Next year, dozens of counties across the country could be left with no insurance companies offering insurance in the Affordable Care Act marketplaces based on where things currently stand.

Nationwide, that could leave marketplace enrollees living in a county with no way to purchase affordable individual health coverage. (As it stands, people who receive ACA subsidies can use them only to purchase coverage in the marketplace.) In addition, could be left with just one insurer to choose from. That’s out of more than 10 million enrollees total.

Since the ACA marketplaces opened in 2014, no county has ever been bare, although it briefly looked last year as if Pinal County, Arizona, would lack any ACA insurer.

Number of insurers, 2014 to 2018

0
1
2—3
4+
2014
2015
2016
2017
2018

What’s changing for 2018

Latest announcement, Aug. 22, 2017

Last empty Wisconsin county gets covered.

The state announced that an insurer, which has not yet been named, will enter the Menominee County marketplace. This leaves only one county nationwide — Paulding County, Ohio — without a marketplace insurer.

Insurers have until the fall to decide whether they’ll remain in the marketplace next year, though deadlines vary by state. So these numbers are still in flux, and more counties could end up bare, or new insurers might join some marketplaces.

Change in insurers 2017 to 2018

≤ —2
-1
0
≥ +1

X

About people are enrolled in a marketplace that is slated to lose at least one insurer in 2018.

In Iowa, for instance, 94 of 99 counties appear at the moment to have just one insurer, Medica — and that company has also threatened to leave. In response, the state has asked the federal government for permission to restructure its marketplace and jettison certain elements to keep insurers in place. Wellmark, which previously announced it would not sell ACA plans in Iowa in 2018, has said it would stay if federal officials grant the state’s request.

Insurers across the country have cited uncertainties created by the Trump administration as a reason for ending their participation in the ACA marketplaces.

For months, the Trump administration has been silent on whether it will continue to pay “cost-sharing reductions” (CSRs) to insurance companies. These payments subsidize about 7 million consumers’ copays and deductibles, as opposed to other subsidies which that defray the costs of insurance premiums.

Eliminating subsidies could leave insurers to foot the bill

How an example doctor visit is paid for under the ACA

The patient, government subsidy and insurance contribute

LOW-INCOME

PATIENT

Co-pay

Cost-sharing reduction

GOVERNMENT

INSURANCE

COMPANY

Insurance

coverage

Cost

of care

HEALTH-CARE

PROVIDER

How it would work without cost-sharing reductions

The insurance company has to make up the difference

LOW-INCOME

PATIENT

Co-pay

No extra government subsidy

 

INSURANCE

COMPANY

Insurance

coverage

Cost

of care

HEALTH-CARE

PROVIDER

Insurer covers

more of cost

The above visualization is an example to demonstrate the cost-sharing reduction scenario. Areas are not representative of the share that each source would pay, which varies by patient, plan and medical procedure.

How aN EXAMPLE doctor visit is paid for under the ACA

The patient, government subsidy and insurance contribute

LOW-INCOME

PATIENT

INSURANCE

COMPANY

HEALTH-CARE

PROVIDER

GOVERNMENT

Cost

of care

Cost-sharing reduction

Insurance

coverage

Co-pay

How it would work without cost-sharing reductions

The insurance company has to make up the difference

LOW-INCOME

PATIENT

INSURANCE

COMPANY

HEALTH-CARE

PROVIDER

Insurer covers

more of cost

Insurance

coverage

Co-pay

No extra

government

subsidy

 

The above visualization is an example to demonstrate the cost-sharing reduction scenario. Areas are not representative of the share that each source would pay, which varies by patient, plan and medical procedure.

If the Trump administration were to stop paying the CSRs, consumers would still be entitled under the ACA to those reductions. Insurance companies would be forced to absorb those costs.

[Trump could quickly doom ACA cost-sharing subsidies for millions of Americans]

Some companies already have decided to hike up their 2018 premiums more than they would otherwise to position themselves for an adverse decision by the administration. Others have left the market entirely.

Where insurers are leaving for 2018 so far

ATRIO Health Plans
Oregon
6 counties

Aetna
Delaware
3 counties
Iowa
76 counties
Nebraska
93 counties
Virginia
51 counties

A spokesman said “uncertainty that has surrounded the future of the exchanges for some time now" was a significant factor. (Story)

Anthem
California
30 counties
Indiana
92 counties
Ohio
88 counties

Their announcement cited "an increasing lack of overall predictability" and "continual changes in federal operations, rules and guidance." (Story)

Blue Cross Blue Shield Healthcare Plan of Georgia
Georgia
73 counties

Blue Cross Blue Shield of Kansas City
Kansas
2 counties
Missouri
30 counties

BridgeSpan Health
Idaho
44 counties
Oregon
17 counties
Washington
8 counties

Cigna Healthcare
Maryland
24 counties

Community Health Plan of Washington
Washington
14 counties

Health Tradition Health Plan
Wisconsin
13 counties

HealthKeepers, Inc.
Virginia
129 counties

Highmark Blue Cross Blue Shield
Pennsylvania
12 counties

Humana
Florida
7 counties
Georgia
9 counties
Illinois
30 counties
Kentucky
9 counties
Louisiana
7 counties
Michigan
9 counties
Missouri
5 counties
Mississippi
32 counties
Ohio
7 counties
Tennessee
30 counties
Texas
10 counties

The company said it was "seeing further signs of an unbalanced risk pool." (Story)

Innovation Health Insurance
Virginia
19 counties

LifeWise Health Plan of WA
Washington
4 counties

As a subsidiary of Premera Blue Cross, this insurer also said it left due to rising costs, not uncertainty. (Story)

MDwise Marketplace
Indiana
92 counties

Molina Healthcare of Washington, Inc.
Washington
6 counties

Molina Marketplace
Utah
7 counties
Wisconsin
30 counties

Premera Blue Cross
Washington
1 counties

Rising costs in rural communities, not uncertainty, lead the carrier to exit. (Story)

Premier Health Plan
Ohio
9 counties

Prominence Health Plan
Texas
3 counties

Prominence HealthFirst
Nevada
7 counties

Regence BlueShield
Washington
3 counties

UnitedHealthcare
Virginia
32 counties

Wellmark
Iowa
40 counties

The decision was driven by "financial risk and an uncertain outlook for the marketplace." (Story)

Correction, June 20, 2017: A previous version of this story incorrectly stated Pinellas County, Arizona was nearly bare in 2017. It was, in fact, Pinal County, Arizona.

About this story

2017 marketplace insurers and announced 2018 exits are from the Robert Wood Johnson Foundation. 2017 marketplace enrollment and 2014-2016 insurer participation are from the Kaiser Family Foundation; data for state-based exchanges are estimates. Because 2018 exits are based in part on compiled news reports, exit data may be incomplete. See something we missed? Email kim.soffen@washpost.com

Originally published June 14, 2017.

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