Some states, like Minnesota, where some carriers propose to drop prices by as much as 12 percent, are setting up a reinsurance program like the one that had been discussed but not adopted on a federal level. Maryland is awaiting federal approval for a similar program that could significantly lower prices in the state.
In Washington state, lawmakers were unsuccessful in their attempts to create a reinsurance program, said Mr. Kreidler, the regulator. “We ran into the same problem some other states did — it’s tough coming up with the money,” he said.
Other states may restrict the sale of policies that compete with the A.C.A. plans or develop their own version of the individual mandate.
But insurers are increasingly comfortable with the current state of the market. In Iowa, Medica was the only remaining insurer in 2018 after the dramatic exit by the state’s Blue Cross plan. The insurer increased its prices there by nearly 60 percent this year. For next year, it is contemplating increases in the single digits, and Wellmark, the Blue Cross plan, said it would get back into the Iowa market in 2019 after talking with state officials.
Citing the relative stability in the environment, Medica also plans to expand into two more states in 2019. It says it is able to factor in the continued uncertainty over the influx of new competing plans. “We have had to become pretty nimble and pretty flexible,” said Geoff Bartsh, an executive with Medica.
Most insurers think the Republicans will not be successful in their legal efforts to undo the law, and they are holding off on making any dramatic moves. But that could change if the courts rule in favor of the Trump administration and the Republican attorneys general. “The big game changer would be the lawsuit in Texas,” Mr. Bartsh said.
In spite of the market’s rockiness, insurers are discovering their customers were loyal. “Last time, they tried everything,” said Michael Neidorff, the chief executive for Centene, including eliminating the subsidies aimed at reducing people’s out-of-pocket costs if they were low income and slashing the outreach efforts. But Mr. Neidorff said the vast majority of people remained enrolled. “People want insurance,” he said.