A study out Thursday tries to better understand the ACA's implementation and its effect on competition among health plans.
For the study, researchers with the ACA Implementation Research Network interviewed representatives of health insurers, providers and provider systems, state insurance regulators, insurance brokers/agents, navigators and others, such as media reporters or policy experts, to examine why carriers chose to enter or exit markets, how provider networks were built, and how state regulatory decisions affected the landscape. The study focuses on competition in California, Florida, Michigan, North Carolina and Texas.
Here are 15 key study findings from each of the states.
California
1. California has the most successful marketplace of any examined in the study, researchers said. They based that on the state's ability to maintain a relatively large number of insurers in its largest metropolitan areas.
2. Covered California, the state's health insurance exchange, enrolled nearly 1.4 million people in the first open enrollment period, and the percentage of uninsured people declined from 17.2 percent to 8.1 percent between 2014 and 2017, according to the study.
3. Researchers said many stakeholders attributed California's decline in uninsured people the state's active purchasing model — including aggressively negotiating with insurers over premiums — as well as their active navigator program — which succeeded in increasing enrollments for individuals between 100 percent and 200 percent of the federal poverty level.
Florida
4. Respondents in Florida see the state marketplace as being largely successful, especially in population-dense areas, according to the study.
5. Researchers said navigators also appear to have played a major role in many parts of the state, despite legislation making navigator licensure more difficult.
6. In Florida, which did not expand Medicaid and opted for a federally-facilitated exchange, a substantial number of insurers entered the market, according to the study. However, the study notes, three major insurers have withdrawn from the exchange since 2015, citing an inability to turn a profit due to the number of sick people who enrolled.
North Carolina
7. Prior to the ACA, North Carolina's individual insurance market was dominated by Blue Cross Blue Shield of North Carolina, which had an 86 percent market share, according to the study. Aetna and UnitedHealthcare became major competitors in the first three years of the exchange, according to the study. By 2016, Aetna and UnitedHealthcare had market shares of 19 percent and 16 percent, respectively.
8. However, Aetna and UnitedHealthcare withdrew from the North Carolina individual marketplace prior to the 2017 open enrollment period, due to higher-than-expected claim costs and the state's lack of Medicaid expansion, researchers said.
9. Additionally, the study notes the interference of the federal government in the proposed Aetna-Humana merger likely contributed to Aetna's decision to pull out.
Michigan
10. Researchers said respondents in Michigan view the marketplace as generally successful over its first three years. They noted Michigan has a partnership exchange that uses the HealthCare.gov web portal, but performs many of the exchange functions at the state level. The state also expanded Medicaid in 2014 via an 1115 waiver.
11. The Michigan marketplace began in 2014 with 13 insurers and expanded to 16 carriers in 2015. Two left the exchange in 2016 and four more did so in 2017.
12. Researchers said respondents attribute the relative strength of the marketplace to the success of regional insurers over national insurers, particularly Medicaid managed care organizations.
Texas
13. Researchers said respondents in Texas, which has not expanded Medicaid, said the state's marketplace "has unraveled rather dramatically in many areas."
14. In 2015 and early 2016 there were 14 and 16 insurers, respectively, offering coverage in the Texas marketplace, according to the study.
15. However, by the 2017 open enrollment period, there were only 10 insurers, and six of these offered plans in 11 or fewer of the state's 254 counties. Even major metro areas, such as Houston and Austin, had only three insurers offering coverage in the marketplace, researchers noted.
In the end, researchers came away with some common themes. Among them:
- Health insurance markets are local
- Claims costs substantially exceeded insurers' expectations
- Mounting losses stemming from high utilization can overwhelm competitive efforts
For more on the common themes that emerged, read the full study here.