Health insurers across the country are making plans to dramatically raise Obamacare premiums or exit marketplaces amid growing exasperation with the Trump administration's erratic management of the program and its conflicting signals about the fate of aid for low-income consumers and other key issues.
At the same time, state insurance regulators — both Democrat and Republican — have increasingly concluded they cannot count on the Trump administration to help them ensure that consumers will have access to a health plan next year.
The growing frustration with the Trump administration's management — reflected in letters to state regulators and in interviews with more than two dozen senior industry and government officials nationwide — undercuts a key White House claim that Obamacare insurance marketplaces are collapsing on their own.
Instead, according to many officials, it is the Trump administration that is driving much of the current instability by refusing to commit to steps to keep markets running, such as funding aid for low-income consumers or enforcing penalties for people who go without insurance.
"All this uncertainty is not helpful," warned Blue Shield of California Chief Executive Paul Markovich, who said health plans were being forced to make plans to raise premiums to account for the turmoil, jeopardizing Americans' coverage.
Markovich was one of the few senior insurance officials who agreed to speak on the record, as many fear retribution from the White House or its allies.
But privately, many executives, including chief executives of major health plans, offered withering criticism of the Trump administration's lack of leadership.
"There is a sense that there are no hands on the wheel and they are just letting the bus careen down the road," said one senior company official, whose comments reflected widely held views in the industry.
Trump and GOP congressional leaders insist the marketplaces are collapsing because of flaws in the original law. They cite premium hikes in some states, and decisions by several insurers to stop selling Obamacare plans, including major national companies such as Humana and UnitedHealth Group. That has left some areas of the country with just one health plan option next year.
"Obamacare has failed," said Alleigh Marre, a spokeswoman for the U.S. Department of Health and Human Services. "For this reason, Republicans are reforming healthcare so it delivers access to quality, affordable coverage to the American people."
Several Republican state insurance commissioners also blamed weaknesses in the law for the current instability.
"There has been uncertainty with the Affordable Care Act since it started," said Maryland Insurance Commissioner Al Redmer Jr. Maryland's largest insurer, CareFirst, is seeking to raise rates by more than 50% next year.
But most health plans and state regulators interviewed for this story said the Trump administration has significantly exacerbated turmoil in the marketplaces in recent months, contributing to rising premiums and the threat of marketplaces exits.
"There is no consistency to the messages," said Ceci Connolly, chief executive of the Alliance of Community Health Plans, whose members include leading health systems such as Kaiser Permanente and Geisinger Health Plan. "We are very confused."
The Trump administration has sent mixed signals about whether it will enforce penalties on people who don't buy health insurance. The penalty, though unpopular, is seen as crucial to inducing younger, healthier people to get coverage.
Trump and his deputies have also repeatedly threatened to withhold federal aid that helps millions of low-income Americans afford their deductibles and co-pays.
The aid, which reimburses insurers for lowering out-of-pocket costs, was paid by the Obama administration, but is now the subject of a lawsuit by congressional Republicans, who argue Congress must approve the payments.
The Trump administration hasn't taken an official position in the lawsuit, and on Monday sought an additional delay in the proceedings.
But in recent months, the president publicly mused about stopping the payments to force Democrats to negotiate a repeal of the current law. It remains unclear whether the administration will continue the payments, known as cost-sharing reductions, or CSRs.
In a letter to Washington state insurance regulators this month, California-based Molina Healthcare, a leading provider of Obamacare plans in many states, warned halting CSRs may cause the collapse of the state's market.
"If the federal government's full CSR funding commitments are in jeopardy, we believe that the viability of the exchange market is in immediate jeopardy of failing," wrote Peter Adler, who oversees Molina's plans in Washington.
The uncertainty created by Trump comes as some Obamacare markets were beginning to stabilize, according to many industry and government officials. In several states, insurers and regulators noted that 2017 was shaping up to be a better year than the first several years of the marketplaces.
Tennessee Blue Cross Blue Shield Chief Executive J.D. Hickey reported in a letter to that state's insurance commissioner this month that "our 2017 performance has improved due to a combination of better claims experience and more sustainable rate structure."
Hickey warned in the letter that "potential negative effects of federal legislative and/or regulatory changes," including not paying CSRs or enforcing the mandate, would require the Tennessee plan "to price-in those downside risks."
Many state insurance regulators are similarly dismayed by the Trump administration's actions, which Washington state Insurance Commissioner Mike Kreidler compared to playing Russian roulette with Americans' health insurance coverage.
"It's ludicrous," said Kreidler, who is a Democrat. "This has real impact on people's lives."
In Colorado, where most consumers continue to have multiple insurance choices, commissioner Marguerite Salazar said the Trump administration threatens the whole market. "My fear is it may collapse," she said.
Mississippi Insurance Commissioner Mike Chaney, a Republican, is so concerned the turmoil will drive away insurers that he's exploring whether the state can make available limited benefit insurance plans as a stopgap.
The plans would likely cap medical care and prescription drug coverage. But Chaney said, "It would be better than nothing."
Insurance industry officials and state regulators have met repeatedly in recent months with senior Trump administration officials in an effort to explain that administration's actions are jeopardizing health coverage for millions of Americans.
But in many cases, the meetings only left insurers and regulators more confused about the administration's plans, according to attendees.
At one recent meeting, Seema Verma, whom Trump picked to oversee the federal Medicare and Medicaid programs, stunned insurance industry officials by suggesting a bargain: The administration would fund the CSRs if insurers supported the House Republican bill to repeal the Affordable Care Act.
"It made no sense," said one official at the meeting.
Many insurers, as well as every leading patient and physician group, believe the House bill is deeply flawed. Independent analyses suggest the legislation, which Trump has enthusiastically backed, would increase the ranks of uninsured by 24 million over the next decade.
Jane Norris, a spokeswoman for the health agency who said she also attended the meeting, said The Times' account was "completely false."
"The assertion that Administrator Verma offered to fund the CSR in exchange for support for legislation is preposterous," she said. "What she said at the ... meeting in April was that no decisions had been made about CSRs."
A group of senior Democrats has asked for additional information about the meeting.
2:50 p.m. May 22: This article was updated with new comments from the Trump administration and Democrats.
3:05 p.m.: This article was updated with additional comments from the Trump administration.