Hundreds of thousands of people may essentially lose health insurance subsidies, face double-digit premium increases or be forced to change doctors unless Congress and the Trump administration move at what would be lightning speeds by Washington standards.

Trump and the Republican Congress have taken the first steps toward repealing the Affordable Care Act but have not yet decided what will replace it. That’s a problem for insurers who need to file next year’s rates for state health insurance marketplaces in April.

Some major insurers are saying they might stop offering coverage on the exchanges unless President Donald Trump and Congress act quickly.

A secret recording made at a Republican retreat in Philadelphia two weeks ago, reported by The Washington Post, showed no consensus on how to proceed.

A major sticking point is that insurers want a guarantee of subsidies to make up for lower deductibles and co-pays — a program that House Republicans have been trying to kill in court.

Insurers are getting antsy over the looming deadline.

Joseph Swedish, CEO of Anthem, told investors recently, “We still need certainty about short-term fixes in order to determine the extent of our participation in the individual market in 2018.”

He said the company may have to “surgically extract” itself from certain regions “or quite frankly even on a larger scale.”

Aetna CEO Mark Bertolini said on a recent earnings call that his company is evaluating whether to stay in the marketplace in Iowa and three other states.

Kristen Cunningham, a spokeswoman for Blue Cross and Blue Shield of Texas and Blue Cross of Oklahoma, also did not offer a guarantee.

“No changes are currently planned,” she said in an email. “There isn’t much to share about 2018 … since there’s just so much we don’t know.”

Blue Cross of Oklahoma is the only insurer in the state’s marketplace. Blue Cross and Blue Shield of Texas is the only insurer in 94 of that state’s 254 counties.

At a recent Senate Health, Education, Labor and Pensions Committee hearing, Chairman Lamar Alexander, R-Tenn., raised the specter of some areas of the country having no insurer on the marketplace.

“We are told that unless we take action fairly quickly, we may reach a situation in 2018 where many Americans have a subsidy through the Affordable Care Act but they don’t have any insurance to buy,” he said. “It would sort of be like having a bus ticket in a town where no buses go by.”

The departure of insurers would also affect areas where other insurance companies sell subsidized insurance, said Sabrina Corlette, a researcher at the Georgetown University Center on Health Insurance Reforms.

Changing to another plan could force patients to change doctors, said Corlette, who surveyed 13 insurers in 28 states.

Corlette said many insurers will leave the marketplace or raise premiums to hedge their bets if there is no replacement in place when the Affordable Care Act is repealed.

Premium increases could be more than 20 percent by insurers who stay in the marketplace despite the uncertainty, said Marilyn Tavenner, president of the industry group America’s Health Insurance Plans, at the Senate hearing. That would not preclude further increases to pay for rising health care costs.

Officials from groups representing insurers, insurance underwriters and state insurance commissioners said at the hearing Congress needs to act by the end of March.

Blue Cross and Blue Shield Association lobbyists also told federal officials at a meeting Tuesday the administration needs to take any regulatory steps it’s considering before April, according to a handout given to the officials.

The uncertainty is opening Republicans to attacks from Democrats.

Sen. Robert Casey, D-Pa., criticized Republicans Thursday for moving to repeal the Affordable Care Act without having settled on a replacement.

“All you have is a lot of talk and a lot of hot air but no plan,” he said on a call with reporters.

At issue is how to preserve the law’s guarantee that insurance companies cannot deny coverage to people with pre-existing conditions such as diabetes or cancer.

A requirement that all people buy insurance did not push enough healthy people to buy insurance to balance the cost of covering sicker, older people.

The House Energy and Commerce committee last week highlighted bills aimed at easing insurers’ concerns.

One being developed by Rep. Susan Brooks, R-Indiana, would push more healthy people to get insurance instead of waiting until they need medical services. Brooks has not released details but said her alternative will be better than a government dictate to buy insurance.

Industry groups want similar sanctions on those who’ve not continuously had insurance for a year and who want to sign up for coverage.

Potential administration actions — such as repealing a requirement on what plans must cover — could be controversial.

Tavenner said “it’s critical” for Congress to keep in place the subsidy for out-of-pocket costs.

Deputy Oklahoma Insurance Commissioner Mike Rhoads said he has talked to insurers about covering his state’s residents, and he’s encouraged that they’re “committed” to trying to make it work.

But insurers are also suspicious of promises made by a government that came up with the Affordable Care Act, only to have House Republicans try to undo their cost-sharing subsidy.

A pending lawsuit by the House to block the subsidy focused on President Barack Obama’s ability to create it without the approval of Congress. But Alexander noted that maintaining the subsidy is something some Republicans “would not like to do.”

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