Deep into the final year of his presidency, Barack Obama is working behind the scenes to secure Obamacare’s legacy, struggling to bolster a program whose ultimate success or failure will likely be determined by his successor.

With no lifeline coming from the divided Congress, Obama and his administration are redoubling their pleas for insurers to shore up the federal health care law and pushing uninsured Americans — especially younger ones — to sign up for coverage. The administration is nervously preparing for its final Obamacare open-enrollment season just a week before Election Day, amid a cascade of headlines about rising premiums, fleeing insurers and narrowing insurance options.


On Monday, Obama met face to face at the White House with leading insurance executives, asking for their continued commitment to the health law despite its recent spate of difficulties. Insurers have come to the White House periodically as the law has rolled out; this time the president made a direct plea for their ongoing support. They in turn pressed their case for steps the administration can still take to strengthen the Obamacare markets.

Notably absent were two of the national insurers that have already bailed on most Obamacare marketplaces — Aetna and UnitedHealth Group.

“We know that this progress has not been without challenges,” Obama wrote this week to each insurer selling Obamacare plans. “Most new enterprises have growing pains and opportunities for improvement. The Marketplace, while strong, is no exception. Time and experience will help drive that improvement, as will constructive policy changes.”

Meanwhile, the administration is taking steps on its own to prevent the marketplaces from collapsing. That includes redoubling efforts to reach out to younger potential Obamacare customers, who have proven particularly challenging to attract in large enough numbers to sustain a high-functioning insurance market. The administration hopes the bully pulpit can bolster that outreach: The president will host a “Millennial Outreach and Engagement Summit” later this month at the White House. And for the first time, the administration will be reaching out directly to individuals who paid a fine last year for not having coverage. HHS Secretary Sylvia Mathews Burwell was on the Hill Thursday updating anxious Democrats about the administration’s efforts to fortify the program.

In a concession to insurers, the administration has also recently taken steps to tighten the enrollment rules to prevent people from gaming Obamacare’s coverage system. Insurers have complained that some customers have been signing up in “special enrollment periods” when they get sick and then dumping coverage once they’ve been treated. Insurers warn the abuse of the rules — designed to help people in special, limited circumstances — is driving up premiums for all Obamacare customers.

Insurers at Monday’s meeting reiterated their concerns about those enrollment issues, according to three insurance officials at the meeting. Burwell and White House senior adviser Valerie Jarrett were among administration officials who attended.

“They are definitely moving in the right direction,” said Mario Molina, CEO of Molina Healthcare. “I think the industry’s concern is how quickly they move on these things."

Martin Hickey, CEO of New Mexico Health Connections, was similarly enthusiastic about the summit with Obama.

“He sincerely seemed to be listening, and I think that gave a lot of comfort to people in the room,” Hickey said. “We all left feeling hopeful that he and the secretary and their staffs would do what they can to address the issues brought up. I honestly felt optimistic.”

But six years after passage of Obama’s signature domestic achievement, the litany of woes afflicting the Obamacare marketplaces is formidable. Enrollment has plateaued at half of what was projected. Three major insurers have largely quit, citing big losses. Double-digit rate hikes are the norm for plans across the country. And roughly one in five Americans may find just one insurer selling plans in their area when they shop for 2017 coverage.

Despite all those problems, the administration still has a compelling case to make for the law’s achievements and for fixing it rather than scrapping it.

On Tuesday, the Census Bureau announced that the uninsured rate last year dipped to 9.1 percent, down more than 4 percentage points since 2013. Nearly 13 million fewer Americans were uninsured last year than prior to the full implementation of Obamacare.

Initial data from the CDC suggests that the uninsured rate has kept right on dropping into this year, to a historic low of 8.6 percent.

In addition, the Obama administration no longer faces the ugly prospect that no insurers will be selling plans in Pinal County, Ariz. The threat of that county becoming an Obamacare ghost town was lifted last week when Blue Cross Blue Shield of Arizona announced that it would sell plans in the county.

But the progress on coverage expansion hasn’t convinced Republicans that the law is sustainable. Most Republicans, including presidential nominee Donald Trump, continue to call for full repeal of the law, which was passed entirely with Democratic votes. That’s made any discussion around legislative fixes to bolster Obamacare a nonstarter.

That unyielding stance has proven potent politically: Republicans have won control of both chambers of Congress in part by demonizing Obamacare. And there’s no chance their stance will change before Election Day. Obamacare’s recent woes have only amped up the apocalyptic rhetoric from Republicans.

“Obamacare is unraveling at an alarming rate,” said Sen. Lamar Alexander (R-Tenn.), chairman of the HELP Committee, on the Senate floor Wednesday. “There’s no excuse for having a failing insurance market where taxpayers are paying most of the bill.”

A hearing this week before the House Energy and Commerce Committee provided another platform for Republicans to bash Obamacare.

“Premium are off the charts,” said Rep. Fred Upton (R-Mich.), who chairs the committee. “Competition has dramatically declined. All in all the everyday patient is left paying more for fewer choices.”

But Democrats countered that Republicans have done everything possible to sabotage Obamacare, holding dozens of repeal votes and hearings to highlight the law’s shortcomings. They stressed that any legislation as complex as the Affordable Care Act is inevitably going to require legislative fixes.

“It’s time to stop having this kabuki dance over and over again, and it’s time to figure out how we can fix the Affordable Care Act,” said Rep. Diana DeGette (D-Colo.).

CMS Acting Administrator Andy Slavitt stressed similar points during testimony before the committee.

“Undertaking fundamental change is rarely easy,” Slavitt said. “Our mantra is to continually learn and adjust.”

But Sen. John McCain (R-Ariz.) scoffed at the idea that Republicans should work to salvage the law. “I remember the victory dance that you guys performed after passing Obamacare without a single Republican vote,” McCain said at a hearing on Thursday. “Now the chickens have come home to roost.”

Without any cooperation from Congress, the administration’s ability to fortify the Obamacare markets remains limited. Of course, the law’s namesake is soon to be a lame duck. That raises at least the possibility that the political gridlock that has existed since Obamacare’s passage could finally ease.

“We’re just hoping that we can get to some practicality come January,” said Ceci Connolly, CEO of the Alliance of Community Health Plans.

