By Anna Wilde Mathews
Health insurers appeared likely to offer Affordable Care Act plans in all U.S. counties next year, despite months of drama and worries among some state officials about last-minute exits, ahead of a late-Wednesday deadline.
Some major insurers that had signaled that they might pull back, including Cigna Corp., Health Care Service Corp., Molina Healthcare Inc., Highmark Health and Independence Blue Cross, this week said they would stick to the states and regions where they had filed to offer ACA coverage.
The final decisions of some insurers, including Centene Corp., hadn't been disclosed as of Wednesday evening, and there was still a risk that companies might make 11th-hour pullbacks.
Wednesday's deadline to sign federal agreements to offer ACA plans marked the end of a monthslong drama in many states. Insurers have repeatedly announced they would depart exchanges, and at various times as many as 145 counties, in states including Nevada, Ohio and Missouri, have appeared at risk of lacking a marketplace insurer for next year, according to the Kaiser Family Foundation. State officials scrambled to find replacements, and in many cases had to approve large rate increases for some insurers to stay.
Cigna earlier confirmed it would withdraw from Maryland's exchange, but on Wednesday said it would definitely continue offering ACA coverage in a half-dozen other states.
Molina will leave the exchanges in Utah and Wisconsin, as previously announced, but on Tuesday said it would remain in seven other states where it sells ACA plans.
Centene, which has said it plans to expand its role in the exchanges next year, didn't respond Wednesday to requests for comment about its final marketplace decisions. Centene is an increasingly important player in a number of states' exchanges, and in some regions it is the only insurer planning to offer ACA coverage in 2018.
The number of insurers in many regions is expected to be thin. Roughly 50% of counties appeared likely to have just one exchange insurer next year, and 30% were projected to have two, according to a tally by the Robert Wood Johnson Foundation, though those totals could change if other insurers disclose withdrawals.
To woo and keep insurers, state officials spent months negotiating, and in many cases they are approving substantial rate increases for next year that include extra boosts to insulate insurers from uncertainty about how the law will be administered.
For instance, Mississippi's one exchange insurer was set to get a rate increase of a 47.4% on average, according to the state's insurance commissioner. In Kentucky, Anthem Inc.'s rates will go up 41.2% and nonprofit CareSource's rates will rise by 56%.
Officials in Pennsylvania and New Jersey, where Independence Blue Cross offers ACA plans, "have been very, very helpful and understanding around rate setting," said Daniel J. Hilferty, the insurer's chief executive. "We feel very good about the partnership we have with those two states."
The biggest issue for insurers is federal payments that reimburse companies for reducing the health-care costs of low-income ACA enrollees, which the Trump administration has threatened to halt. The potential loss of those payments was expected to add about 20% on average to the cost of middle-tier ACA silver plans, according to an analysis by the Congressional Budget Office.
Insurers have also sought increases tied to the concern that the health law's coverage mandate, which is supposed to prod healthy people to enroll in coverage, will be weakly enforced or seen as toothless by consumers.
Insurers say that the rate increases, along with other factors like the perception of a weakened coverage mandate, carry a serious risk: There could be a drop in the number of enrollees, particularly the healthy ones whom insurers need to avoid a continuing cycle of rate increases. People whose incomes are too high to get federal premium subsidies may drop coverage or opt for cheaper, skinnier policies.
"You need the healthy individuals to balance out your risk profile," said Pamela Morris, chief executive of CareSource, which will offer exchange plans in four states next year. "That's always a huge concern."
Insurers are also worried about the impact of the Trump administration's announced cuts in funding for advertising and grants for groups that help people sign up for coverage. This year's open-enrollment period, which starts Nov. 1, is shorter than in past years, and the Trump administration also has said that the federal exchange, HealthCare.gov, could be shut down during chunks of that time for maintenance.
The Department of Health and Human Services said in a statement, "Insurers have been fleeing Obamacare's individual market, leaving nearly half of our nation's counties with only one coverage option. Americans are once again facing skyrocketing costs and plummeting choices because of Obamacare's fundamental failures."
In deciding to remain in the exchanges, the insurers are keeping their hands in what some still hope will become a sustainable, profitable business. A Kaiser Family Foundation analysis found insurers' financial results on exchange plans improved in the first quarter of this year, a sign of potentially emerging stability.
Alexis Miller, a Highmark senior vice president, said the company is projecting it will roughly break even on its exchange business next year, with rate increases that "mitigated to a good degree the risk that we believe to be the greatest." Sticking with the exchanges helps Highmark's relations with its customers and the states where it does business, she said, and gives it a voice as future changes are debated.
"We think we are better off participating, and staying in the game and shaping what comes next," she said.
Next year will see a continued shift in which types of insurers are in the exchanges. The largest national players, such as UnitedHealth Group Inc., Aetna Inc., and Humana Inc., by next year will have almost completely abandoned the marketplaces.
Another major national insurer, Anthem, said Wednesday that it would leave Maine's exchange next year, a possibility it had warned of earlier. Including Maine, Anthem has said it would exit exchanges in five states and pull back in an additional five. Anthem offered exchange plans in 14 states this year.
Filling the breach in some states that have seen insurers exit are Medicaid-focused insurers such as CareSource, Molina and Centene. Blue Cross Blue Shield insurers, most of which are nonprofits, remain the backbone of many marketplaces.
Write to Anna Wilde Mathews at [email protected]