Few options remain for some consumers in ACA marketplaces

Senate Republicans failed this week to repeal the Affordable Care Act, which has provided insurance to 12 million people. Most people enrolled under the ACA have at least two insurers to choose from, but next year, 3 million people may have only one choice, and people living in 45 counties could be left with none. Mary Agnes Carey of Kaiser Health News joins Hari Sreenivasan to discuss.

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    When the U.S. Senate fell short this week of the Republicans' goal to repeal the affordable care act, it left the ACAC in place, at least for now. And today on Twitter, President Trump seemed to threaten those lawmakers and insurance companies, saying, quote: If a new healthcare bill is not approved quickly, bailouts for insurance companies and bailouts for members of Congress will end very soon.

    The president might have been referring to cost-sharing reduction payments, which lower the amount individuals have to pay for deductibles, co-payments and insurance. Currently, Obamacare provides insurance to 12 million people through private policies purchased on exchanges. But some of the exchanges have seen insurers like Aetna, Anthem, Cigna, and Humana pull out.

    That trend, according to "The New York Times," "Reuters" and "Kaiser Health News" could leave 3 million people in more than 1,300 counties with only one Obamacare participating insurer next year. Forty-five or more counties could have none.

    For more, I'm joined from Washington by Mary Agnes Carey of "Kaiser Health News".

    How did we get to this situation? You know, the president likes to describe it as Obamacare imploding. But we're clearly seeing that there's a disparity in how much choice consumers have when they go to these exchanges.


    Insurers have been very concerned about the uncertainty around the Affordable Care Act. As you mentioned, there's been a lot of discussion on Capitol Hill about repealing and replacing the law. That fell apart this week in the Senate. There's been concern about whether or not the Trump administration would fund these cost-sharing subsidies that help low-income people with their out-of-pocket costs. And there's also been concern from insurers about tough enforcement of the individual mandate, this requirement that most Americans have insurance or pay a fine.

    So, when you look at that collectively, insurers are getting worried, and some are deciding not to go into some markets or leave other markets or raise their prices to try to compensate for that uncertainty.


    I remember when the ACA first passed, one of the big sort of compromises to the insurance industry was saying, hey, this individual mandate will be in place. Everyone will have to have insurance. So, you're going to have an opportunity to find new customers.

  • CAREY:

    Right. But the thought has been also that has been the opportunity for the insurers, and they have gotten in, but they knew initially the sickest people would come in first. They have been very, very expensive.

    And then there's also been ongoing concern about the price of the premiums. Some people have opted, rather, not to enroll and simply pay that individual mandate penalty. So the individual mandate, of course, we know has been a lightning rod on Capitol Hill. Republicans hate it. They say Americans shouldn't be required to purchase insurance or be told what insurance to buy. So, it has been a focal point of this ever since the Affordable Care Act was created.


    Insurance companies are also responsible to their shareholders. They're thinking a couple of years out. So, really, in the past couple of years, we've seen them start to make moves regardless of who was going to win this White House.

  • CAREY:

    You know, they looked at the market, as you mentioned, some are in and some are out. And again, we get back to the uncertainty. Is this a marketplace where they want to be? Will this marketplace be supported by the Trump administration? Will the rules and regulations of the Affordable Care Act be implemented and overseen by the Trump administration and that has just been at the focal point of this entire thing when the insurers are involved?


    What about Medicaid expansion or at least the subsidies and how much the Affordable Care Act or any sort of a replacement will pay? What can the insurance companies expect?

  • CAREY:

    Well, right now, since things have fallen apart about this on Capitol Hill, the Medicaid expansion, which 31 states embraced, is still there. So they could still count on that enrollment. And for now, the subsidies that as you mentioned earlier fund about eight out of 10 beneficiaries are still there.

    The key point on the subsidy issue is this cost sharing subsidy. That is the subsidy that helps nearly 7 million enrollees with their out-of-pocket costs. And insurers are very worried that the Trump administration might stop funding that.


    What sort of actions can be taken for what are called these bare counties, where basically there are now currently no insurers on the exchanges, or as those counties grow in number?

  • CAREY:

    There's a variety of proposals that could be embraced. Claire McCaskill, a Democratic senator from Missouri, has a plan that says if you're in a bare county, you should be able to buy health insurance on the same exchange here in the District of Columbia, where members of Congress buy coverage.

    There's also a variety of coverage out there to help insure with their high-cost cases. This is called reinsurance. That program existed for three years. It's going away in 2018. So, you've got members on both sides of the aisle talking about that, and the thought is if you step in and try to help with those high-cost cases, that premiums could be reduced.

    But we also have to remember those broader bills from Republicans in the House and the Senate, all included money for state markets to try to help these insurers. So, it's kind of a moving target at this point.


    All right. Mary Agnes Carey of "Kaiser Health News", thanks so much for joining us.

  • CAREY:

    Thanks for having me.

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