House Speaker Paul Ryan (R-WI) said Monday evening at a town hall that “dozens of counties” across the country have no insurer on the Obamacare marketplace. But in reality, not a single county currently has no insurer and just one is at risk of not having an insurer next year.

“The status quo is not an option. Obamacare is not working,” Ryan told a constituent who asked about the GOP’s ongoing efforts to repeal and potentially replace the Affordable Care act. “A third of the counties in Wisconsin are down to one insurer right here. We’ve got dozens of counties around America that have zero insurers left.”

Ryan says "the House has done its job” with Obamacare repeal efforts: “The Senate has to get back and keep at it” https://t.co/dNBbdaS0Pw — CNN Politics (@CNNPolitics) August 22, 2017

Ryan’s wrong. His comments Monday are part of a consistent pattern by Republicans in Congress and in the Trump administration to misrepresent Obamacare as broken.


Nearly every county in the country currently has at least one insurer. As of Monday, at least one insurer has filed in every county but one, according to the Kaiser Family Foundation.

There have been previous concerns that dozens of counties across the country could be left without an insurer in 2018. In early June, 45 counties were at risk of not having a single available insurer on the marketplace, which was expected to leave an estimated 35,000 people without coverage options.

The concern about “bare counties” quickly became a central talking point among Republicans in Congress and others who claim the ACA is broken.

When Humana announced it would pull out of the Obamacare markets in 2018, President Trump tweeted, “Obamacare continues to fail.”

Obamacare continues to fail. Humana to pull out in 2018. Will repeal, replace & save healthcare for ALL Americans. https://t.co/glWEQ0lNR4 — Donald J. Trump (@realDonaldTrump) February 14, 2017

Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, called the high number of potentially bare counties “another failing report card for the [Obamacare] exchanges.”


But tides have turned in recent weeks. The Kaiser Family Foundation found that there’s just one county in Ohio where an insurer has yet to file for 2018.

There are still concerns about too few insurers participating in the exchanges. According to Kaiser, 21 percent of counties currently have just one insurer, compared to just six percent in 2014. Many Congressional Democrats argue it’s vital Congress take steps to stabilize Obamacare marketplaces.

But when Republicans talk about the ACA, they are wont to leave out two major reasons that insurers have pulled out of the exchanges.

The first is that insurers might have been less likely to exit the exchanges if more states had accepted Obamacare’s optional Medicaid expansion, as the government-funded insurance program for low-income Americans reduces the costs to private insurers.

The second is that market “uncertainty” stoked by Trump and other Republicans has had a tangible effect creating, well, market uncertainty.

Earlier this month, when insurance companies made rate requests for 2018, many insurers who requested rate increases cited the fact that they may need to raise their premiums if Trump takes steps to undermine the ACA.


For instance, Trump may choose not to enforce the individual mandate or not to make the cost-sharing reduction payments (CSRs) to insurers — both moves that could destabilize the marketplaces.

The individual mandate makes premiums less expensive by ensuring that healthy, young people must purchase insurance, thereby subsidizing the more expensive, sicker and older people in the insurance pool. The CSRs are payments the federal government makes to insurers to help cover the costs of insuring lower-income people. Although the White House recently announced it would continue making the CSR payments, Trump can decide to stop making the payments at any time.

At any rate, the ACA is certainly working better than recent proposals to repeal and (maybe) replace it would.

“The status quo is not an option,” Ryan said Monday night. “You just described your premium increases, your deductible increases… Doing nothing really isn’t an option. The Senate, honestly, the Senate has to get back and keep at it.”

But if the goal is to provide Americans with good health insurance, with cheaper premiums and deductibles, the attempts to repeal and potentially replace the ACA don’t do that.

The CBO estimated that the repeal and replace bill that passed the House would leave 23 million more people uninsured in the next decade. A “repeal and delay” proposal that a number of Congressional Republicans have advocated for would leave 32 million more people uninsured by 2026, with premiums expected to double during that time.

But we should perhaps cut Ryan some slack because it’s not clear he knows how insurance works. In March, the speaker said insurance can’t work if healthy people have to pay more to subsidize the sick, despite the fact that this is literally the definition of health insurance.