Protesters carry signs during a health care rally in front of Trump Tower in New York. (Bryan R. Smith/AFP)

As President Trump urges politicians to “let Obamacare implode,” suggesting that the law will unravel on its own and leave people across the country with no health-insurance options, states are finding their own ways to fill in the gaps in coverage for next year.

Ohio's insurance director announced Monday that by working together with five companies, all but one of its counties would have insurance options next year on the exchanges created by the Affordable Care Act. Twenty Ohio counties had been at risk of being bare in 2018, with no insurers selling plans on the exchanges where people can buy health coverage with the aid of federal subsidies. That void was created in June when the major insurer, Anthem, announced that it would pull out of the state.

“Ohio has long had a strong insurance system, and once again our insurers stepped up at an important time for thousands of Ohioans, taking unprecedented action to provide access to health insurance for Ohioans who otherwise were without options,” insurance director Jillian Froment said in a statement.

A single Ohio county, Paulding County, still has no insurer expected to offer plans on the exchange. Froment said that regulators are searching for coverage options for that county.

State insurance commissioners have been working with companies to plug potential gaps over the past few months. After quite a bit of suspense over whether Iowa would have any insurers offering marketplace plans next year, the Midwestern insurer Medica stepped in to offer plans statewide. Missouri, once at risk of seeing multiple counties lose their insurance options, was able to work with the insurer Centene to fill in bare counties.

“State insurance regulators have a fair amount of  latitude to get plans to participate,” said Dan Mendelson, president of Avalere Health, a consulting firm. “There is a back-and-forth that provides some level of insulation from the craziness of the federal legislative process and the federal administrative process. The states really have an interest in providing continuity.”

The announcement leaves a dwindling number of U.S. counties — 19, to date — at risk of having no insurers selling exchange plans. There are 12,076 people enrolled in those counties who could potentially have no choices next year, according to an analysis by the Kaiser Family Foundation.

Having a single insurer is far from the rich consumer choice that many envisioned, including President Barack Obama, who said people should “shop around in the new marketplace.” And all insurers are closely watching what the White House will do about billions of dollars in federal payments that help cushion lower-income Americans from their out-of-pocket health-care costs, including deductibles.

Trump has repeatedly threatened to stop making the so-called cost-sharing reduction payments to insurers. On Twitter over the weekend, Trump referred to the payments as “BAILOUTS for Insurance Companies.”

The payments, projected to add up to $7 billion this year, are made directly to insurance companies, but their practical effect is to lower co-payments and deductibles for lower-income Americans who buy insurance on the exchanges. Households with income between $24,600 and $61,500 for a family of four, benefit from the payments.

Discontinuing the payments could undermine the work that state insurance commissioners have done to persuade companies to participate in covering their states' counties — and would also result in premium hikes.

“What we know from insurers is some insurers will make the decision not to participate in the exchange market in 2018 if the cost-sharing reduction payments are not funded,” Tennessee's insurance commissioner, Julie Mix McPeak, said.

The next round of cost-sharing payments is due to be issued by the U.S. Treasury on Aug. 21. Trump administration officials have said that a decision could be coming this week on whether to continue those payments.

Mendelson said that the important thing to remember is that the White House has the discretion — and the power — to make the Affordable Care Act disintegrate over the coming weeks and months. “They really have the ability to fulfill the failure prophecy,” he said. “They can do that if they decide they want to.”

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