The first health insurance policy Lisa Eimer purchased under Obamacare in 2014 was canceled.
The price of the next plan shot up about 20 percent in a year.
When the 35-year-old Nottingham woman describes her coverage during the early days of the Affordable Care Act, she uses words such as “fantastic.” When she talks about the current system — and the next round of premium increases to come — she has a different word: “Outrageous.”
Following the dramatic failure of Senate Republicans to repeal President Barack Obama’s seven-year-old health care law early Friday, attention in Washington and across the nation is shifting back again to a fundamental question: Whether the health care exchanges set up under the Affordable Care Act are stable enough to survive on their own.
For some 130,000 Marylanders, the answer is more than academic.
After years of rising premiums, Eimer, an executive assistant at a charter school in Baltimore, now pays about $440 a month for a policy with such a high deductible that she never files a claim.
“It would be cheaper for me to pay [for health care] out of pocket,” she said. “There’s going to come a point where it will be completely unaffordable.”
President Donald J. Trump, who made repealing Obamacare a central theme of his presidential campaign last year, has said repeatedly that the individual insurance market set up under the 2010 health care law is doomed to collapse.
"As I said from the beginning, let ObamaCare implode, then deal," Trump posted on Twitter hours after the Senate killed its latest repeal effort. "Watch!"
Health care analysts say that rhetoric is overblown, and that the success or failure of the health exchanges set up under Obamacare rests largely with the Trump administration itself. But even in states like Maryland, where the law received strong support from the public and local officials, the signs of strain are evident.
Three insurance companies — Aetna, Cigna and UnitedHealthcare — have pulled out of the state exchange. A fourth, Evergreen Health, said last week it would wind down current policies and would not offer more. That will leave only two insurers — CareFirst BlueCross BlueShield and Kaiser Permanente of the Mid-Atlantic States — selling Obamacare plans in Maryland.
CareFirst, the state's predominant insurer, has asked for an average 52 percent increase in premiums next year; state regulators are reviewing the request. President and CEO Chet Burrell said Friday the company would decide this week whether it needs to seek a greater rate increase — on the order of 5 percent to 10 percent more.
Health care policy consultant Robert Laszewski said the developments were troubling.
"This should be one of the examples of a successful pool, and yet CareFirst just can't catch up," he said.
Health care analysts and insurers blame the instability on several factors. Too many young, healthy people have ignored the individual mandate to buy insurance because the penalty is less than the cost of a policy.
Because the Affordable Care Act now requires insurance companies to write new policies for people with pre-existing conditions, some wait until they get sick to buy insurance.
Another cause of the premium increases is uncertainty about whether the Trump administration — which has been highly critical of Obamacare — will push on the system's weak spots.
"What you've got is a problem going into the Trump inauguration,” Laszewski said. “The [market] was in horrible trouble. And then Trump comes along and says he's not going to enforce the individual mandate. And that creates even more uncertainty."
Trump could make it clear that his administration will not enforce tax penalties on people who don’t buy coverage — a move that would likely encourage more healthy people to leave the market. Or he could follow through on threats to withhold the cost-sharing subsidies that help low-income families pay for out-of-pocket costs. Either approach would increase premiums, driving more young and healthy people out of risk pools.
Burrell said about 20 percent of CareFirst's rate increase request for next year is based on fears that the Trump administration will no longer enforce the individual mandate.
He said higher rates might be needed, particularly if officials cut off the subsidies for low-income enrollees. He said no one will get premium relief until insurers get help covering the most expensive people — those with more than $15,000 a year in claims.
The Senate vote Friday “does not mean we are in a period of stability,” he said. “This is a period of great, great instability. Insurance is no longer affordable or achievable for many people … The story isn’t over, and the challenges to make the market stable are not over.”
Some say there are signs conditions are improving. In a study released this month, the nonpartisan Kaiser Family Foundation found that insurers spent 75 percent of premiums on claims in the first three months of this year, compared with 86 percent during the same period in 2016 and 88 percent in 2015.
Karen Pollitz, a senior fellow at the foundation, said insurers initially came into the market too low, and the rates are now beginning to catch up with reality.
“It's really hard to make this market stable all by itself, because people come and go,” Pollitz said. “They have [now] been able to set premiums that are enough to cover the claims.”
Now, however, “the current uncertainty just changes all of that all over again.”
The Maryland exchange has been convening focus groups this summer to help determine whether officials need to tweak their marketing during open enrollment to appeal to younger people, reassure folks that the exchange is still open for business and reach new enrollees, according to Dr. Howard M. Haft, its interim director.
“The exchange is running and covering a lot of people,” he said. “Uncertainty in Washington is … the wildcard in the discussion.”
Eimer is precisely the kind of customer insurers selling in Maryland’s marketplace need: Like roughly 40 percent of customers in the exchange, she and her 13-year-old son are relatively healthy. She wants health insurance in case something catastrophic happens to her family.
But she is also the kind of person who has been most affected by years of premium increases. Nearly a quarter of Obamacare enrollees, including Eimer, earn too much to qualify for federal subsidies to offset the cost of premiums. That means Eimer and others like her must shoulder rate increases themselves.
“It’s terrifying,” said Eimer, “Every time I hear something in the news, I want to follow it, but it's also agonizing.”
Democrats, who passed the health care law in 2010 without Republican support, have acknowledged problems with it. But they have suggested those issues could be fixed with relatively minor changes rather than a wholesale repeal. Sen. Chris Van Hollen said Trump must first stop working to undercut the current system.
“The president needs to stop doing everything he can to sabotage the Affordable Care Act,” the Maryland Democrat said in an interview. “We know in Maryland that the lion’s share of the increase requests … is a direct result of the Trump’s administration’s sabotage.”
Republicans have taken a different view. Rep. Andy Harris, a former Johns Hopkins anesthesiologist who has run repeatedly on repealing Obamacare, said the system itself hasn’t worked for insurers or enrollees.
“I think [insurers are] tired of losing money on the policies,” the Baltimore County lawmaker said.
Amid the hyperpartisan debate in Washington, those in Maryland who would be most affected by changes to Obamacare view its challenges through a pragmatic lens. Several people who buy coverage in the state's health insurance exchange said they just want the problems to be fixed.
Jim Honsberger describes himself as a Republican. But the Sykesville man said he would be fine with either a full repeal of Obamacare, an idea embraced by conservatives, or moving to a single-payer health care system, which has been embraced by some liberal Democrats.
Under a single-payer system, the federal government would provide Medicare-style insurance to everyone.
Honsberger, 59, said his premium has nearly doubled to $1,200 a month since last year.
"I'm so fed up with the system right now," he said. "Everyone has done half-measures, and the half-measures have just left us a lot of nothing."
House Republicans passed a comprehensive health care bill in May, but cuts it proposed for Medicaid were unpalatable to many GOP senators. The nonpartisan Congressional Budget Office concluded that the bill would reduce average premiums by between 4 percent and 20 percent in 2026 compared to the current law, but said 23 million fewer people would have coverage.
Republican leaders in the Senate have been unable to gather enough GOP support for that measure, or any other version of repeal. A last-ditch effort that would have eliminated some portions of Obamacare — including the individual mandate — died early Friday after three Republicans joined Democrats in opposition.
Senate Majority Leader Mitch McConnell suggested that Congress should move on from the health care debate, but it is not clear whether that will happen. The GOP repeal effort has appeared dead many times before only to surge back to life.
Continuing increases in premiums would likely spur calls for lawmakers to give health care another try.
Riding instructor Aviva Nebesky owns a horse farm in Bowie. The 58-year-old woman and her husband, who is self-employed, have held a CareFirst policy for years. Nebesky said they currently pay close to $24,000 a year in premiums.
Nebesky said she doesn’t intend to let their private insurance coverage lapse before they become eligible for Medicare at age 65. But the increases that already have been proposed would take a huge hit on their budget. And Nebesky is concerned that plans under consideration in Congress could make matters worse.
“My husband and I are lucky. We can afford our premiums,” she said. “Not everyone is as lucky.”