BARTLESVILLE, Okla. — When President Trump describes the Affordable Care Act as “imploding,” Lori Roll, an insurance agent here, does not consider it hyperbole.
Only one health insurer in Oklahoma is left selling coverage through the federal marketplace, and the hospital in this city of 36,000 is not in the network. Premiums are among the highest in the country, and while most marketplace customers qualify for the Affordable Care Act’s income-based subsidies that lower the cost, many of Ms. Roll’s middle-class clients do not.
“A lot of them are friends,” she said, “and I’m having to tell them: ‘My God, your premium just doubled. I’m so sorry.’”
In neighboring New Mexico, also under Republican leadership, the Affordable Care Act marketplace is in far better shape. Marketplace customers can still choose among four insurers, and the state has one of the lowest average premium costs.
Nearly four years after they opened, the Affordable Care Act’s health insurance marketplaces, also known as exchanges, are not uniformly failing, as Mr. Trump likes to claim. Instead, they have risen or fallen in no small part because of political and policy decisions by each state. New Mexico embraced the law and its marketplace has been healthy, while Oklahoma resisted at every step and its marketplace is foundering.
But now both states are worried that political maneuvering at the federal level may deeply destabilize the marketplaces. In an effort to get Democrats to negotiate, Mr. Trump has threatened to stop paying more than $7 billion in subsidies to insurers that don’t charge deductibles and co-payments to millions of poor people. Uncertainty about the subsidies, which are a critical financial underpinning of the law, may drive more insurers out of the market — leaving Oklahoma with no health plans in the marketplace — and raise premiums significantly higher for those that stay.
Politics at both the state and federal levels have been critical to shaping the success and failure of the Affordable Care Act. Oklahoma and New Mexico offer a case study of how that has played out.
New Mexico expanded Medicaid as soon as the law allowed, oversees its marketplace and conducts vigorous outreach to draw in potential customers, moves that have most likely helped attract healthier customers.
Oklahoma has raged against the law since its passage, challenging its subsidies in a lawsuit and refusing to expand Medicaid or set up its own state-run insurance exchange. Instead, the federal government runs the state’s marketplace through HealthCare.gov, an option taken by more than two dozen mostly Republican states.
“I was never for Obamacare from the beginning,” John D. Doak, the Oklahoma insurance commissioner, said in an interview at his office, where a red trucker hat that says “Make Health Insurance Great Again” sits on his desk.
The uninsured populations in both New Mexico and Oklahoma have fallen since the law took effect. But New Mexico’s progress has been stronger, even though it started with a higher rate of uninsured.
Oklahoma’s uninsured rate was the third highest in the country in 2015, the most recent year available: 13.9 percent, according to the Census Bureau, compared with 17.7 percent in 2013, just before the Affordable Care Act’s coverage provisions took effect. New Mexico’s uninsured rate fell to 10.9 percent in 2015 from 18.6 percent in 2013.
Here in Bartlesville, an oil town that has felt the economic impact of the drop in oil prices, the anger that Ms. Roll and many of her clients feel is directed more at the health law — and its champion, former President Barack Obama — than at the state’s unyielding resistance to it.
“You don’t get on the Titanic when you know it’s going to sink,” said David Moore, 51, who owns a fishing tackle business.
Mr. Moore, a self-described “libertarian guy” who voted for Mr. Trump, avoided a doubling of his premiums this year by switching to a small group health plan with his wife, an audiologist, and one of her employees. But Mr. Moore, who earns too much to qualify for premium subsidies under the Affordable Care Act, still saw his monthly premiums increase sharply for his plan covering his family of four, to $1,100 from $700, with a $12,000 deductible.
“My biggest problem with this is our government picking winners and losers,” Mr. Moore said, referring to the fact that lower-income people get large subsidies under the law and higher-income people do not. “I’m a loser. And it should not be this way.”
Cameron Jarrett, 31, is equally disappointed with his insurance options, even though his employer gives him money toward his premium and he gets a subsidy, too. He pays the rest: $303 a month for a Blue Cross plan that covers his family of three, with a $12,000 deductible.
Still, Mr. Jarrett, another Trump voter who wants the Affordable Care Act repealed, does not entirely blame the law.
“States like Oklahoma that sit on their hands and do nothing — that’s not helping,” he said. “If we’re going to do this, let’s give it every opportunity to work, even if it’s not a policy I agree with over all.”
Mr. Trump and Republicans in Congress have repeatedly pointed to markets like Oklahoma’s, with just a single insurer, as a sign that the Affordable Care Act exchanges are deeply troubled. But Oklahoma’s individual market has never been very competitive. In New Mexico, several local insurers have long competed on the individual market, but Blue Cross has been the dominant player in Oklahoma for years, and is now the only insurer offering plans on the exchange. Even when other insurers offered plans through the Affordable Care Act marketplace during its first few years, Blue Cross scooped up by far the most customers.
In addition to big decisions, like whether to expand Medicaid, some seemingly minor ones may have influenced the marketplaces’ health. Oklahoma has continued to allow about 45,000 people to keep old policies that do not meet Affordable Care Act standards. People with this type of “transitional” policy tend to be healthy, and may have helped the risk pool if they had been required to buy insurance through the exchange. Oklahoma is also one of three states that do not review insurers’ proposed rates from year to year, ceding the job to the federal government instead.
In New Mexico, on the other hand, insurance regulators did not allow people to keep their old plans and required any insurer that sold plans through the Affordable Care Act marketplace to offer them in every county. John G. Franchini, the state’s superintendent of insurance, has also negotiated rates with insurers, even denying a 52 percent increase requested by Blue Cross and Blue Shield of New Mexico for 2016.
Now, seven years after Mr. Obama signed the Affordable Care Act into law, Oklahoma is changing its stance and seeking a more active role. The state is preparing to ask the federal government’s permission to change how the Affordable Care Act works here through waivers allowed under the law. One of its proposals is to help very poor people afford private plans by giving them subsidies.
The state may also ask for permission to “re-evaluate” and perhaps reduce the package of essential benefits that the Affordable Care Act requires every insurance plan to have. And it wants plans under the law to be sold not through the federal marketplace, but through a local program called Insure Oklahoma, which has provided subsidized coverage to a small subset of low-income residents here since before the health law took effect.
The changes, which the state hopes would make insurance more affordable and provide more choices, would have to be approved by the Trump administration and in some cases by the Legislature. Most would not go into effect until 2019 at the earliest.
Meanwhile, Oklahoma, which has faced a series of budget crises because of the oil industry downturn, does not have the money to help pay insurers’ costs next year, as Alaska and Minnesota are doing. So Oklahoma is looking to the Trump administration and Congress to help stabilize its marketplace in time for next year and persuade Blue Cross to stay.
Mr. Doak raised alarms last month when he wrote in a letter to Gov. Mary Fallin, a fellow Republican critic of the health law, that Blue Cross was “making preparations to withdraw” from the marketplace. Blue Cross, which is operated as a nonprofit insurance company, said it had not made a final decision about next year.
“We certainly want to continue to offer products in 2018,” said Kurt Kossen, an executive at Health Care Service Corporation, Blue Cross’s parent company.
Mr. Doak said that without any stabilization funds or other federal efforts to stabilize the individual insurance market, another round of steep premium increases was inevitable here.
But Blue Cross plans have generally been doing better in the marketplaces, and Health Care Service Corporation, which offers plans in Oklahoma, New Mexico and three other states, is losing less money. It aggressively raised prices last year, with a 75 percent average rate increase in Oklahoma.
A major factor in the insurers’ losses was the decision by Congress not to fully fund a program aimed at protecting insurers during the early years of the Affordable Care Act, when the companies did not know what to charge. Mike Rhoads, the deputy insurance commissioner, said Blue Cross “started too low,” with some of the lowest prices in the country in 2014.
Regulators in both states say that now, the fate of the marketplaces depends very much on the actions of Congress and the Trump administration.
“We’re just a little boat in this ocean,” said Mr. Franchini, the New Mexico superintendent. “If there’s a tidal wave from Washington, it could scuttle us.”