President Donald Trump contends the health care law is “dead,” but residents of all but one county in America will be able to get an Obamacare health plan next year.

Poised for their fifth enrollment cycle this fall, the Obamacare insurance markets are proving more resilient than many anticipated, with insurers jumping in to cover regions other companies fled, undercutting GOP predictions of widespread market collapses.


“I don’t think the individual market is dead or imploding,” said Kathy Hempstead, who heads insurance programs at the Robert Wood Johnson Foundation.

Bare counties that had been abandoned by health plans once posed a significant threat to a small segment of the Obamacare market as national and regional insurers suffering heavy losses withdrew. More than 80 counties with 92,000 enrollees at various times this year have been at risk of becoming Obamacare deserts in 2018, according to the Kaiser Family Foundation.

The Trump administration showcased those places as evidence of Obamacare's failure as it sought to build momentum for the floundering GOP repeal effort in Congress. But in a sign of how embedded the health law has become — and why Republicans have struggled to unwind it — officials in red and blue states hustled to win back reluctant health plans to ensure constituents wouldn’t be shut out of coverage.

And in the weeks since repeal legislation flamed out in the Senate, typically risk-averse insurers have rushed in serve those small pockets of the country both to save Obamacare — and because they saw a chance to make money.

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Just this week, for instance, Centene, a national insurer that’s been successful in the Obamacare marketplaces, agreed to cover 14 counties in Nevada where no insurer had filed plans for 2018, and Wisconsin insurance officials said a company committed to covering its sole bare county.

"There are times when companies stand up and they do what they feel is right," Nevada Gov. Brian Sandoval, a Republican who's been supportive of the Affordable Care Act, said during a press conference announcing Centene's decision. "This is a proud day for me as governor of this state, that in times of crisis we all come together to find a solution."

Centene, which signed up to sell plans in more than half of the 81 counties that were at risk of being barren next year, also saw a business opportunity. Since the overwhelming majority of Obamacare customers qualify for income-based subsidies, they will be largely immune to huge premium increases and unlikely to drop coverage. That gives a lone insurer incredible power to set higher rates.

“For 2018, we intend to grow this profitable segment of our business,” Centene CEO Michael Neidorff said on a call with investors last month.

The danger period for the Obamacare markets is not over. Insurers could bail on the marketplaces in coming weeks if Trump follows through on threats to pull cost-sharing subsidies, which help insurers pay medical bills for low-income Obamacare customers. Most insurers have until late September to sign contracts committing to the marketplaces in 2018.

“There’s a lot that could happen in those six weeks,” said Jillian Froment, director of the Ohio Department of Insurance.

And competition in the wobbly Obamacare markets is still anemic. National insurers like Aetna and UnitedHealth Group have largely abandoned the markets, while the largest Blue Cross Blue Shield plan, Anthem, is pulling out of multiple states. Nearly half of counties nationwide have just one insurer selling plans, essentially giving consumers a take-it-or-leave-it proposition.

“I think our market is fragile,” said J.P. Wieske, Wisconsin’s deputy commissioner of insurance. “I’m probably not sleeping as well as I was last year.”

Unlike the previous administration, top Trump health officials haven’t actively courted insurers to join the marketplaces. Instead, they’ve regularly highlighted the declining competition.

“As Obamacare continues to collapse, the administration is considering its options on how to address the challenges Americans are facing by canceled plans, higher costs, and failing markets,” HHS spokeswoman Alleigh Marré said in a statement.

State officials have been far more aggressive to fill in the gaps.

Ohio was facing the prospect of having 20 counties without insurers, largely because of Anthem’s decision to exit the state. But Ohio officials eventually reached agreement with five health plans to cover all but one of the barren counties.

“I personally called the CEOs and just asked them to consider if they were in a position to assist with providing coverage,” said Froment, the Ohio insurance commissioner. “In the end it was these companies that really stepped up and helped us solve this problem.”

Now on the eve of next enrollment period, which begins in November, the only potential region without an Obamacare offering in 2018 is a rural western Ohio county where just 334 people enrolled this year. Froment said she is “hopeful” she can still attract a company to Paulding County.

Washington State officials were caught off guard in June when no insurer filed plans to sell in two counties. That’s because the state typically has had some of the most robust Obamacare competition in the country. Washington Insurance Commissioner Mike Kreidler, a Democrat, said he appealed in part to insurance officials’ sense of civic responsibility in seeking companies to fill the barren counties.

“They have a reputation issue that they care about,” Kreidler said. “How are they going to be perceived if they’re the one that bailed on a county?”