Aetna's move to reduce its Affordable Care Act exchange presence in 11 states means that, for now, some counties have zero insurers scheduled to offer plans once 2017 open enrollment begins in November.
Various public figures, including Donald Trump, Bernie Sanders and Elizabeth Warren, have responded to Aetna's decreased participation in the exchanges.
For Trump, it's evidence of a "broken law," according to The Wall Street Journal. But Warren said the move is political leverage launched in response to the Justice Department's suit to block the proposed Aetna-Humana merger. Sanders, meanwhile, tweeted:
Our health cannot continue to be dependent upon the whims of insurance companies whose only goal is to make as much profit as possible.— Bernie Sanders (@BernieSanders) August 16, 2016
Health policy researchers and one attorney offered more even-handed, analytical takes on the news. Cynthia Cox, a Kaiser Family Foundation health policy expert, told the Associated Press the move will be felt in Southern states and rural areas.
“We could be looking at about one in four counties in the U.S. with just one exchange insurer next year,” she also told Kaiser Health News.
Sabrina Corlette of the Georgetown University Health Policy Institute noted exchange volatility may continue for a few years. Fundamentally, however, "the marketplaces are not crashing and burning by any means," Corlette told AP.
Bryan Rotella, a healthcare lawyer, sees the Aetna exit as part of a domino of major insurers decreasing their ACA participation.
"Aetna pulling out is like Lehman Brothers failing during the mortgage crisis. It is the bellwether that highlights the underlying fault line in the Affordable Care Act," he told FierceHeathPayer in an email.
"Insurance is about predicting risk," Rotella said. "Eliminating preexisting conditions as a part of health insurance rating, while very humane and understandable, puts blinders on the companies taking the risk. It was doomed to eventually fail, which is happening sooner rather than later."
So how have insurers been dealing with financial losses on individual ACA plans? A few examples:
- In Pinal County, Arizona, the exits of Aetna and UnitedHealth effect 10,000 enrollees who no longer have plans to choose from, approximately 85 percent of whom receive subsidies to purchase ACA plans, according to KHN.
- Scott & White Health Plan cites “fundamental flaws” in the risk-adjustment program as one reason for ceasing its operations of ACA individual products in 58 Texas counties, according to The Dallas Morning News. A recent Robert Wood Johnson report suggests extending the reinsurance program may make Medicare sustainable.
- Insurers are not leaving ACA exchanges altogether, but are scaling back the number of counties in which they offer plans. In sum, Aetna exited 11 of 15 states it originally operated in; UnitedHealth has left 31 of 34 states it first offered individual products; and Humana has reduced its presence from 19 states to 11.
So what happens next?
"The solutions now are either an expensive government takeover of the system or the implementation of a better privately run initiative that takes advantage of now available volumes of patient outcome data for the good of the whole population," Rotella tells FierceHealthPayer.
Insurers bolting from ACA marketplaces gives critics a platform to say, “I told you so.” The combined exits of United, Aetna, and Humana will impact approximately 1 million to 1.5 million of the 13 million people who signed up during 2016 open enrollment, according to KHN.
Nevertheless, some insurers may see opportunity where United, Aetna, and Humana have sufffered financial defeats. Though just 25 percent of counties will host one insurer, “this could change between now and open enrollment in November,” Cox told KHN.
The absence of insurers on certain exchanges makes the public option germane. Hillary Clinton has expressed support of a public option, but has yet to comment on Aetna's decision on either her campaign's blog or social media outlets.