Five places most likely to lose ObamaCare insurers

The immense uncertainty surrounding ObamaCare has some areas wondering whether they’ll soon be in a dead zone — a place without any insurance plans to buy on the healthcare exchanges.

Insurance companies are in the midst of filing premium requests for the Affordable Care Act’s (ACA) marketplaces. But before seeking those premium hikes, they’ll have to decide whether to continue offering coverage at all.

It’s a difficult task, as Congress and the White House haven’t yet committed to funding crucial payments to compensate insurers for subsidizing out-of-pocket costs for some lower-income enrollees. It’s also unclear if ObamaCare will continue to be the law of the land.

If the about $7 billion in payments to insurers aren’t funded, and if core ObamaCare provisions — such as the individual mandate to buy insurance — aren’t enforced, the damage to insurance markets could be severe.

{mosads}But for some regions, the worry that there won’t be any insurance plan to buy, or a limited number, is particularly acute — even before decisions around the payments or what happens to ObamaCare are made.

Here are five places at risk.

Missouri

The state is facing an insurance commissioner’s biggest fear: bare counties.

In May, Blue Cross Blue Shield of Kansas City announced it was exiting the marketplace, leaving 25 counties in Missouri without any carrier willing to sell ACA plans for 2018.

There’s still time, though. 

Final decisions aren’t made until the fall, and officials are likely trying to lure other insurers into the area behind the scenes.

That’s just what happened last year in Pinal County, Ariz., when Blue Cross Blue Shield of Arizona stepped up to the plate. This year, the Knoxville area was also saved by the company — Blue Cross Blue Shield of Tennessee decided it would return to the area for 2018, with a few caveats.

“I think the Blues are, generally speaking, more committed to staying in the individual market,” said Cynthia Cox, associate director for the Program for the Study of Health Reform and Private Insurance at the Kaiser Family Foundation.

“That’s what makes the Missouri situation more troubling than some of the other places where we’ve been looking, is that without the Blue Cross Blue Shield plan, it’s not clear who’s going to move into those counties.”

Iowa

Medica is the only insurer selling ObamaCare plans in most Iowa counties, and it hasn’t made a final decision yet on whether it will stay or leave, according to its spokesman, Larry Bussey.  

Gundersen Health Plan sells in five Iowa counties, but it hasn’t decided if it will participate again on the state’s exchange, spokeswoman Jennifer Dinehart wrote in an email.

April wasn’t a good month for Iowa’s exchange. Both Aetna and Wellmark Blue Cross and Blue Shield announced they wouldn’t sell individual plans for 2018.

Wellmark’s chairman and CEO, John Forsyth, detailed what it would take for the company to re-enter Iowa’s market in a Sunday op-ed in the Des Moines Register. The list included incentivizing continuous coverage, tightening rules for special enrollment periods, basing financial help on age and income, offering reinsurance and allowing flexible plan design.

Nebraska

The state is in a fairly similar situation to Iowa.

Last month, Aetna announced it would exit its last ObamaCare markets, which included Nebraska, and left Medica as the only carrier selling plans to the state on the ObamaCare exchanges.

“Things are still changing daily,” Geoff Bartsh, vice president for Medica’s individual and family business, told The Omaha World-Herald Friday. “We’re still looking at changes and will continue to evaluate things. We are still planning to participate in the Nebraska market for 2018. We haven’t made any final decisions on that yet.”

Medica intends to sell plans on the state’s marketplace, Bussey told The Hill. 

Tennessee’s Knoxville area

Tennessee has already had to scramble to avoid coverage-free areas.

Humana announced it wouldn’t sell insurance on the exchanges in February, leaving the Knoxville area without any plans for 2018. The state’s insurance commissioner, Julie Mix McPeak, quickly began conversations with the two insurance companies left in the state to see if one would expand its coverage.

Blue Cross Blue Shield of Tennessee obliged — but with a few conditions. The company wanted to be able to exit the market “in the event of any post-bid changes that destabilize the market,” it said in a letter.

More insurers could flee the ObamaCare markets if payments to insurers aren’t funded and if the individual mandate isn’t enforced — or if the uncertainty continues. Insurers aren’t locked into selling plans until the fall.

They could also increase the cost of a plan, and a Kaiser analysis shows an average 19 percent hike if cost-sharing subsidy payments aren’t made.

“With all the uncertainty that insurers are facing next year, it could very well be another area of the country that could pop up as being at risk of having no company next year,” Cox said. “A lot can change between now and September.”

Sen. Lamar Alexander (R-Tenn.) — the chairman of the Senate Health, Education, Labor and Pensions Committee — has been vocal about the need to temporarily repair ObamaCare.

He and the state’s other GOP senator, Bob Corker, have proposed a bill that would let residents living in areas without an insurer use their ObamaCare financial assistance to purchase any state-approved plan.

Sen. Claire McCaskill (D-Mo.) has the Democratic counter — those in bare counties could buy health coverage on the D.C. exchange, which is where many lawmakers and congressional staffers buy insurance. 

Rural areas

Historically, rural areas have less competition in their insurance markets — and that’s still true under the ACA.

On average, urban areas had 2.5 insurers participating in 2017, compared to two insurers in more rural regions.

There are a number of rural areas with only one insurer, so if a company leaves that state, it “could mean there is no coverage option for some people living in those counties. In those counties with only one issuer, the future of the exchange essentially depends on that one company,” Cox said.

“I think just within a given state the rural areas are probably most at risk of having no insurance company,” Cox said. “It’s easier for a plan to set up a favorable network in an urban area, and there’s also generally just more insurers wanting to participate in urban areas.”