With insurance premiums rising amid congressional Republicans' failed attack on the Affordable Care Act, a group of bureaucrats whom few Americans can identify hold considerable power over consumers' health plans: state insurance commissioners.
Elected in 11 states, appointed in the others, they are central characters in the unfolding drama that is the nation's health coverage.
"What's the worst job to have right now? Insurance commissioner," said Christopher Koller, a former Rhode Island commissioner who is president of the Milbank Memorial Fund, a foundation that works to improve health. "They're trying to keep the market stable."
Most are wrestling with how to take on this task amid the ongoing political rancor in Washington, as insurers exit ACA marketplaces and the White House threatens to let the law collapse. Several commissioners are slated to testify Wednesday before the Senate Health Committee on the first of four days of hearings on how to best stabilize premiums and the individual insurance market.
Across the country, the majority of commissioners have the authority to reject or modify coverage rates they deem excessive. Even in states where they don't, the office can serve as a powerful bully pulpit. California Commissioner Dave Jones, for example, lacks the statutory muscle to override insurers' rate increases, but he often uses his position to publicly call out their premium hikes.
"Historically, insurance commissioners have seen themselves as civil servants more than politicians . . . and have kind of stayed out of political battles," said Tim Jost, emeritus professor at the Washington and Lee University School of Law, who also serves as a consumer advocate with the National Association of Insurance Commissioners.
The political pressures on many have rarely been more intense, however. When Tennessee's commissioner, Julie Mix McPeak, persuaded Blue Cross Blue Shield of Tennessee to return to areas of the state that it had left the previous year, "some critics said I was going out of my way to prop up Obamacare," she recalled. "But others said I wasn't doing enough because I'm from a red state and that must mean we want Obamacare to fail. But I just want access to coverage."
The individual insurance market, where about 12 million people enrolled in 2017 ACA health plans because they lacked employer-based coverage, is the focus for much of the drama.
Republicans calling for the repeal and replacement of the ACA say that this market is imploding. Democrats counter that conditions in most of the insurance exchanges created under the law are improving. The commissioners are caught in the middle.
Some had to scramble this summer — negotiating, offering incentives or just downright pleading — to get insurers to stay in their markets. At one point, more than 40 counties nationwide were at risk of having zero insurers selling ACA marketplace plans for next year. All "bare" counties were finally covered on Aug. 24, when CareSource agreed to provide coverage in Ohio's Paulding Country.
McPeak and other commissioners say cost issues need to be tackled, but they first must deal with the more immediate problems.
"We can't get to affordability if I don't have a policy for people to buy," she said.
These efforts are being made more complicated by President Trump's repeated threats to eliminate billions of dollars in payments that effectively reduce deductibles and other expenses for lower-income Americans with ACA plans. The cost-sharing reductions, which are being paid to insurers on a month-to-month basis, probably will be a topic during the upcoming Senate hearings.
"We would all like to know what the rules are. When there is uncertainty, it's difficult to make short- or long-term decisions," said Al Redmer Jr., Maryland's insurance commissioner.
The commissioners reflect some of the partisan divide.
Trump and Congress are causing uncertainty that is "sabotaging the progress we've made," Washington State Insurance Commissioner Mike Kreidler, a Democrat and former member of Congress, wrote in June.
But Oklahoma Insurance Commissioner John Doak calls the law "this disastrous experiment." Doak, a Republican who previously worked for various insurance companies, blames ACA regulations for "so many insurers dropping out of exchanges or resorting to double-digit premium increases."
Commissioners' regulatory powers vary by state. "Some states have comprehensive protections for consumers . . . while others have limited protection," said Claire McAndrew, director of campaign strategy at the liberal consumer advocacy organization Families USA.
No matter the state, though, every commissioner can come up against the formidable strength of the insurance industry lobby — as well as the industry's influence within a legislature.
J. Robert Hunter, director of insurance at the Consumer Federation of America, remembers when he took up his post as insurance commissioner in Texas. He met with lawmakers, some of whom were "unabashed" in their support of the industry. If he went too hard on insurers, they warned him, "We'll hurt your budget."
He didn't play ball, he maintains.
"If insurers are always happy, something is wrong," Hunter said. "Insurance commissioners' jobs are to hold them to account."
Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.