Insurers have begun to submit their rate request for 2019 for the Health Insurance Marketplaces, which were created as part of the Patient Protection and Affordable Care Act (ACA). Insurers in Virginia and Maryland are requesting rate increases of as much as 90%, prompting concern that this linchpin of the ACA will not survive. In May 2018, Al Redmer Jr, insurance commissioner of Maryland, stated that “we’ve been in a death spiral for a year or 2.” These comments echo a statement from Tennessee insurance commissioner Julie McPeak, who in 2016 expressed concern that the Health Insurance Marketplace was “very near collapse.”