Recent decisions by giant health insurers to pull back from Obamacare exchanges across the country could make this fall's enrollment period crucial to the program that has helped millions of people gain health coverage.
"We won't know until the next open enrollment, are we still moving forward or are we stalled or moving backward?" said Gary Claxton, director of the nonprofit research group Health Care Marketplace Project at Kaiser Family Foundation. "If the market grows, then I think many insurers will find a way to be part of it.
"The next couple of months are a moment of truth," he said.
On Monday night, insurance giant Aetna announced it would stop offering Obamacare in 11 of 15 states. Aetna said the move was needed because of rising costs and having too many sick patients compared with those who are healthier and use less medical care.
Similar reasons were given by Humana and UnitedHealthcare, which also have announced plans to reduce their Obamacare business across the nation.
The decisions have little immediate impact on California. Aetna was not offering policies on the state's exchange known as Covered California. And UnitedHealthcare had just 1,200 members this year, accounting for less than one-tenth of 1% of the marketplace's 1.4 million consumers.
But the moves are part of a trend that continues to raise questions about the program's sustainability.
"You can't look at Aetna by itself," said Robert Laszewski, a healthcare consultant in Virginia. "If the pool is unstable and everybody is losing money, what is the long-term outlook? It's not good."
Last week, Blue Shield of California said it would mostly shut down for the four days after Labor Day because of recent unexpected losses, including from Covered California.
Most of Blue Shield's 6,000 employees in California will be forced to take the week off to reduce the company's payroll liabilities, said Steve Shivinsky, the insurer's spokesman.
And across the country, premiums for Obamacare are soaring.
In July, Covered California officials said that premiums would rise an average of 13.2% in 2017 – more than three times the increase of the last two years.
In many other states, the 2017 premium hikes are far higher.
In Tennessee, Cigna and Humana recently said the premium increases they asked for earlier this summer of 23% and 29%, respectively, would still not be enough. In an effort to prevent more insurers from abandoning Tennessee's exchange, the insurance regulator agreed this month that the companies could refile for even larger increases.
Experts disagree on whether the latest pullbacks and price hikes, floating in a sea of election-year politics, signal that the nation's health insurance exchanges have reached a terrible tipping point — or whether they are simply seeking a new state of equilibrium.
"I don't think this is the beginning of bigger problems," said Gerald Kominski, director of the UCLA Center for Health Policy Research. "It's an adjustment."
This year marks the end of a mechanism that had held down rates for the first three years of Obamacare, which was created by the 2010 law known as the Affordable Care Act. The mechanism had provided more money to those insurers covering the sickest and most expensive patients.
Kominski said he believed Aetna's move was prompted more by the Justice Department's recent filing of a lawsuit against its proposed merger with Humana than any inability to make money selling Obamacare policies.
Indeed, Aetna had warned Justice Department officials in early July that it would reduce its presence on the Obamacare exchanges if officials opposed the merger, according to a letter signed by Mark Bertolini, Aetna's chief executive. The July 5 letter was obtained Wednesday by the Huffington Post.
Bertolini wrote that Aetna believed "it is very likely that we would need to leave the public exchange business entirely and plan for additional business efficiencies should our deal ultimately be blocked."
"They are basically playing a game of chicken with the federal government," Kominski said.
Sara Collins, vice president for healthcare coverage and access at The Commonwealth Fund, a foundation that supports independent research on healthcare policy, said she believes the Obamacare markets are maturing rather than dying.
Collins noted that major carriers including Blue Cross, Blue Shield and Kaiser Permanente have not pulled out of the Obamacare exchanges.
She said the insurance pools appear to be working better in larger states like California, which continue to lure multiple carriers to compete with one another for business.
"It's not surprising that we're seeing some shake-up in the marketplace this year," Collins said. "There are going to be winners and losers like any competitive market you can think of. Some will compete and gain market share, others won't."