The nation's health insurers, resigned to the idea that Republicans will repeal the Affordable Care Act, on Tuesday publicly outlined for the first time what the industry wants to stay in the state marketplaces, which have provided millions of Americans with insurance under the law.
The insurers, some which have already started leaving the marketplaces because they are losing money, say they need a clear commitment from the Trump administration and congressional leaders that the government will continue offsetting some costs for low-income people. They also want to keep in place rules that encourage young and healthy people to sign up, which the insurers say are crucial to a stable market for individual buyers.
The demands are a sort of warning shot to Republicans. While the party is eager to repeal the law as quickly as possible, and many have promised a replacement, its members are divided over what shape any new plan should take. If they do not come up with an alternative, more than 22 million people would be left uninsured — including more than 10 million who have bought individual plans on state marketplaces.
On Tuesday, Marilyn Tavenner, chief executive of America's Health Insurance Plans, a leading industry trade group, warned that the state marketplaces were already on unstable financial footing. Failing to continue the funding aimed at low-income Americans, she said, would have far-reaching consequences because the business would become much tougher for insurers.
"The market has already been a little wobbly this year," Tavenner said. "If insurance companies believe cost-sharing subsidies will not continue, they are going to pull out of the market during the next logical opportunity."
Insurers could decide within a few months whether to pull out of the state marketplaces for 2018, a deadline they are pushing to have delayed.
The trade group, one of two major groups representing insurers, was a major force in the passage of the law in 2010 and is expected to be influential in its discussions with Republicans. While its clout has been reduced by the departure of large members like UnitedHealth Group, the organization has a powerful voice in Congress.
The Blue Cross Blue Shield Association, the other major trade group, has not yet said what it needs from Republican lawmakers to continue operating in the market.
Tavenner, a former Medicare official in charge of overseeing the creation of the state marketplaces, brings deep knowledge of both the government's and the industry's roles in health care. She said her group had begun meeting with members of Congress and their staffs.
Hospital groups also held a news conference Tuesday to warn of what they said would be the dire financial consequences of a repeal if the cuts to hospital funding that were part of the Affordable Care Act were not also restored.
While insurers say they do not plan to fight the Republicans' efforts to repeal the law, they are in no hurry to see it unwound. And Tavenner said the industry would support a delay so it could prepare for the changes.
"We would love to see a three-year time frame, as long as possible," she said.
The marketplaces, now 3 years old, have not become as robust as expected by many of the people behind the Affordable Care Act. Even President Barack Obama, who pushed the law and the marketplaces through Congress, has suggested possible improvements.
Some of the largest insurers, like UnitedHealth and Aetna, have stopped selling policies on some of the state marketplaces after losing hundreds of millions of dollars, and other insurers say they are still debating whether to stay in the market. Many have raised their premiums sharply.
Tavenner acknowledged that the current law "needed to be improved." But she emphasized that there was widespread agreement among Republicans about the need for some the law's provisions, including covering people with expensive medical conditions. President-elect Donald Trump has also signaled his support of this popular provision.
"There are common starting platforms," she said.
Tavenner did not give many details about her group's positions, but she said its top priority was to stop the immediate threat of eliminating the subsidies for plans sold to low-income people. House Republicans have already sued to block these payments, and the lawsuit is now delayed. If the new administration chose not to defend the lawsuit, the money would disappear, and insurers would probably rush to the exits because fewer potential customers would be available.
Another of the industry's concerns is ensuring that enough young and healthy people sign up to stabilize the market. Republicans have discussed eliminating one of the law's main tools, the so-called individual mandate — a tax levied on those who do not enroll.
In talking with Congress, Tavenner said, her members are emphasizing the need for some alternative, especially after criticism by insurers that the penalty is not large enough to persuade enough people to enroll.
"There's not one magic solution," she said.
Tavenner pointed to some of the provisions in Medicare that encourage people to sign up before they become sick. And she discussed some options to ease how insurers price their policies to be able to offer plans that are less expensive to younger people.
She also argued that the insurers had no desire to return to the time before the law was passed, when people with pre-existing conditions were routinely denied coverage in the individual market.
Still, the industry seems willing to embrace some of the ideas being discussed by Republicans, including giving individuals more choices of plans and more accountability for the cost of their health care. Republicans also seem eager to put the states in charge of some of the details of how coverage in both the individual market and Medicaid will look. Tavenner said the industry had a long history of working with state insurance regulators.
Republicans are discussing other ways to stabilize the market, including the creation of high-risk pools, where people with expensive medical conditions might be covered, bringing down the coverage costs for everyone else.
"We would hesitate to rush back to that," Tavenner said. In the past, those programs, typically run by the states, have not been adequately funded, she noted.
The insurers are also beginning to discuss a potential overhaul of Medicare, pushed by House Speaker Paul D. Ryan, who favors so-called premium support, or vouchers, as a way for people to find coverage.
"We're not big fans of that approach," said Tavenner, although she said the industry would still be open to discussing the idea.
Tavenner said the industry wanted to know more about what the Republicans were planning, including information on the fate of the Medicaid expansion under the law.
"We still have more questions than answers," she said. "We don't want to disrupt individuals who are relying on our coverage," she said.