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There are no more counties without any Obamacare plans

Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

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Paulding County, Ohio, come on down!

The last empty Obamacare county, where 380 customers on the individual marketplaces were at risk of having no insurance options at all next year, has been filled. CareSource, which had filled other bare counties in Ohio and Indiana this summer, agreed to sell coverage there in 2018.

With that, every county in the country will have at least one insurer for its Obamacare market in 2018.

It's a sharp reversal for the law. In June, when Republicans were still working to repeal and replace Obamacare while President Trump threatened to deal it a devastating blow, there were 47 counties, with 38,000 customers, without insurers. At one time or another this year, 82 counties were at risk, according to the Kaiser Family Foundation.

So Obamacare didn't implode. Why? I walked through some of the reasons earlier today. More briefly, I'd break it down like this:

  1. Insurers see a solid business opportunity in bare counties. They can set prices to recoup their costs, knowing that most customers who receive subsidies through Obamacare will be insulated from premium increases. The feds will pick up the tab.
  2. State officials worked hard behind the scenes — and had ample leverage, as the still-predominant regulators of insurance — to bring carriers on board. We saw this play out in Nevada and Ohio, where governors flew in insurance executives for meetings and insurance officials got into nitty-gritty negotiations matching different insurers to different counties.
  3. Republicans failed to repeal and replace Obamacare, and Trump hasn't followed through on his threat to cut off the law's payments to insurers. I wouldn't say things are stable or certain, but they are more so than they looked over the summer — and now Congress is turning explicitly to shoring up the markets, not overhauling them.
  4. A few companies — namely Centene, which filled 45 of these empty counties — specifically invested in helping the law. Sarah profiled the former Obama administration executive now in a leadership role at that company.

This isn't a perfect solution, especially for people who don't receive subsidies and therefore aren't protected from premium increases in a monopolized market. It's also possible that Trump does something in the next few weeks to disrupt the market again — insurers have until the end of September before they are truly locked into selling plans in 2018.

We're still likely to hear a lot about counties with only one insurer. There are 1,340 of them, with 2.7 million Obamacare customers, according to our estimates.

That's a real issue. But I thought I'd share a couple of observations from Craig Garthwaite, a health economist at Northwestern University.

First, he pointed out that the problem is not that insurers will charge exorbitantly high premiums in a monopoly — there is little evidence of that happening, he said, and we know from aggregate data that insurers aren't exactly making a killing in the Obamacare markets.

"We should be careful about why exactly we care about the monopoly," he said. "As long as there are meaningful opportunities for entry, I don’t think we should worry that much."

The real problem is for consumers, who were promised under Obamacare the opportunity to choose from a variety of health insurance options. That opportunity is either narrowed or completely lost in a monopolized market.

"When there’s a monopoly provider in the exchanges, we lose that ability to match with the plan that’s best for you," Garthwaite said.

He made one last point, something that's easy to forget as we grow accustomed to blaming any and every problem in the insurance market on Obamacare:

"We’ve had trouble offering insurance in rural counties for a long time. This was neither created by nor will it be solved by the ACA."

Map of the Day


A full Obamacare market. The empty counties were shown in yellow, but they're all gone now. We'll probably be talking about the gray counties a lot more in the coming weeks and months. Those are the areas that have only one insurer selling plans right now. They don't comprise the majority of the marketplace (about 2.6 million customers out of 9.6 million, by our internal estimates), but that's still a lot of people with limited options.

Kliff’s Notes

With research help from Caitlin Davis

Today's top news

Analysis and longer reads

  • “McConnell’s Kentucky Loses Big If Repeal Revives. Will He Keep Trying?”: “With Congress poised to reconvene in September, it remains unclear whether McConnell will try again to repeal Obamacare or shrink Medicaid, after several failed attempts. But perhaps a more fundamental question is whether Republican politicians who tried — and may try again — to take away often vital health care benefits from their voters will pay a political price.” —Michael McAuliffe and Lisa Gillespie, Kaiser Health News
  • “Medicare to divulge when a doc's patient is in an ACO”: “The CMS is making a more concerted effort to make sure doctors know which patients they're responsible for in Medicare accountable care organizations. The CMS has updated the Medicare website to allow a beneficiary to list his or her primary-care doctor. If that doctor is in an ACO, the beneficiary would be assigned to both that provider and their ACO starting next year.” —Virgil Dickson, Modern Healthcare
  • “Rural-urban gap in some vaccination rates leaves health officials puzzled”: “New data on vaccination rates among U.S. teenagers provide some heartening news — but also pose a bit of a mystery. The report, from the Centers for Disease Control and Prevention, shows parents of teenagers are in the main following the CDC’s advice and keeping their children up to date on vaccines that should be administered in the early teens.” —Helen Branswell, STAT

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