In his high-stakes strategy to overhaul the federal health law, President Donald Trump is threatening to upend the individual health insurance market. But if the market actually breaks, could anyone put it back together again?

The question is more than theoretical. Since Jan. 20, the Trump administration has already acted to depress enrollment in Affordable Care Act plans, has instructed the IRS to back off enforcement of the requirement that most people have health insurance or pay a penalty and threatened to withhold billions of dollars owed to insurance companies. All of those actions make it more difficult for insurers to enroll the healthy people needed to offset the costs of the sick, who make it a priority to have coverage.

The president himself has made his strategy clear in interviews and tweets. “The Democrats will make a deal with me on healthcare as soon as ObamaCare folds — not long,” Trump tweeted March 28. “Do not worry, we are in very good shape!”

But the individual insurance market is not in such good shape.

A growing number of insurers are asking for double-digit premium increases or deciding to leave the market altogether. In the latest announcement, Anthem said Tuesday that it was pulling out of the Ohio marketplace, where it serves more than 10,000 customers, next year. And while most analysts say the market probably would eventually rebound, in the short term things could get messy.

“Is the administration doing what it needs to do to stabilize the market? No, they’re doing the opposite,” says Kevin Counihan, CEO of the insurance exchange program during the Obama administration.

Trump’s biggest weapon by far is refusing to reimburse insurance companies for billions of dollars in payments the law requires them to make to help policyholders with incomes up to 250 percent of the federal poverty level, about $30,015 for an individual and $61,500 for a family of four, afford their deductibles and other out-of-pocket payments. These “cost-sharing subsidies” are being challenged in an ongoing lawsuit filed by Republican House members against Health and Human Services in 2014, and Trump can effectively end them at any time by dropping the suit.

Meanwhile, major insurance companies like Aetna and Humana have already announced that they won’t participate in the health exchange market for 2018.

Other insurance companies have said they would like to stay in, but only if they are granted huge rate hikes, citing the uncertainty of whether the Trump administration will repay them for the cost-sharing discounts and whether it will enforce the health law’s “individual mandate” that requires most people to have coverage or pay a fine.

In Pennsylvania, for example, insurers are seeking premium increases of less than 10 percent for 2018 – but warn that if the mandate to have insurance is not enforced or cost-sharing reductions are not paid, those increases could balloon to 36 percent or more.

Those who follow the market closely say the exits and requests for large premium increases are no surprise. “It’s just been one thing after another in this market,” says Kurt Giesa, an actuarial expert at the consulting firm Oliver Wyman. He said if the administration follows through on its threat not to fund the cost-sharing subsidies for the rest of the year, “that could be the straw that breaks the camel’s back.”

Giesa pointed out that it’s not just insurance companies that would suffer if the individual insurance market is crippled. “That strategy of crashing the market has real human consequences,” he says. “There are 15 million-plus people relying on that.”

That group includes not only people who purchase insurance through the “health exchange” state marketplaces, but also those who purchase insurance on their own, usually because they earn too much to get federal assistance paying their premiums. Premium subsidies are available to those who earn less than 400 percent of the poverty level, about $48,240 for an individual and $98,400 for a family of four.

People who pay their own way are the ones getting hit hardest, says insurance industry consultant Robert Laszewski. “There is a horrific death spiral going on with the [non-subsidized] part of the market right now,” he says, because rate hikes are limited for those getting help from the government, but not for those paying the full premiums.

A major question is how hard would it be for the government to regain the trust of insurers as a reliable business partner, regardless of what changes are eventually made.

Counihan acknowledges that insurers felt they were treated unfairly even before the Trump administration took office, when Republicans in Congress prevented full payment of “risk corridor” funds that the law promised to insurers who enrolled more than their expected share of sick people. Insurers are still owed millions of those dollars, and many have sued the federal government to try to get the money.

Counihan said the first words out of the mouths of most insurance CEOs he met with were “we don’t trust you guys.”

Giesa says the government’s misbehavior goes back even further – to the fall of 2013, when the Obama administration allowed some consumers to keep their old plans. That effectively kept healthy people out of the new markets, “after companies had set their prices,” Giesa says, resulting in some big losses for insurance companies.

Despite the woes, insurance analysts say they doubt the individual market would stay down for long.

One reason, says Laszewski, is that for many nonprofit insurers serving the individual market as the insurer of last resort is part of their mission, unlike with big commercial insurers. Boards of Blue Cross Blue Shield plans and other nonprofits, he says, tend to be made up of representatives of “labor, the local hospitals, big employers. … They have community connections. So it’s going to take a lot to drive them off.”

Another reason insurers will likely return or work to remain in the individual market is that it’s part of the future of health care, says Counihan. With so many people now working for themselves in the “gig economy,” he says, selling insurance “is going to be more business-to-consumer than business-to-business.”

“This market could grow,” agrees Giesa. “And I don’t think [insurance companies] want to be left out completely from this market if there’s an opportunity to break even, or make a little money.”

In the end, says Counihan, regardless of what he considers the Trump administration’s “disorganized neglect, I think this market is here to stay.”

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

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Every Friday, Christine Crawford has a counseling session at a clinic at New York City’s Mount Sinai Health System as she moves ahead with plans for gender transition surgery later this year. In addition to the many medical and psychosocial issues, there are practical ones as well. So, Crawford was thrilled when a Mount Sinai representative told her they would assign a lawyer to help her legally change her name to Christine.

The lawyer filed her name-change petition with the court and helped Crawford with other steps, such as notifying her former spouse and publishing the name change in the newspaper. She gave Crawford information about what she needed to do to make the change official with organizations such as the Social Security Administration and the Department of Motor Vehicles.

Perhaps best of all, when Crawford graduated with a master’s degree in social work last month, her diploma had her new name on it.

“[The lawyer] was able to expedite the petition and the court date,” Crawford says. “She was a godsend.”

As health care systems continue to shift toward becoming comprehensive medical homes for patients, health care providers are increasingly incorporating lawyers into the team of professionals who are on hand to help with legal issues at no additional charge to patients.

Roughly 300 health care systems, children’s hospitals and federally qualified health centers have set up these programs, says Ellen Lawton, co-director of the National Center for Medical-Legal Partnership at George Washington University in Washington, D.C.

The pairing makes sense in many ways. Legal issues all too often can cascade into problems with bad medical outcomes. Lawyers might file for an order of protection from a violent spouse, help appeal an insurance claim denial or get involved in child custody, guardianship or power of attorney issues.

For Care Connections at Lancaster General Health/Penn Medicine in Lancaster, Pa., housing problems are a key area that requires legal expertise. The four-year-old program provides comprehensive primary care services for people with complex health and social needs, especially patients who are frequently hospitalized, says Dr. Jeffrey Martin, managing physician for the program.

For someone with severe asthma and other chronic medical conditions, “it’s hard to use inhalers and take 16 other medications if you’re living in the back of a car or on someone’s couch,” Martin says.

When someone is fighting eviction, has problems with federal housing subsidies, suffers a utility shut-off or has poor housing conditions, the staff members of Care Connections call on Catherine Schultz. She is a legal aid attorney with MidPenn Legal Services, which has a contract to work on such cases for Lancaster General Hospital.

Martin describes the case of one patient, a licensed practical nurse in her mid-30s who was diagnosed with multiple sclerosis. The woman lost her job because she could no longer work, and then her car was repossessed. She stopped taking her medications and couldn’t make it to her medical appointments.

Schultz worked to get this patient a federal housing subsidy and helped her apply for Social Security disability benefits, and then appeal the administration’s denial of benefits. They’re awaiting the results of the appeal.

In fee-for-service medicine, the hospital’s work traditionally was considered finished once patients were discharged, Lawton notes.

But health care has shifted toward value-based care that focuses on outcomes and avoiding preventable hospital readmissions. Now, “you are accountable for patients beyond the four walls of the hospital, and you have to think creatively about how to create stability for them,” Lawton says.

With that in mind, many health care systems are focusing on medical-legal partnerships that target patients who are high users of services.

“Once upon a time, the attitude of the provider was, ‘It’s not my problem that you have mold in your apartment,’ ” says Emma Kagel, manager of medical-legal partnerships at Denver-based Centura Health System. ” ‘I’m just going to keep pumping you full of steroids and give you an inhaler.’ ” That attitude, she says, doesn’t work with value-based care.

Funding is always a problem for these programs where demand far outstrips supply. They are frequently staffed by legal aid attorneys under contract to the health care providers. Some programs use private sector lawyers working on a pro bono basis.

Mount Sinai, whose program is just getting off the ground, is taking a hybrid approach. In addition to a grant from the Manhattan District Attorney’s Office to provide child and family law services, the hospital partnered with law firms and other organizations to provide transgender and end-of-life legal services on a pro bono basis.

Sena Kim-Reuter, president of the Mount Sinai Medical Legal Partnership, says she’s focused on identifying gaps in patients’ needs where she can offer assistance. “There’s no way to handle all of it,” she says.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Follow Michelle Andrews on Twitter @mandrews110.

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Nancy and Dan Gapinski of Glendale, Wis., remember a time when they couldn’t really communicate with their own son.

“He used to not really have any kinds of conversations with us. He did a lot of echoing things that we said, and scripting from movies,” Nancy Gapinski says as she and her husband wait for their son Ben’s school bus to arrive. “A lot of times kids didn’t know how to respond to him then, and didn’t know what he was trying to say and conversations wouldn’t really go anywhere.”

But that’s all changed. On a recent Friday afternoon, 10-year-old Ben hops off the bus, greets both his parents and starts chatting about his day.

“So what I did today was I had an extra recess today, and also I had to do two star math tests,” he reports. He says he did pretty well on those tests.

When Ben was a toddler he was diagnosed with an autism spectrum disorder. He barely communicated with his parents and needed constant monitoring to stay safe.

The Gapinskis needed help. They found a therapist to work with Ben for 24 hours a week, which cost more $50,000 a year. Dan’s workplace insurance paid for some of the costs, but not all.

So they turned to Medicaid.

Ben’s disability was severe enough – he was deemed by the state to require “an institutional level of care” — that he was eligible for Wisconsin’s children’s long-term care program, funded by Medicaid.

“They work with the child on basic language skills, trying to learn words, trying to do some intellectual exercises,” Ben’s father Dan recalls. “It eventually graduates into some back and forth conversation, and doing homework and doing things that are more like what normal kids do.”

While Medicaid is best known as a health care program for poor people, more than 80 percent of its budget goes to care for the elderly, the disabled and children, according to the Kaiser Family Foundation. Only 15 percent goes to health care for able-bodied adults.

The program has been growing in recent years and it now makes up almost 10 percent of federal spending. That’s why it’s the number one target in President Trump’s proposed budget, and figures prominently in the Republican proposal to replace the Affordable Care Act. Some estimates suggest the program could be cut by more than 1 trillion dollars over 10 years.

After three years of intense therapy, Ben now goes to his local public school and works on grade level in math and English. He no longer works with his private therapist or uses Medicaid benefits.

“We just decided not to reapply,” Nancy says. “The need had been met.”

President Trump and Republicans in Congress have proposed massive cuts to Medicaid’s budget over the next decade, and Nancy and Dan Gapinski worry that the services they used for Ben won’t be there if he needs them in the future, or be there for other families.

“I don’t know what Ben will need in his lifetime,” Nancy Gapinski says. “Our goals for him are very much like our goals for our daughter Zoe. We really want for them to be active, engaged citizens.”

Ben’s not the only one in the Gapinski home who has used Medicaid services. His grandmother Evelyn Benjamin is also a beneficiary.

Evelyn is 84. She’s had a few falls and depends on a walker to get around. She also has heart disease and uses three different inhalers.

“They take very good care of me,” Evelyn says, sipping tea in the living room surrounded by her family. “I’m very lucky to be one that can stay in my home, and know that I’m cared for.”

Evelyn has health insurance through Medicare. But after her husband suffered a stroke and needed constant care, she depleted her savings and now qualifies for Medicaid as well. It helps pay for her 12 prescription medications and, through a Medicaid-funded program called IRIS, she gets in-home help.

Wisconsin’s IRIS program is an example of how states tailor Medicaid to their own needs. It gives beneficiaries a budget to use for the services they need, and it allows people to hire whoever they want.

So Evelyn hired her daughter, Nancy, who gave up her full-time career to care for her mother and son. She works part-time from home, and supplements that income with $11.50 an hour for 20 hours a week caring for her mother. She says it’s helped keep them out of bankruptcy. And her hourly rate is a fraction of the going rate for such services from an agency. According to a 2015 study by Genworth, home health aides and homemaker services in Milwaukee cost an average of about $22 an hour.

“It’s just a big, big help for not only me, but for my daughter who worries about me constantly,” Evelyn says.

Nancy Gapinski worries that help may disappear under the proposed budget cuts. That’s because the services her family uses are considered optional under the Medicaid law. The program is required to pay for doctor visits, hospital care and even nursing home care. But in-home support services that Evelyn uses and therapies like those Ben received aren’t.

Dan Gapinski says his children love having their grandmother around. When they have nightmares they climb into her bed and they giggle with her in the living room.

“I don’t think we, as a society, appreciate the value of that,” he says. “There’s a lot of talk about entitlements and how that’s become a bit of dirty word. We don’t take the satisfaction in having made a greater society by making these kinds of situations possible.”

The day I visited the Gapinskis, Ben was excited to go on a sleepover at his aunt’s house. He was packing up pajamas, his Nintendo DS game, some comic books and Minecraft books.

As he heads for the door, his grandmother calls out for a hug.

“Give my love to Aunt Susie OK?” she says, while reaching her arms around Ben.

“Yeah, I’ll give your heart to Aunt Susie,” he replies with a laugh.

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