The number of counties that have at least three Affordable Care Act marketplace payers dropped in 2017 and again in 2018, according to a new report in Health Affairs.
Payer participation at the county level stayed mostly stable in 2015 and 2016 as 80% of countries had at least three marketplace payers. That equaled 93% of the population.
The percentage dropped to only 36% of counties and 60% of the population in 2018 as more payers left the exchanges, especially in low-population areas.
The findings suggest the impacts from the Trump administration and other Republican efforts to weaken the 2010 law.
Researchers found that counties without at least three payers in the ACA exchanges were more likely to be in states where Republicans controlled the executive and legislative branches of government. They also tended to be rural and had higher mortality rates.
Competition was more common in states with a higher proportion of Hispanic citizens between the ages of 45 and 64 and in states that expanded Medicaid under the health law.
Non-expansion status was the strongest predictor of limited exchange competition. The report found that there could be a connection between not expanding Medicaid and having limited ACA payer competition.
"Previous work has demonstrated that the largest health insurers in the United States are highly dependent on Medicaid and Medicare for enrollments, revenues and profits. Thus, states' decisions to expand Medicaid may increase the attractiveness of their markets to insurers and could have important spillover effects in the marketplaces," according to the report.
The exchange market saw its share of instability over the past three years. Members have faced double-digit premium increases as payers have tried to offset policy changes that could harm the exchanges.
Republicans tried to repeal the ACA in 2017 and President Donald Trump remains opposed to the law. These actions have caused multiple payers to leave the exchanges rather than face more uncertainty. Last year, state regulators scrambled to ensure that all counties were covered by at least one payer in the exchanges, and members faced huge premium increases.
Despite these efforts, things are looking up for the exchanges in 2019. Every county will have at least one payer in the exchanges and regulators didn't even need a major effort to get all counties filled for next year.
That stability was evident in a recent analysis by the Associated Press and Avalere Health. That report found that the average proposed or approved premium increase for ACA plans is only 3.6% for 2019. In fact, 11 states expect an average premium decrease and 41 states expect reductions or hikes of less than 10%. That's a far cry from the double-digit annual increases that were the norm in the ACA exchanges in previous years.
The relatively stable premiums are a positive for the exchanges, but the marketplace still faces issues, including a court case in Texas that could wipe out the ACA. The Department of Justice is arguing in opposition of the health law.
Other problems for the exchanges are the Trump administration's plans to expand short-term health plans and association health plans next year. Proponents say these plans will offer lower-cost options, but critics charge this will result in healthy people leaving the exchanges, creating a sicker risk pool. That means higher premiums in the exchanges, they warn.
Those aren't the only problems for the ACA. Congressional Republicans also wiped out the individual mandate penalty for 2019 and Trump eliminated cost-sharing reduction payments for insurers.
Despite all of these trends working against the ACA, payers have found stability and many are even thriving in the exchanges. A May Kaiser Family Foundation review of 2017 data found insurance companies found profitability in the marketplace. Medical loss ratios improved in 2016 and averaged 82% in 2017 after large premium increases, leading to more premiums than paid out claims.