If Synthetic Repeal is the Trump administration health policy going forward, I do not expect unified push back from insurers.
Fundamentally, insurers hate uncertainty that is impossible for them to price and they hate surprises which they could not price against. They can handle risk. That is their entire business model, pooling and managing risk in a coherent manner while utilizing advanced statistical methods and very large pools to spread risk across their entire portfolio.
The threat to not fund Cost Sharing Reduction (CSR) subsidies was a strong threat in the early part of 2017 that rapidly decayed and is mostly impotent now because it would have been an unpriced surprise. Insurers are now pricing in the probability that CSR will not be paid for 2018 in the majority of states. If CSR is paid, it’s only upside gravy. If CSR is not paid, the rates are high enough that the insurers should not be losing money in 2018 unless there are extreme claim profiles.
2018 will limp forward with high enrollment on the Exchanges in some states like California that is engaged in active outreach and smart remediation of administration sabotage and low enrollment at high costs in states like Indiana. And if Synthetic Sabotage is the playbook, insurers will adjust for 2019.
Insurers already started to price in bad risk pools for 2018. They increased their morbidity projection. Morbidity is the average health/sickness of a risk pool. A sicker risk pool means higher premiums. If actuaries were to prepare 2019 rates starting today and are told to assume that there will be a split market, no mandate enforcement, little advertising and general chaos, they will look at Tennessee or Iowa for a relevant anchor experience and jack up the local morbidity factor for the Exchange risk pool. Insurance companies can make money on very sick risk pools as long the rates are high enough and the post-subsidy premiums are low enough. Premera made money in Alaska on high pre-subsidy rates.
If insurers have a year to prepare for atrocious morbidity, they can make money on the Exchanges as well as on their new or revitalized underwritten, association health plans. And if they can make money, they will not fight too hard.