Facing an uncertain future as the Affordable Care Act teeters, health insurers have stepped up lobbying efforts to make sure their wish list of policy changes comes true.
Demand is high in Washington for industry operatives who can educate lawmakers, administration officials and their staffers about the effect of changes to President Barack Obama's health care law.
"It's really difficult to quantify how busy it is," said a health insurance lobbyist who spoke on the condition of anonymity. "I like to think I have a lot of time to thoughtfully look through stuff and read things. That isn't the case right now. You're running around with your hair on fire."
As the fight for access heats up, some industry watchdogs fear that consumers will suffer as deep-pocketed insurers look out for their own bottom lines.
Insurers from all sectors, including life, health and auto, spent nearly $147 million on lobbying in 2016, according to public records. They poured more than $79 million into political contributions.
Hoping to tighten marketplace rules, retain federal subsidies for plan members and raise rates for older enrollees, insurers in the individual market are going all in to make sure they get favorable legislation and regulations to guide any repeal, revision or replacement of the Affordable Care Act.
It's not just insurers looking for extra help. Expect securities, banking and energy interests to "lobby up" as well under the business-friendly Trump administration, said Burdett Loomis, a political science professor at the University of Kansas who's an expert on interest groups and congressional lobbying.
"Structurally, there's nothing Trump could have done to encourage more people making money off lobbying than to disrupt health care, financial services and energy all at once," Loomis said. "It's a full employment act for lobbyists."
Medicaid Health Plans of America, a trade group, is adding a second in-house lobbyist and hiring a new outside lobbying company, essentially doubling its efforts to influence legislation, said Jeff Myers, the group's president and CEO.
It was clear to the group's board members and to him that "we're entering into some uncharted waters and we really need to dramatically increase our bandwidth," said Myers, whose member plans cover 73 percent of the nation's Medicaid enrollees.
Myers' group wants to lower the cost of care for dual Medicaid-Medicare enrollees, improve access to substance abuse and mental health services, and lower the program's prescription drug costs _ all amid the threat of terminating the ACA's Medicaid expansion.
These kinds of negotiations will determine the future of the ACA and affect millions of lives.
"My worry is that consumers will not have a seat at the table," said Wendell Potter, a former health insurance executive who writes about industry shortcomings.
While insurers support continued federal subsidies to help people pay for marketplace coverage, millions of others could lose coverage if the Medicaid expansion is halted. Potter fears that whatever remains of the health law once the dust settles, consumers will face diminished coverage and higher prices when the final details of the repeal effort are hashed out.
"I'm pessimistic about the outcome, quite frankly," Potter said. "I know how influential those lobbyists are because there's so much money behind them."
America's Health Insurance Plans, an industry trade group, spent nearly $7 million for lobbying in 2016, according to public records.
Blue Cross and Blue Shield and its subsidiaries spent more than $25 million. The insurer includes 39 independent companies that collectively cover nearly 98 million people.
Lobbyist spending is almost certain to rise this year as the Trump administration rewires the ACA through rule changes and executive orders and Congress wades through more than a half-dozen repeal proposals.
The Capitol Hill lobbyist likened the environment to the early days of the Affordable Care Act negotiations shortly after Barack Obama was first elected president in 2008.
"In 2008 and 2009, every week we were having a hearing or a markup, or somebody was dropping a report on us. Or a new proposal or a new regulation came out. It was nonstop for almost two years. For me, it's like that," the lobbyist said.
Potter, a former health analyst at the Center for Public Integrity, a nonpartisan research center, fears the worst for consumers.
"I'm afraid it will take us back to an individual market that resembles what we had before, which was hardly a market at all," Potter said. "It worked for insurance companies, but it sure didn't work very well for most consumers."
But health insurers are facing unusual head winds as they try to operate in a time of uncertainty for the health care law. Lower enrollment and higher-than-expected medical costs led many to leave the marketplace and those that raised premiums significantly in 2017.
To continue beyond this year, insurers want to stabilize the individual insurance market through rule changes that will help attract healthier people to coverage. Their lower medical costs help insurers offset sicker, higher-cost enrollees.
"Without that stability it will be a challenge for health plans to design products and price those products effectively" for 2018, said Kristine Grow, senior vice president for communications at America's Health Insurance Plans.
One change insurers want is to stop allowing people to enroll in a marketplace plan, then take advantage of a 90-day grace period in which coverage is provided even without payment of premiums. Insurers lose money in those situations because people run up medical bills and sometimes never make a payment. Some simply re-enroll the following year in different plans.
Insurers also want to change an ACA rule that allows them to charge older plan members only three times more than younger ones. Insurers want to charge up to five times more because older plan members typically have much higher medical costs.
Doing so would allows plans to offer cheaper coverage for young people, whom they need in order to keep an optimal mix of healthy and sick plan members so that "premiums go down for everyone," Grow said.
But AARP is already fighting the proposal. A new study it commissioned shows premiums for people 60 and over would jump an average of 22 percent, or $3,192 per year, under the proposed change. Those ages 50 to 59 would see an average 13 percent increase of about $1,524 per year.
Trump is expected to issue a new federal rule that will address these and other insurer concerns, said Ed Haislmaier, a senior research fellow at the Heritage Foundation who consulted the Trump administration about marketplace problems.
Expect the AARP to ramp up its lobbying efforts in opposition.