the same as the bill's previous version, The Post's Amy Goldstein reports. The Congressional Budget Office released its updated estimate yesterday, even though Republicans appear to lack the votes even to start debate on the measure.

In hopes of gaining enough votes to pass it, McConnell had rejiggered the bill to preserve some of the ACA taxes and give more money to states to help pay for insurance for high-cost patients. Because the revised measure would retain more taxes, it would have a greater impact on lowering the federal deficit — a $420 billion reduction between next year and 2026, compared with $321 billion under the previous bill.

The CBO also says the most recent version would cause a slightly slower erosion of health coverage, with 15 million fewer Americans predicted to be insured in 2018 compared with current law. That would be 2 million fewer losing insurance next year than under earlier legislation -- although a decade from now, the coverage losses would be the same.

--Office of Management and Budget Director Mick Mulvaney, who has suggested in the past that CBO can't be trusted, criticized the agency again yesterday.

“We can talk for an hour about this CBO if we wanted to,” Mulvaney said, according to Politico. “Keep in mind that Jonathan Gruber who helped fashion Obamacare, his methodology is still being used by the CBO to measure the replacement and the repeal bill, so it’s almost like it’s not a fair analysis."

(Mulvaney was referring to Gruber, an MIT professor who advised the White House back in 2009 and 2010 as it was helping craft the ACA. Gruber has since come under fire for some of his more candid comments about the health-care law.)

Mulvaney also said nobody makes their decisions based on a CBO score, even though its projections of 22 million people losing coverage gave many senators pause.

“I think folks who care about the issue want to know about methodologies and want to know what we are getting ready to do on substantive basis and what we are replacing,” Mulvaney said. “The real issue is that there are people who are actually losing coverage today under Obamacare, and that’s where I think the discussion should be.”

House Speaker Paul D. Ryan also cast doubt on the CBO score, per Bloomberg's Sahil Kapur:

Democrats noted that Republicans hadn't improved their 22 million uninsured Americans projection from the previous bill:

Senate Finance Committee Chairman Ron Wyden (D-Ore.):

HEALTH ON THE HILL

--The Senate's health-care bill rode some wild waves this week, appearing to fold on Monday and then undergoing some fits and starts as members met to try to reach consensus. "Senators left town for the weekend under a cloud of confusion after McConnell reopened talks on a discarded plan to repeal and replace the Affordable Care Act under heavy pressure from President Trump," my colleagues Kelsey Snell and Amy Goldstein report. "The White House intervention sparked a flurry of meetings and activity, but the rush produced no new evidence that the bill can pass."

"Senators had difficulty keeping up with the information in a rapidly shifting week when leaders floated intensions to vote on both bills," they write. "McConnell started the week by promising to hold a vote on the repeal-and-replacement plan released last week. Facing fatal opposition to that plan, McConnell then announced that the Senate would vote on a repeal-only bill that passed the Senate in 2015 before being vetoed by President Obama...By week’s end, leaders had returned to a repeal-and-replace strategy at Trump’s behest."

"On Thursday, most GOP senators could not say what legislation they expected to vote on next week, and skeptics appeared no closer to backing the new plan," Kelsey and Amy continue. "Conservatives such as Sen. Rand Paul (R-Ky.), who want to go further to pare back the ACA, and moderates such as Sens. Susan Collins (R-Maine) and Dean Heller (D-Nev.) who worry about leaving millions without health-care coverage, remained undecided."

“It’s still very vague and nebulous,” Paul said. “It’s hard to say you’ll vote to proceed if you don’t know what you’re proceeding to.”

Sen. Bob Corker (R-Tenn.) compared the whole thing to a bazaar, per IJR's Haley Bryd:

No. 2 Senate Republican John Cornyn's response, when asked which bill the chamber will try to take up next week, per Kelsey:

MALPRACTICE

Of the 836 false or misleading claims Trump has made at his six-month mark in office, The Post’s Fact Checker team found that the president’s most-repeated line is some version of the claim that Obamacare is “essentially dead.” He’s made the claim 44 times — but it’s not entirely accurate.

“The Congressional Budget Office has said that the Obamacare exchanges, despite well-documented issues, are not imploding and are expected to remain stable for the foreseeable future,” write Glenn Kessler, Michelle Ye Hee Lee and Meg Kelly. “If anything, actions taken by the Trump administration have spawned uncertainty. Several insurance companies have cited Trump administration policy as a reason to leave insurance markets in certain states, though others have sensed opportunity and moved in to replace insurers who have left.”

(Amy Goldstein and I have written about the uncertainty insurers face following the collapse of the Republican health-care effort here. )

It shows the limits of Trump’s rhetoric. Even as Trump insisted dozens of times that the ACA is already dead, he's failed to convince Democrats to work with him or with Republicans or pull enough Republican support to pass the Senate bill.

Trump has also made several other misstatements about Obamacare. “Trump, as he did during the presidential campaign, also exaggerated the impact of increases in premiums on the Obamacare exchanges, cherry-picking numbers from a handful of states," Glenn, Michelle and Meg write. "Trump also frequently uses the calculation of premium increases without incorporating the impact of tax credits — which most people in the exchanges receive. If you take the subsidies into account, the average monthly premium of most people in the Obamacare exchanges goes down, not up.”

You can follow the Fact Checker’s ongoing database of the president’s false or misleading claims here.

A few more reads from The Post and beyond:

TRUMP TEMPERATURE

MEDICAL MISSIVES

REPRODUCTIVE WARS

DAYBOOK

Coming Up

The Bipartisan Policy Center will hold an event on July 25 on “The Future of Comparative Effectiveness Research.”

SUGAR RUSH

House Minority Leader Nancy Pelosi (D-Calif.) tells Republicans: "We're ready to work in a bipartisan way" on health care:

Watch President Trump crush a vial during a product demonstration:

Here are some of Sen. John McCain's (R-Ariz.) most courageous political moments:

What you need to know about the kind of brain tumor John McCain was diagnosed with:

Three things lawmakers want to know from Jared Kushner, Paul Manafort and Donald Trump Jr.: