So the struggle is real, at least for these 5 million or so people. Will it become more severe now that an Obamacare replacement is off the table?

According to Cox and others, it depends on what the Trump administration does to stabilize insurance markets. If they do nothing, things will probably get worse. For example, by pulling advertising for Obamacare in the final days of open enrollment earlier this year, when more young people sign up for insurance, the administration might have already dampened young peoples’ enrollment, leaving a sicker and more expensive mix of enrollees. It’s likely more insurers will announce they’re pulling out of the exchanges, Cox said, since the anti-ACA stance of the administration has injected more uncertainty into what many already thought were difficult markets. That might leave some counties without a single insurer on the exchange. (It’s unlikely the mandate to buy insurance would be enforced against people in those counties, however.)

If the Trump administration stops enforcing the individual mandate entirely—it has already softened the rule—or grants lots of exemptions to people who simply don’t want to buy insurance, the mix of people in the individual market could become much sicker. That, combined with the instability insurers are already feeling, could cause premiums to rise further.

“I think [premiums] will go up and will go up higher than if they would have if none of this conversation around repealing the ACA was happening,” Cox said.

Because insurers increased Obamacare rates so much last year, it was considered a “one-time event,” according to an S&P Global Ratings analysis. But the Trump administration’s highly public Obamacare criticism, combined with three months of discussion about repeal, might have made insurers newly nervous. “If none of this stuff had happened, and Hillary had been elected, insurers would have said ‘we had big increases, but we’re okay now,’” said John Holahan, a fellow in the Health Policy Center at the Urban Institute.

The problem is, Obamacare isn’t a grandfather clock that Obama set into effortless, perpetual motion. It’s more like a cantankerous old car, one that requires lots of maintenance to keep it purring. As my colleague Vann Newkirk explained last week, there’s a lot the administration could do to undermine the individual market further. House Republicans are currently fighting a lawsuit to stop Obamacare’s payments to insurers to help pay for their customers’ deductibles. It’s up to the Trump administration to either keep fighting that lawsuit or get the House to drop it so those payments can continue—otherwise, many insurers might leave or raise their prices.

“If the administration continues to dispute its obligation to pay health plans for the cost sharing assistance they provide and continues to refuse to pay the risk corridor amounts owed, then it will effectively be making the administrative decision to harm markets everywhere,” said Sara Rosenbaum, a health-policy professor at George Washington University. Together, stopping the enforcement of the individual mandate and stopping the payments to insurers would amount to a rise in premiums of about 25 to 30 percent, said Andy Slavitt, the former acting administrator of the Centers for Medicare and Medicaid Services.