State insurance commissioners testify Wednesday before the Senate health committee on ways to shore up the Affordable Care Act marketplaces. From left, Julie McPeak of Tennessee; Mike Kreidler of Washington; Lori Wing-Heier of Alaska; Theresa Miller of Pennsylvania; and Joan Doak of Oklahoma. (Manuel Balce Ceneta/AP)

A bipartisan group of state insurance commissioners on Wednesday sketched out possible common ground where Congress could strengthen the Affordable Care Act's insurance marketplaces, but the chance of lawmakers coalescing around even a modest consensus remains unclear.

At the first of four hearings before the Senate Health, Education, Labor and Pensions Committee, which is trying to forge a small set of improvements to the ACA's shaky exchanges, the commissioners urged senators to guarantee at least two more years of funding for subsidies to insurers that President Trump has repeatedly threatened to abolish.

They also said the government should gives states more flexibility to bypass certain ACA insurance requirements and should recreate a pool of money the law originally provided to help buffer health plans from the expense of covering customers with unusually high medical costs.

The set of ideas advocated in a large, crowded hearing room amount to a strategy to slow recent spikes in premium rates by some health plans sold on ACA marketplaces and to expand consumers' choices given major insurers' defections from some marketplaces. The ideas track the basic contours of changes being touted by Republicans or Democrats — though not necessarily by both — on the HELP committee.

The hearings this week and next are part of a compressed timeline that the committee has set for itself to negotiate a narrow, bipartisan plan that might help the marketplaces. It is a modest goal but one that is a sharp strategic reversal following events in late July when GOP senators' plans to tear apart much of the law imploded spectacularly.

HELP Chairman Lamar Alexander (R-Tenn.) opened Wednesday morning's session by saying that he wanted to reach an agreement by the end of next week. He pointed out that 31 GOP and Democratic senators had turned out for a private coffee before the hearing to talk about how they might arrive at a consensus. "That's a remarkable level of interest," he said.

In outlining his vision for a "small, limited bipartisan step on health insurance," Alexander called on the Trump administration to promise funding for the ACA's "cost-sharing" subsidies through 2018. He also said the government should allow states greater freedom to deviate from a variety of ACA rules, including the benefits that health plans sold through marketplaces must include.

Alexander acknowledged that each party "may be reluctant to support" certain elements but added, "This is a compromise we ought to be able to accept … If we don't, millions of Americans will be hurt."

The committee's top Democrat, Washington Sen. Patty Murray, said senators "need to seize this opportunity." But she noted that they have little time for doing so if they hope to influence insurers' rates or participation before Sept. 27, the deadline for companies participating in the marketplaces to sign government contracts for the coming year.

Murray took a less conciliatory tone than the chairman, saying that "threading this needle will not be easy" and accusing the Trump administration of sabotage of the sprawling health-care law — most recently last week, when officials slashed federal funding of outreach activities and consumer assistance for the ACA's fifth annual enrollment season. Sign-ups start on Nov. 1.

[Trump officials slash advertising, grants to help Americans get Affordable Care Act insurance]

And she quickly reflected the Democrats' differences with their Republican counterparts. The government should promise insurers cost-sharing payments for multiple years, she said.

Other committee Democrats made clear that they expect any compromise to include language or funding aimed at bolstering the enrollment-related activities cut last week. Given Trump's repeated attacks on the law and the recent debate in Congress over dismantling the ACA, "if we're going to boost enrollment in 2018, we're going to have to do things to overcome it," Wisconsin Sen. Tammy Baldwin said in an interview.

Republican senators have privately appealed to the White House to consider accepting a limited package to avert further premium spikes for the coming year. One senator, who asked for anonymity in order to speak frankly, said that Vice President Pence seemed open to the idea this week.

GOP Sens. Bill Cassidy (La.) and Lindsey Graham (Ga.) met with Pence at the Capitol on Wednesday afternoon to discuss their own health-care plan.

The hearings, which continue Thursday with testimony from a bipartisan group of governors, follow Senate Republicans' dramatic failure in late July to overturn central parts of the ACA. This new effort may yield a practical, bipartisan response acknowledging that the insurance exchanges — conduits to medical coverage for about 10 million Americans — will continue to exist. Or it could provide another piece of evidence that the ACA is so politically toxic that compromise on it eludes even the senators most open to collaboration on health policy.

Regardless of the negotiations' fate, the hearings mark the closest collaboration between Republicans and Democrats in years on an issue that has defined their ideological differences perhaps more than any other.

The five state insurance commissioners who testified on Wednesday were invited to provide a ground-level view of ways that the marketplaces in their states have become shakier and to offer suggestions about shoring them up.

Julie McPeak, commissioner of the Tennessee Department of Commerce and Insurance and the incoming president of the National Association of Insurance Commissioners, testified that her state's marketplace had deteriorated further since she said a year ago that it was "very near collapse." McPeak, a Republican, said that 78 of Tennessee's 95 counties will have only one insurer selling ACA health plans for 2018. She urged Congress to start fixing exchanges nationwide by guaranteeing payments of those cost-sharing subsidies and recreating the federal pool of reinsurance money.

Washington's insurance commissioner, Mike Kreidler, said his state has seen a "serious jolt to the system" this year because of "the growing uncertainties and actions of the administration. Our individual insurance markets are in serious peril."

Kreidler, a Democrat, testified that Congress should guarantee cost-sharing payments on a permanent basis — longer than even Murray is urging. He also said lawmakers should leave in place the government's rules spelling out the benefits that ACA health plans must cover, as well as the share of insurance costs that consumers pay.

While President Trump has repeatedly threatened to end the cost-sharing payments, and his administration has each month left their status mystery until just before they are paid, senators and commissioners of both parties endorsed them on Wednesday. The lingering dispute is over how long, with Republican and Democratic commissioners calling for an extension at least through 2019 to reassure a jittery insurance industry.

"We realize that uncertainty within the market is deadly," said Sen. Lisa Murkowski (R-Alaska) said, who asked whether funding the payments through the end of next year would be long enough.

Lori Wing-Heier, who directs the Alaska Division of Insurance, replied that paying through 2019 would be a minimum, while Kreidler said it "should be longer than that."

Some testimony provided support for the GOP's goal of making it easier for states to change their individual insurance market through waivers. "The current waiver process is very cumbersome," said Pennsylvania Insurance Commissioner Theresa Miller, suggesting Congress could simply require a letter from a governor rather than legislative approval of a waiver request. "The more we can streamline the process, the better it would be."

No matter the end result of the panel's efforts this month, Sen. Sheldon Whitehouse (D-R.I.) said its bipartisan approach should become a model for broader attempts by the chamber to improve health care. Ticking off goals — from reducing geographic variations in medical practice to improving care at the end of life — Whitehouse said "there is nothing Democratic or Republican" about them.