Across broad swaths of the Midwest, the fate of the Affordable Care Act increasingly rests on the shoulders of a small nonprofit health insurance plan headquartered in suburban Minneapolis.

Medica is not a household name. It provides health insurance to 700,000 people scattered across Iowa, Minnesota, North Dakota, Nebraska, Kansas, and Wisconsin. The plan’s enrollment is dwarfed by that of big health plans like UnitedHealth (47 million patients) and Aetna (20 million).

Medica stuck around the Obamacare marketplaces as big for-profit plans fled, scared away by dismal financial returns and uncertainty wrought by the Trump administration.

“We may find ourselves with a large number of lives in many of these states that we didn’t earn in the traditional sense of the word, by beating the competition,” says Geoff Bartsh, Medica’s vice president of individual market business. “We just happen to be the last person standing.”

The plan is currently undecided as to where it will stick around in 2018. Executives say they would hope to remain with the marketplaces, but much of their decision-making rests on getting more certainty and stability about the law’s direction from the Trump administration and state regulators.

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