WASHINGTON – Political uncertainty over health care could spell doom for millions of Americans participating in Obamacare marketplace exchanges.

And Iowa could be the first state to experience a blackout by insurance companies who write policies to individuals who don’t get coverage from an employer and are also not eligible for Medicare or Medicaid.

Two of Iowa’s insurers — Aetna and Wellmark Blue Cross & Blue Shield — announced last month they are pulling out of the state next year due to uncertainty in Washington and financial losses.

Medica, the lone remaining Iowa marketplace insurer, reported last week it may likely follow suit for the same reasons, leaving more than 70,000 Iowans without health insurance.

Millions of low and middle-income individuals living in one-third of the nation’s counties, particularly in rural areas, could likewise find themselves without subsidized insurance. Oklahoma and several other states are also down to one insurer.

“Still no decision on 2018,” said Kristen Cunningham, spokeswoman for Blue Cross & Blue Shield of Oklahoma, the only insurer still participating in that state’s marketplace exchange.

Oklahoma’s state insurance commissioner, John Doak, said in March 140,000 individuals in the Sooner State rely on subsidized insurance through the exchanges. He described the potential blackout in Oklahoma as a “dire situation.”

The Trump administration could help address the disquiet by continuing to provide subsidies to the marketplace insurance companies. The subsidies are used by the insurers to keep deductibles and co-payments affordable to individuals in the exchanges.  

There is little chance Congress will move promptly on the contentious Republican health care bill narrowly passed by the House last Thursday. It is now before the Senate and at least one moderate Republican, Sen. Susan Collins of Maine, said she believes the House version is so unacceptable a rewrite from scratch is in order.

The problem is insurance companies have to decide by next month whether they will offer plans in the marketplace exchanges next year. Right now they are in limbo and anxious about making commitments.

Thirteen Senate Democrats — including Pennsylvania’s Bob Casey, Massachusetts’ Elizabeth Warren and Ed Markey, and Michigan’s Debbie Stabenow — wrote President Donald Trump’s budget director Monday, criticizing the administration for not doing enough to encourage companies to continue selling insurance in the exchanges.

The industry group, America’s Health Insurance Plans, said a key factor determining whether insurers stay or leave states is whether the administration continues to pay insurers $7 billion per year in subsidies to lower deductibles and co-payments under the current law.

The Trump administration has yet to decide whether it will stop making the payments beyond this month.

Medica Vice President Geoff Bartsh sent shock waves through Iowa last week with his announcement Medica is seriously considering departing the state “without swift action by the state or Congress to provide stability to Iowa’s individual insurance market.”

The company needs “a stable market, established rules of the road and a clear understanding of the market’s risk” to stay, he said in a statement.

Medica’s announcement set off a blame game.

House Speaker Paul Ryan and other Republican leaders pointed to Iowa as an example of why Obamacare is failing and needs to be replaced.

Democrats’ countered insurers are considering fleeing the marketplace exchanges because the Republican-controlled Congress has been unable to pass a replacement bill, creating uncertainty over subsidies necessary to make policies affordable to individuals in the exchanges.

“The Republicans’ call for repeal without a clear plan has created needless uncertainty for providers, insurers and Iowans alike,” said Rep. Dave Loebsack, D-Iowa, in a statement Monday. “It is long past time that Republicans realize that health care is not a football to be thrown around for political gain. We are talking about real people’s lives here.”

The Senate Democrats letter to White House Budget Director Mick Mulvaney pointed to the subsidies as critical to lifting the ambiguity facing insurers.

“The uncertainty being caused ty the administration’s rhetoric is threating the future of the ACA,” the letter said. “Holding the health care of millions of people hostage as a bargaining chip is unacceptable.”

Contact CNHI Washington reporter Kery Murakami at kmurakami@cnhi.com.