State officials and health care groups in Indiana, Nevada and Ohio are working to fill empty insurance exchanges next year either by striking deals with insurers or finding alternative arrangements for impacted residents.
Thirty-eight counties and more than 25,000 residents between the three states are in jeopardy of having no exchange option in 2018, unless an insurer steps in before the deadline this fall. Republicans have used dwindling plan participation as ammunition in their fight to repeal the 2010 health care law, but insurers cite the uncertainty in Washington as one major reason for their withdrawals.
Wisconsin-based Gundersen Health Plan is the latest to exit in Iowa, citing “unstable market conditions.” While the move only affects 370 residents in five counties, it leaves Medica as the state’s sole exchange plan after Aetna and Wellmark fled. Medica has filed to offer plans statewide, albeit with an eye-popping 44 percent premium increase request.
Nevada residents are facing the prospect of no exchange insurer in 14 of the state’s 17 counties. Heather Korbulic, executive director for Nevada HealthLink, the state exchange, said she is dedicating “every waking moment” to finding a solution for the so-called “bare counties,” the majority of which were stranded after Anthem announced its withdrawal last month.
Anthem, which will offer a high-deductible catastrophic option outside of the Obamacare exchange, cited as the main reason for its exit a lack of clarity from Washington on issues like the healthcare law’s mandate that most Americans buy insurance and certain consumer subsidies. Korbulic is working to convince insurers like Anthem to return, but the debate on Capitol Hill is thwarting her efforts.
“It’s difficult when you don’t exactly know why, and when you don’t have any control,” Korbulic said.
If those talks fail, she’s pushing for plans in the three remaining counties to take enrollees from other areas. But if an Elko resident has to drive four hours to Reno for a doctor’s appointment, that’s “not ideal,” she said. She’s also searching for flexibility in Medicaid, the Children’s Health Insurance Program and state programs that might help absorb some stranded consumers.
As a last resort, Korbulic is working with rural hospitals and clinics to help residents stuck without an insurance plan. One such option is a group of clinics that offers uninsured residents a medical discount program, the Access to Healthcare Network. Another is the state’s federally qualified health centers, which offer services on a sliding fee scale based on a person’s income.
Korbulic is also considering an emergency waiver similar to one in Iowa, which would let the state implement changes to the 2010 health care law (PL 111-148, PL 111-152). Ohio has considered such a waiver as well under the law’s so-called 1332 waiver system.
The biggest impact could be the political effect, said Steve Messinger, director of policy for the Nevada Primary Care Association. GOP Gov. Brian Sandoval, whose final year in office is next year, has repeatedly slammed the Senate health care effort.
“If the governor can turn one of these companies around, that will be a big score for him on his way out the door,” Messinger said.
One possible lifeline could be Centene, which is entering the Nevada market in 2018 and expanding in Indiana and Ohio. But the insurer has not specified which counties it will enter, and a Centene aide said the company will not have further details until the filing and review process is complete.
Searching for a Solution
Ohio is in perhaps the most dire situation of the three states, with roughly 13,400 residents in 20 counties facing the prospect of an empty exchange next year. A Department of Insurance spokesman said the state is “working to identify coverage options, but that process will take some time.”
Not everyone thinks the state is doing enough to solve the problem. Steve Wagner, executive director of the Universal Health Care Action Network in Ohio, said Ohio Gov. John Kasich’s administration and state lawmakers are essentially letting the situation “blow up.”
The state could require Medicaid plans to offer exchange plans in underserved areas, Wagner said, or waive part of a health insurance tax for any insurer that enters one of the bare counties. The state theoretically could also let abandoned consumers buy into Medicaid.
“That would absolutely change the dynamic,” Wagner said. “But we have a legislature that right now was about to try and freeze the Medicaid expansion in July 2018.”
Kasich, a Republican, has been one of the most outspoken critics of the GOP’s repeal efforts while his administration has simultaneously bashed the 2010 health care law. A Frequently Asked Questions document on the state’s insurance website blames the law for the current situation, saying the “best, long-term fix is to repeal” and replace it.
State lawmakers recently decided against overriding Kasich’s veto of their bid to halt Medicaid expansion enrollment. Medicaid is one of the flashpoints pitting Republicans against each other in Congress.
In Indiana, 3,700 residents in four counties might be left without an exchange option after Anthem and local insurer MDWise announced their withdrawals. An Indiana Department of Insurance spokeswoman said the state is “working hard” to find an option for the impacted residents, but would not comment further.
Residents in those counties will have access to federally qualified health centers like in Nevada, according to Phil Morphew, CEO of the Indiana Primary Health Care Association. But people could have to travel up to 75 miles to reach a clinic, if they even know it exists.
“It is a problem and one that I don’t have a ready solution to,” Morphew said.
Any option, short of having an insurer step in, will come with caveats for the people affected.
While Korbulic hopes Nevada will come up with a workable option for the bare counties, she’s not optimistic.
“The most simplistic option is to have a carrier expand,” she said. “Every other plan has layers and layers of complications.”