Republicans have spent the better part of a year claiming that Obamacare was finally unraveling just the way they always predicted it would. For proof, they often pointed to parts of the country where carriers had decided to pull out of the local market, and it looked as if there might not be any insurers offering coverage through the law's exchanges in 2018. As counties in states such as Tennessee, Nevada, and Missouri faced the possibility of becoming insurance deserts, conservatives claimed vindication, and cited the problems as evidence that the Affordable Care Act needed to be replaced immediately. Donald Trump, for his part, proclaimed Obamacare “essentially dead” and ready to “explode.”
Unfortunately for the GOP, reality has refused to cooperate with their talking points. With just about a month to go before insurers have to make the final decisions on whether to participate in next year's market, Politico notes that there is just one market left in the country without an insurer lined up. The last bare patch left is Ohio's Paulding County, where only 334 residents were enrolled through the exchange next year.
While Paulding's plight is no doubt a sign of Obamacare's flaws—the system lacks an insurer of last resort to deal with market failures—the fact remains that almost every single American will have at least one insurer to choose from next year. The law has not collapsed.
Relatively few individuals were ever in real danger of going without insurance options next year. According to the Kaiser Family Foundation, just 82 counties with about 92,000 Obamacare enrollees faced a serious risk of being left without a carrier (that list did not include Iowa, where, despite a great deal of anxiety and speculation that it might, the state's last major insurer never pulled out of the exchanges). We're talking about less than 1 percent of a 10.3 million-person nationwide pool of customers.
The insurers that swooped in to the handful of markets that were at risk of being abandoned generally fell into two categories. In one bucket, there were nonprofit carriers such as Blue Cross Blue Shield of Tennessee and CareSource in Ohio, which tend to view covering the individual market as part of their organizational mission and are willing to take a risk on sparsely populated rural counties that may turn out to be unprofitable. In the other, you largely had Centene, a for-profit insurer that picked up the slack in Missouri and Nevada while also expanding in Florida, Georgia, Indiana, Ohio, Texas, and Washington, even as major carriers like Aetna and Anthem chose to bail on the exchanges.
Thanks to its background as a Medicaid coverage provider, Centene has generally been confident in its ability to make a profit while serving Obamacare's lower-income, cost-conscious consumer base. Between it, other lower-cost insurance providers, and the nonprofit carriers, it seems that the exchanges may have a stable base of insurers at this point who can guarantee coverage availability for the vast majority of the country.
The obvious downside here is that many counties are now stuck being served by an insurance monopoly. And some of the carriers that decided to stick around in markets that otherwise would have been left empty are requesting major price hikes in return. Iowa's last insurer, Medica, has asked state regulators for a 57 percent premium increase, for instance. Just because the exchanges will be functioning next year does not mean they are necessarily working as intended everywhere, or that prices are staying in check.
There is also plenty the Trump administration can still do to undermine the exchanges, either over the next month or further down the line. If the president wanted to rattle the insurance markets before insurers ink their final contracts in September, Trump could cut off the cost-sharing payments that compensate carriers for offering low-income customers discount coverage. While the Congressional Budget Office thinks the markets would likely absorb the blow and continue to function, such a move could certainly convince some insurers to step away from the exchanges for at least the short term. Meanwhile, the administration already seems to be undertaking a more subtle campaign of sabotage by dialing back Obamacare outreach efforts, which could lower enrollment—particularly if it also chooses to relax enforcement of the the individual mandate.
Still, even with a hostile White House throwing an enormous amount of uncertainty into the mix, Obamacare is managing to function in all but one small corner of the country. The law is a lot more resilient than Republicans claimed, or hoped.