Katherine Hempstead's slides from the Center for Health Journalism webinar, "Left in Limbo: Obamacare’s Shaky Insurance Exchanges," 6.7.17 More info: https://www.centerforhealthjournalism.org/content/left-limbo-obamacares-shaky-insurance-exchanges

1. Time frame for issues in the individual market…
National State
Short Run
CSRs Market Conditions
Medium Run
Repeal/Replace Counter measures
Long Run
Bigger Reforms Bigger Reforms

2. Repeal/Replace
• Still great deal of uncertainty but…
• Senate making progress
• Cleared hurdle with Parliamentarian
• Likelihood of success may be increasing
• Vote by late June (?)

3. Meanwhile…CSRs/Bare counties
• Cost Sharing Reductions – will they be paid?
• WH – delayed decision until August
• Has not committed to paying in June
• Will Congress will eventually appropriate?
• Failure to pay = rate increases, withdrawals
• Failure to decide = rate increases, withdrawals
• Must be resolved this summer – fatigue about issue
• “Bare county” policy efforts – McCaskill etc..

4. Major state issue: Market Conditions:
Rate filings, carrier participation, etc…

5. Rate filings
• Approx 8-10 states so far
• In some states, carriers have made multiple rate requests making different
assumptions about CSRs
• http://www.serff.com/documents/plan_year_2018_state_deadlines.pdf
• Average thus far closer to @ 10% assuming CSRs - @ 25% assuming no CSRs
• Rate filings contain important information about carrier mindset and financial
performance, also can serve political purposes.
• Example: BCBS NC – explicitly notes price of CSR uncertainty
• http://mediacenter.bcbsnc.com/news/bcbsnc-files-average-rate-increase-of-18-
8-percent-for-aca-coverage-in-2017
• Anthem in Ohio – exits, but leaves the door open to return

6. Market conditions – financial performance
• How are carriers doing financially?
• Multiple reports that conditions improved: (S & P in Q4 2016)
• https://www.axios.com/large-blue-cross-blue-shield-insurer-reverses-
aca-losses-2418954360.html
• Some financial information available for 2017 from National
Association of Insurance Commissioners
• Can look at some measures of financial performance information of
carriers in particular states

7. Example: Anthem – Ohio
Q1 2017 Q1 2016
Enrollment 101,307 79,114
Premiums 149,210,461 90,184,320
Claims 90,243,217 58,826,120
Ratio 60.48% 65.23%
Patient Days/1000 mm 39.4 18.7
Ambulatory/1000 mm 814.8 563.6

8. State problems are not random – risk factors
for market trouble
Structural factors Policy factors
Poor health Failure to expand Medicaid
Low income Permit transition products
Non-competitive provider markets History of “limited coverage specialists”
Small market size Continues to allow “limited coverage specialists”
States with structural and policy risk factors more likely to have poor outcomes such as:
Poor carrier participation
Large premium increases
Low turnout

9. “Leakage”
• Transition plans
• “Limited coverage specialists”
• Sharing ministries
• Very important factor in states that are struggling
• Role of insurance department

10. 0 .2 .4 .6 .8
Percent of 2013 issuers that were limited coverage specialists
HI
MA
NJ
RI
VT
WA
DC
ME
NY
WI
CA
MD
PA
MN
OR
DE
FL
SD
MI
VA
CT
ND
TX
OH
NV
OK
CO
GA
ID
IL
WV
AR
LA
IN
KY
MO
NM
UT
KS
SC
AZ
NC
TN
NE
AK
IA
NH
AL
MS
WY
MT
Source:RWJF

11. 0
50
100
150
200
250
300
350
2013 2014 2015 2016 2017
Issuers in the Individual Market, 2013-2017
Blues Plans National Commercal Limited coverage specialists
Medicaid Managed Care Provider Sponsored Plans Regional Plans
Co-ops and other publicly owned

12. 0 .1 .2 .3 .4 .5
Percent of 2017 issuers that are limited coverage specialists
AK
CA
CT
DC
HI
ID
IN
KY
MA
ME
MN
ND
NH
NJ
NM
NY
OR
RI
SD
VT
WA
WI
FL
MI
VA
IL
NV
TX
IA
MO
PA
OH
UT
KS
GA
AR
MD
CO
DE
NC
OK
WV
MT
LA
SC
TN
AZ
MS
AL
NE
WY
Source:RWJF

13. State policy initiatives
Varying time horizons
• Defense – require EHBs, access to contraception, etc…
• Stabilize
• Require individual market participation to Medicaid
• Reinsurance – 1332 waiver

14. Individual market issues in states
• Carrier participation
• State risk factors
• Financial performance of carriers
• Leakage
• Insurance department issues
• Possibility of bare counties?
• Potential responses/contingency plans
• Premium and benefit design changes, networks, etc….
• http://www.rwjf.org/en/library/research/2017/04/hix-compare-2014-
2017-datasets.html

15. Longer run issues
States
• Single payer – CA
• Medicaid buy-in – Nevada
National
Single payer
Medicare/Medicare Advantage for all
Auto enrollment in catastrophic plan