Health Care Uncertainty Leaves Many Missouri Counties Without ACA Marketplace Coverage

Jun 29, 2017

Insurance is all about predicting the future, so with the future of the Affordable Care Act in flux, uncertainty about what’s going to happen has made 2017 a tricky year for insurance companies.

“Oh, it’s tough, because businesses don’t plan backwards. They plan forwards. They want to think about what the business is going to look like next year and two years out and three years out,” says Timothy McBride, a health economist at Washington University in Saint Louis.

A Republican-controlled Congress bent on repealing the Affordable Care Act, and a president who’s threatened to cut subsidies worth billions to low-income people, have left many insurers jittery. They wonder if the subsidies that customers use to buy their plans will even be around next year.

“Probably a lot of the people would just drop out and not buy the plans,” McBride says. “So insurers are going to say, ‘Well then, we’re not going to have any customers, then we’ll just drop out.’”

July 17th is the deadline for health insurers to files rates for 2018, and it appears that dozens of Missouri counties may be left with no one selling plans on the Affordable Care Act’s health exchange.

That could make it much harder for thousands of Missourians to get the health insurance they need – although there’s still room for insurers to enter the market and some health experts still hold out hope for what they call “bare counties.”

Blue Cross and Blue Shield of Kansas City said in May that it would exit the Affordable Care Act exchange in 2018 in its 30-county area in northwest Missouri and in two Kansas counties. Company officials declined to comment but said in a news release it had lost $100 million on exchange plans over the previous three years.   

The move could leave 18,000 people with no choice of plans next year. Exchange plans are the only ones that come with government subsidies, and since most exchange customers get subsides, many simply won’t be able to afford health insurance.

“It could be that if an insurer leaves, then we could wind up in a situation where there are literally zero choices for people in certain rating areas. We just haven’t faced that yet,” McBride says.

Nationally, 47 counties, including ones in Ohio and Indiana, may end up with no exchange plans. Almost all of these counties are rural, and that’s because insurers face a lot of challenges crafting plans for those areas, says Caroline Pearson of Avalere Health.

“Enrollment in rural counties is smaller,” Pearson says. “It’s also harder for insurers to build an efficient provider network in those areas. So it makes it difficult for insurers to build an efficient, low-cost product.”

Some states have managed to avoid the problem of bare counties by encouraging insurance companies to stick it out. And in a few cases, states have gotten tough with insurers.

“We have seen a few states like New York that have attempted to go a step further and actually tie exchange participation to participation in other programs, like the state’s Medicaid program. So in that case, the state is really using a little bit of its leverage to try to force plans to offer coverage,” Pearson says.

But in states that are less Obamacare-friendly, like Missouri, that’s highly unlikely to happen.

Missouri bars any public agency from involvement in the exchange, which might actually make it illegal for the state to step in when insurers decide to drop out.

But the fact is, the summer is still negotiation time and things remain in flux for 2018. Two weeks ago, Saint Louis-based Centene, which already operates Medicaid plans in Missouri, said it would sell exchange plans in Missouri, Nevada and Kansas -- although it hasn’t said in which counties.

Pearson says a company like Centene could succeed in places where giants like Anthem and United have failed.

“They really understand how to deliver care to lower-income populations, and they also tend to be very efficient in the way that they contract with providers and have really low rates. So they’ve really used their Medicaid experience to their advantage, and I think may fair better than some of their competitors,” Pearson says.

Now that a vote on the Senate health care bill has been postponed, the uncertainty plaguing the insurance marketplace is likely to intensify. Whether people in northwest Missouri will have access to affordable insurance remains anybody’s guess. 

Alex Smith is a health reporter for KCUR. You can reach him on Twitter @AlexSmithKCUR