It’s a problem that’s likely to be replicated elsewhere, says Timothy Jost, an emeritus professor of law at Washington and Lee University in Virginia and an expert on the health law. “In many states, it’s going to be hard to maintain a functional individual market,” he says. “Charlottesville is sort of ahead of everybody else in this ... but this is the direction things are heading.”

Insurers nationwide that intend to participate in the individual market face spring deadlines to file forms for 2019 plans and rate proposals. In Virginia, these dates are April 20 and May 4, respectively.

The situation in Charlottesville has left many residents at their wits’ end about how to pay for their health insurance, prompting the evolution of an angry and rebellious civic movement and thrusting the costs of coverage into the center of local politics.

Charlottesville for Reasonable Health Insurance, a grassroots organization with a Facebook group of more than 700 people, has already claimed small victories in the state legislature, such as propelling the passage of a bill that will alleviate the cost burden for some of its members. But its highest priority has been pressing state regulators to explain and possibly reconsider the decision that allowed for the stunning premium increase.

In the midst of various bureaucratic fits and starts, the state Bureau of Insurance (BOI) responded to the group April 11 by reiterating that Optima’s rates were “actuarially justified.” Ian Dixon, one of the group’s organizers, says they plan to appeal this finding to the State Corporation Commission. “We’re not going away, that’s for sure,” Dixon says. “They’re hoping they can wait us out ... They would drag this out for a year if they could.”

At the same time, the group has expanded its focus to other issues on health-care costs, such as price transparency and regulatory reform.

The trouble started in summer 2017, when the state’s major insurance carriers announced they would be leaving the individual market in Virginia, saying the market was “shrinking and deteriorating”—pointing to the instability of Obamacare under the Trump administration. Their departures left Albemarle County, home to Charlottesville, bare—meaning residents had no insurance options.

When Optima opted to continue to offer plans in and around Charlottesville, state insurance regulators breathed a collective sigh of relief. But Optima’s decision came with updated rate-increase proposals, which gained the okay of the under-the-gun BOI, led by Commissioner Scott White.

“I think the [regulators] decided they were willing to accept almost anything to get someone to cover Albemarle County and Charlottesville,” Jost says.

About 15 miles north of Charlottesville on U.S. 29, there’s a billboard that some residents now view with bitter irony. It features a smiling man with the message: “I chose Optima.”