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Obamacare Remains Unstable, Even as Insurers Fill Bare Counties

Premiums are on the rise and competition remains weak in much of the country.

Jeff Malet Photography/NewscomJeff Malet Photography/NewscomAt the beginning of the summer, as congressional Republicans were pushing to pass health care legislation, it looked as if, in some places, a major component of Obamacare might simply cease to exist, all on its own.

More than 40 counties across the country appeared likely to have no insurer available in the health law's exchanges. Major news organizations published reports warning that, after insurers made their final decisions, hundreds of counties could ultimately be left bare under the law.

Instead, the opposite has happened.

All of the counties that were expected to be bare now have at least one participating insurer. The Republican effort to rewrite the health care law has stalled indefinitely, and may never be revived. A new government report published today finds that health insurance coverage has increased nationally this year by about 500,000 people. Obamacare, which languished in the polls throughout President Obama's time in office, is now more popular than ever.

Yet all is not entirely well with the law. Although there are no bare counties, major health insurance companies like Aetna and UnitedHealth have pulled out of the program, and 47 percent of counties, covering about 23 percent of health law enrollees, will have just one option in the exchange.

This is hardly the boon for consumer choice that President Obama promised back in 2009, when he declared, in a speech making the case for health care reform, "My guiding principle is, and always has been, that consumers do better when there is choice and competition. That's how the market works. Unfortunately, in 34 states, 75 percent of the insurance market is controlled by five or fewer companies. In Alabama, almost 90 percent is controlled by just one company. And without competition, the price of insurance goes up and quality goes down."

Under Obamacare, dramatic price increases are exactly what's happening. In Maryland, for example, a state that has generally favored the law, exchange premiums will jump an average of 33 percent. And that hike is lower than what insurers requested: State insurance regulators negotiated carriers down from initial requests for rate increases averaging 43 percent.

Although the majority of the people covered under Obamacare will be relatively insulated from those hikes thanks to the law's insurance subsidies, that just means that taxpayers will shoulder the additional cost. And those who earn too much income to qualify for subsidies will be stuck with substantially higher bills, yet again. So it's no surprise that they are fleeing: The market for unsubsidized coverage shrank 29 percent in the last year, according to insurance industry consultant Bob Laszewski.

Among the insurers that has stepped in to fill many of the counties that were expected to be bare is Centene, which built its business on Medicaid managed care, in which insurers take over caseloads from states. Centene has been more successful than other companies in Obamacare's exchanges, in part by relying on narrow provider networks. Under these sorts of plans, coverage through Obamacare looks more like coverage through Medicaid than what most people expect from private insurance.

Even the bare county problem, meanwhile, may be merely delayed rather than solved. In Ohio, which earlier this year expected to have 20 counties with no insurer, the state's Department of Insurance Director, Jillian Froment said, "This is a temporary solution and one that only applies to 2018. Beyond that, insurers are still looking for predictability in the health insurance market."

Predictability, in this case, may turn out to mean "stabilization funds"—or, less generously, publicly funded bailouts. The future of the health care law looks less like total collapse and more like consistent unsteadiness and worries about decline, while lawmakers attempt to prop it up on a nominally temporary basis.

The health care law may have avoided repeal, or any of the not-quite-repeal options that congressional Republicans considered. And it may have plugged the holes in the insurance market, at least for now. But it has hardly settled into a stable equilibrium, and the ways in which it is unstable and inadequate are unlikely to improve rapidly on their own. Obamacare may not be failing. But in many ways, it is flailing.

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  • JFree||

    Even the bare county problem, meanwhile, may be merely delayed rather than solved.

    The bare county problem is not an insurance problem. It is a lack of local doctors problem. Course no one seems to care about that cuz Dems think everything will be a dandy as long as everyone has insurance and Reps think everything will be dandy as long as NC insurers can sell NC doctor coverage to folks in ND

  • NotAnotherSkippy||

    Right. All the providers disappeared and the insurance companies lied about leaving.

  • JFree||

    It's worse than that. Even for those counties that still have family or other basic care doctors, the more 'insurance' (which won't actually pay for those doctors cuz deductibles) that those residents have to buy, the less they will have to pay the only doctors who are there - making it even less likely that new doctors will replace retiring doctors there. Which is confirmed by 'work preferences' of final-year residents - just 17% of them would 'prefer' to work in a town of less than 100,000 people (and a whole lot fewer than that take jobs there). They know our system is designed to drive them to 'pill hills' and research centers - and that is also then who is attracted into medicine.

    Just in Texas - 30 counties (pop 120,000) have no doctor at all. 29 counties (pop 160,000) have one doctor each. 147 counties (pop 2million) don't have an ObGyn. 185 counties (pop 3.2 million) don't have a psychiatrist. 155 counties (pop 2.1 million) don't have a general surgeon. They don't need some fucking 'insurance' and insurance companies know that. They need DOCTORS. And without doctors there, there's no future employers there either. And no surprise - only illegals are going to move to those counties to work. These aren't places where Americans will decide to start a family.

  • jerbigge||

    Easy way to do this is to cover the costs of the doctor's education and in return the doctor works on salary for a decade which pays off the cost of his or her education. Instead of standing around complaining about the lack of doctors, I'm sure an offer to cover the cost of their educations would be certainly "encourage" them to provide their services (at a lower price) since they wouldn't have student debt to pay off as is the case now.

  • JFree||

    I think that could work too. But they'd have to want it to work. TX has had that sort of thing since 1985 (PELRP?) and things have prob gotten worse.

    Those who benefit (wealthier urban/burbs) from tilting things towards concentrated pill hills apparently don't want any change - so its funded via tax on chaw tobacco, pays off loans so fast doctors can't really even settle in to new practice (and then move back to pillhills) and it funds fewer doctors, and the doctors still have to go into debt to set up their practice infrastructure (and presumably take a loss if they can't sell to new doctor).

    As usual - cronyism for me but FYTW. Prob not unique to TX either. That's just the one big state data I had.

  • Sanjuro Tsubaki||

    My last in-network doctor quit her practice because Obamacare didn't get repealed, even though she appeared to be the sort of person least likely to vote for Trump. Doubt my particular county is "bare", but there just might be a reason for the lack of doctors problem.

  • Uncle Joe||

    Did she join another practice? Many doctors are giving up their "one doc shops", so they can have vacations & days where they aren't necessarily on call.

    No doctor is forced to accept patients who are on ACA plans. Nor, are they forced to accept Medicaid or Medicare. There are plenty of doctors who locate themselves in areas where they know they will be seeing well heeled/well insured patients. Locating a practice in a poor, rural county is even more of a financial struggle than being in an urban neighborhood where all your patients are on Medicaid. Fortunately, some place value on the Hippocratic Oath, but they still need to pay off their loans.

    If she indeed quit medicine completely because the ACA repeal failed, she was on the verge of retiring or she has some loose connections in her head. It's not likely she's going to make more money in a totally new job. That statement smells like BS.

  • JFree||

    Locating a practice in a poor, rural county is even more of a financial struggle than being in an urban neighborhood where all your patients are on Medicaid.

    My guess is this problem also gets worse the richer the US gets since doctor pay will almost always rise faster than unskilled/rural pay. IDK what the solution is - other than municipalities creating/owning a basic physical infrastructure themselves and then contracting docs to come in occasionally so docs can focus solely on patient stuff rather than general business stuff as well.

    Whatever the solution is - it is different for basic care docs compared to hospital/specialists and 'insurance' (of whatever type - public or private) can only be the latter.

  • Libertarian||

    "Premiums are on the rise and competition remains weak in much of the country."

    If only someone could have warned us.

  • loveconstitution1789||

    I know. I cannot think of a single person who predicted this exact scenario, can you?

    And then the left says that Obamacare is more popular than ever. If its so popular, why aren't people willing to shell out more money for more expensive health insurance and why are health insurance companies pulling out?

  • Uncle Jay||

    RE: Obamacare Remains Unstable, Even as Insurers Fill Bare Counties

    "Premiums are on the rise and competition remains weak in much of the country."

    Wasn't that the whole point of Obamacare?

  • loveconstitution1789||

    " Obamacare, which languished in the polls throughout President Obama's time in office, is now more popular than ever."
    Free stuff usually is.

    Flush this turd that is ObamaCare.

  • BYODB||

    I'd be more curious about the exact breakdown of which company is still in those exchanges.


    Among the insurers that has stepped in to fill many of the counties that were expected to be bare is Centene, which built its business on Medicaid managed care, in which insurers take over caseloads from states. Centene has been more successful than other companies in Obamacare's exchanges, in part by relying on narrow provider networks. Under these sorts of plans, coverage through Obamacare looks more like coverage through Medicaid than what most people expect from private insurance.


    Yeah, exactly what I thought.

  • Conchfritters||

    Blue horseshoe loves Centene

  • Longtobefree||

    and 47 percent of counties, covering about 23 percent of health law enrollees, will have just one option in the exchange.

    I call that single payer.
    Welcome to the revolution!

  • NotAnotherSkippy||

    We had to destroy the competition to save the competition.

  • Conchfritters||

    Who said they were out of options?

  • Uncle Joe||

    The sources linked are already out of date. The entire state of Colorado shows only one insurer, but in fact all nine existing insurers are offering plans for 2018.

    http://www.denverpost.com/2017.....ange-2018/

    Most of the other states where there are only going to be one insurer, are either in states that have been hostile to the ACA from the get go, or states with largely rural areas that are challenging for insurance companies to make a profit in.

    For example, two of the three insurers in Alabama left the market because Blue Cross of Alabama controlled 90% of the market. They were unable to negotiate rates as low as BC of A from providers. Couple that higher cost with the uncertainty Trump has cast over subsidies & it's not surprising they left Alabama.

  • Stalwart Sam||

    I'm still really confused about the rise in popularity bit. Is it simply Democrats and Moderates rallying around the program the moment the Republicans targeted when they were well aware of its problems while Obama was around?

  • Uncle Joe||

    People figured out that Obamacare & the ACA are actually the same thing.

  • Sanjuro Tsubaki||

    Suderman goes out on a limb with yet another dire predicition of difficulty for Obamacare, and drama ensues.

  • John B. Egan||

    Apparently the author of this article doesn't keep up with the news. The reason for poor coverage and increasing rates can't be blamed on the president who declared that the ACA was just a first step towards Single Payer. It has to be dumped right in the laps of Trump, Ryan and the GOP who are doing everything to fulfill their promise to kill it off. More recently, Trump declared that he would let 'Obamacare collapse under its own weight'....What he should have said (as if he could tell thr truth if asked what time it was..) is ' The GOP and I are unable to provide that beautiful and cheaper replacement for Obamacare, because after 8 years of griping, we never really had a plan anyway'.. so we will hamstring it with indecision:

    ** St Louis Dispatch: Who's to blame for higher health premiums in 2018? Study faults Trump.

    ** Washington Examiner : Ousted Molina CEO blames Trump, GOP for Obamacare problems

    ** Mic: Health care costs going up? Blame Donald Trump, insurance executives say

    ** L.A. Times: Health insurers plan big Obamacare rate hikes — and they blame Trump

    ** Common Dreams Org: Analysis Shows Trump/GOP Sabotage to Blame for Coming Insurance Rate Hikes.

  • Uncle Joe||

    The last "bare county" was Paulding, OH. There are only 19,000 people living in Paulding County & a whopping 334 people are enrolled in ACA insurance. The administrative overhead for offering plans for such a tiny number of people makes it challenging to turn a profit, especially if those people are divided between many insurers.

    Insurers need to make agreements with service providers. They need to negotiate rates for services, which requires knowing the local market. They need to process claims & make payments. As you Libertarians are quick to point out, nothing is free. One person out of that 334 could put the insurer into the red by having a major health crisis.

    The simple solution... really the only solution is to use the companies that manage Medicaid & Medicare to offer plans in places where there are simply too few people to support a real insurance market. It's no surprise that those companies are the ones filling the gap for bare counties.

  • JFree||

    And only 6 primary doctors and 3 specialists in that county - where the nearest city is Indiana not Ohio. They do have a hospital though so they are doing generally the right thing re actual medical infrastructure/access.

    http://www.countyhealthrankings.org

  • TJJ2000||

    Free Market = Affordable for Everyone
    1) Dental Insurance $7/month
    2) Hair Cut $5/month

    Government Regulated = Un-Affordable by Everyone
    1) Ear Ache Check-up = $300/JUST TO BLOODY SCHEDULE AND APPOINTMENT!

    Will people ever wake-up and realize EVERYTHING! And I mean EVERYTHING the government gets in charge of will become utterly Un-Affordable by Everyone! Just as it has with Education right after Federal started taking over. And Housing - right after Fannie Mae and Freddie Mac passed. And the more things No-One can afford the more things that will be come Communistic-ly ran.

    Soon it will be, "Welcome to USSA" instead of "Welcome to Venezuela"

  • Duelles||

    I like my medicare and thank workers of the world all the time for provinding me with insurance. Problem is that here in NM it takes me a month to 6 weeks to get a Dr. Appointment. Low reimbursements keep Drs. away from my state. So. . . For things that really matter I go out of state and pay. Often I can make a deal to pay slightly more than ins. Reimbursements and less than the "real" cost of treatment (which Drs cannot ever figure out, anyway) so always make a deal. Government wage and price controls flat out suck!

  • swampwiz||

    Actually, there is competition; it's just that - for any single market - one insurer is doing such a good job that no one else can put forth a good enough network at a comparable price. In essence, the market is becoming a de facto single-payer system, only without the benefit of having everyone buy into the system (the mandate is still far too weak) - something that could be solved by simply taxing everyone and giving them the coverage (ironically, the conservatives seem to be heading in this direction, at least in the form of "catastrophic" coverage).

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