A version of this story originally appeared on The Hill Extra.

Rural areas would be hit particularly hard if Congress and the Trump administration don’t send clear signals that they’re committed to helping keep ObamaCare’s insurance marketplaces stable next year, advocates warn.

Insurers are in the midst of deciding which ObamaCare markets to enter, and they need assurances that they won’t have to pay billions for out-of-pocket costs for certain low-income consumers. Rural areas already have fewer care options than their urban peers.

A “crisis in rural counties,” is possible without more clarity, said Alan Morgan, the CEO of the National Rural Health Association, an umbrella group representing hospitals, doctors and others that work in rural areas.

“Without any intervention, this is going to be a mess.”

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Even before the Affordable Care Act, rural areas had fewer choices. While ObamaCare gave all Americans an avenue to buy insurance, it didn't give all rural areas competitive insurance markets. In 2017, about 41 percent of rural areas only had one insurer.

Without certainty, insurers could exit marketplaces, leaving rural areas without any carriers. Rural hospitals could then be tasked with providing care to a population that could be increasingly uninsured.

“It really does all come down to that one company's decision about whether to stay or go,” said Cynthia Cox, associate director of Kaiser Family Foundation’s Program for the Study of Health Reform and Private Insurance.

House Republicans are in the midst of trying to revive their bill to repeal and replace ObamaCare, which fell apart in spectacular fashion last month.

Even Republicans who've been actively pushing to kill ObamaCare are acutely aware of the needs of rural areas.

Sen. Lamar Alexander Andrew (Lamar) Lamar AlexanderTrump health officials grilled over reports of politics in COVID-19 response Now is the time to renew our focus on students and their futures CDC says asymptomatic people don't need testing, draws criticism from experts MORE (R-Tenn.) has been pushing to repair ObamaCare before it's repealed.

Alexander and fellow Tennessee Republican Bob Corker Robert (Bob) Phillips CorkerHas Congress captured Russia policy? Tennessee primary battle turns nasty for Republicans Cheney clashes with Trump MORE, have teamed up to introduce a bill to let Americans receive subsidies if they didn’t have any insurer in their marketplace.

The divide between urban Americans voting Democrat and those in rural areas voting Republican has become even more pronounced. Trump won rural America handedly with 62 percent of the votes, according to Pew Research Center.

Meanwhile, insurers are readying their rates for plan year 2018 and want to know that they’ll continue to receive payments for providing their consumers with cost-sharing reduction subsidies.

The White House hasn’t been particularly clear on what it will do, as President Trump floated the possibility of ending the payments to force Democrats to the healthcare negotiating table.

Health executives met a top Trump health official on Tuesday but came out with no assurances.

They aren’t the only ones pushing for cost-sharing reduction payments. Other parts of the industry also want to know that they’ll be funded, and health experts have said discontinuing the funds could be a fatal blow to ObamaCare’s insurance markets.

“We are concerned and it's not just rural areas, it's a lot of different areas but ... the rural areas can be hit the hardest here,” Joanna Hiatt Kim, vice president of payment policy for the American Hospital Association, told The Hill Extra.

No options on the insurance exchanges could lead to more people without insurance, creating woes for both patients and providers.

Patients will be on the hook for greater out-of-pocket costs and hospitals could be providing care without compensation, which could accelerate even more rural hospital closures.

Since 2010, more than 75 rural hospitals have closed.

“Rural hospitals are small, there [are] less economies of scale, and there's less wiggle room in the system,” Hiatt Kim said. “A big increase in charity care could be a huge problem for them because many of them are operating on really thin margins and a big increase in charity care could eat that up very, very quickly.”

Last August, Aetna decided to pull out of Arizona’s ObamaCare marketplaces — a decision which left Pinal County, Ariz., without any insurer selling plans on the exchanges.

The county quickly gained media attention for being the first to possibly have zero insurers in the marketplace and has been a frequent talking point from Republicans touting their case that the law is failing.

But the no-insurer scenario never actually came to fruition, as Blue Cross Blue Shield of Arizona decided to sell plans in the county.

“The Obama administration and the Arizona Insurance Department worked with Blue Cross Blue Shield to try and encourage them to stay in the market,” Cox said.

“It's not clear the Trump administration or even other state insurance departments would work in the same way or have that same relationship with their plan to be able to encourage them to come back into that county.”

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