Soaring prices and fewer choices may greet customers when they return to the Affordable Care Act's insurance marketplaces this fall, in part because insurers are facing deep uncertainty about whether the Trump administration will continue to make key subsidy payments and enforce other parts of the existing law that help control prices.
Assurances don't look to be coming anytime soon. "As I said from the beginning, let ObamaCare implode, then deal. Watch!" President Donald Trump tweeted early Friday, soon after the Senate narrowly rejected the latest push to dismantle the Obama-era health care law.
Health and Human Services Secretary Tom Price said in a statement after the Senate vote that the Trump administration would pursue its health care goals through regulation.
That kind of uncertainty rattles insurers, many of whom have already stopped selling policies through public insurance markets established by the health law because they were losing money.
Their main concern now is that the Trump administration will stop paying crucial subsides called for in the law that help reduce costs like deductibles for people with low incomes. The subsidies, estimated at $7 billion a year, have been challenged by Republicans in court, and Trump has only guaranteed them through this month.
If they stop, insurers will have to raise prices for coverage, known as premiums, because by law they must still offer the same reduced deductibles for their low-income customers.
Leerink analyst Ana Gupte surveyed several states and has said that insurers are asking for price hikes of around 36 percent when they assume the subsidies go away, compared with about 18 percent if they stay.
People with low incomes might be shielded from these hikes in part because the law provides tax credits that cover much of the premium.
But those who make too much to qualify for that help — and tend to vote Republican — could get hit hard, noted health care consultant Robert Laszewski, a former insurance executive.
"(Trump's) hurting his own people," Laszewski said.
Of course, all shoppers will be hurt if insurers leave markets, noted Urban Institute health economist Linda Blumberg.
"Then there's nowhere to use your subsidy," she said.
The Blue Cross-Blue Shield insurer Anthem has already withdrawn from markets in Ohio, Wisconsin and Indiana. CEO Joseph Swedish said Wednesday the company may cut back further if it doesn't get certainty on the subsidies "quickly."
Insurers have until the middle of next month to finalize their 2018 prices, industry officials say. They must leave enough time for the rates to be submitted to the marketplaces, and then for the on-line exchanges that sell the coverage to be tested before enrollment for next year's plans begins on Nov. 1.
If insurers want to back out of a market, they have until about late September to do so.
Options already have grown thin. About a third of the U.S.'s approximately 3,000 counties have only one insurer selling coverage on their exchange, which is the only place where shoppers can get tax credits based on their income to help buy coverage. Those credits are separate from the subsidies for low-income customers.
Nearly 40 counties currently have no choices for next year on their exchanges.
Dan Mendelson, president of the consulting firm Avalere, says there is some hope that the Trump administration could yet shore up the system. He thinks the administration could recognize that it will be held accountable by voters for the condition of the law's marketplaces. Further deterioration "would be very negative for them," he said.
"I think in the end they're going to have to stabilize these markets," he said.