It’s working … right? If the clock is ticking on the Senate Republican effort to pass an ObamaCare repeal-and-replace bill, then time is also running out on Americans outside of urban cores stuck in the ObamaCare system. Anthem, which had previously been bullish on ObamaCare, announced that it will pull out of exchanges in most of Nevada — leaving thousands there with no access to health insurance within the mandatory system:

Anthem Inc.’s decision to quit offering Obamacare plans in much of Nevada will leave large parts of the state without options on the health law’s exchanges.

The health insurer, a one-time Obamacare stalwart, has accelerated its retreat in recent weeks, blaming in part the uncertainty about the fate of the health law in Washington for making it difficult to come up with plans and calculate premiums.

In Nevada, officials including Republican governor Brian Sandoval called the situation a crisis Wednesday night. Anthem will now offer plans on the Affordable Care Act’s exchange in just three of the state’s more-populated counties, after previously selling coverage statewide. That leaves about 8,000 people in 13 counties and Carson City without access to Obamacare health plans and the government subsidies that often come with them, according to the state’s Silver State Health Insurance Exchange.

It’s the fourth state in which Anthem has departed recently. Their exits from Wisconsin, Indiana, and Ohio also left counties with no options to satisfy the mandate. In those cases as well as Nevada, Anthem was simply the last company to stick around.

Anthem blames the need to exit on “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.” That explanation could be used to attack both the Obama and Trump administrations, but the exit of other insurers from the same markets before 2017 makes it clear where the difficulties lie. Also, it’s worth noting that Anthem announced two months ago that their ObamaCare business had improved in 2017, but clearly not enough to justify sticking around.

One would think this crisis would allow Republicans to claim the moral high ground on repeal, but as I write in my column at The Fiscal Times today, the GOP never prepared for the public-relations fight, and their disunity is creating a circular firing squad:

What happened? Despite having several years to develop a repeal-and-replace plan, Republicans on Capitol Hill have looked unprepared for leadership, and at odds with each other on the priorities in health-care reform. The biggest problem to emerge, especially in the Senate, is a lack of preparation for the entirely predictable reaction to a rollback of the Medicaid expansion, which Republicans have long sought but have done little to put into a narrative that can compete in the political marketplace. …

Instead, the lack of preparation and unity for this debate created a vacuum among Republicans, which allowed Democrats to create the dominant narratives on reductions in coverage and worse. Sen. Elizabeth Warren announced on the Senate floor that “these cuts are blood money,” while pounding her fist on the podium. “People will die! Let’s be very clear,” she continued, “Senate Republicans are paying for tax cuts for the wealthy with American lives.”

Furthermore, the need to show cost savings for reconciliation has left Republicans open to the charge that they are cutting Medicaid spending. The Senate bill, like the House bill before it, actually leaves in place “modest annual increases” for Medicaid, as The New York Times acknowledges. The bills eliminate the massive projected increases in Medicaid spending necessary to keep subsidizing Medicaid expansion enrollees at far greater rates than those below the poverty line but do not reduce Medicaid spending in any year within the decade-long projection. Democrats have pushed back by claiming that rising costs effectively transform the more modest increases into cuts, but as Blahous demonstrates, the Medicaid expansion itself has created those exploding costs.

Rather than focus on the necessities of reform and creating a unified platform for it, Republicans in the House and then in the Senate have let themselves get stampeded by the Democrats’ scare tactics and demonization. That manifested itself in both chambers in legislation that tried to nibble at the edges of repeal and reform rather than tackle them directly, and in both cases required White House intervention to remind Republicans that voters expect them to fulfill their promises, and to govern.

That’s now true for rural voters in Nevada specifically. It’s time for Senate Republicans, and House Republicans for that matter, to get serious and produce a real bill that will put America back on the track to rational health-insurance markets.