Consumers buying insurance on the health care exchanges will have less choice of insurer and plans as they shop around during the six-week 2018 enrollment period.
Just 45 percent of enrollees live in areas with three or more competing insurers, down from 75 percent in the first open-enrollment window, according to the latest report published by the Department of Health and Human Services (HHS).
A little under 30 percent of the approximately 10 million expected to buy coverage on the exchanges will have one insurance company to choose from, and a further 26 percent will have two.
Eight states will have only one issuer in 2018, including Alaska, Delaware, Iowa, Mississippi, Nebraska, Oklahoma, South Carolina and Wyoming.
Much attention has been directed toward Iowa after its regulators withdrew an application for a waiver to opt out of the exchanges altogether and offer a single insurance plan with lower premiums and higher deductibles.
Iowa is an example of a state doing everything to not help themselves, argues David Anderson, a health policy expert at Duke University's Margolis Center for Health Policy.
There is a large non-Affordable Care Act market, which is keeping healthy people out of the exchanges, Anderson said.
"That means those on the ACA exchanges tend to be much sicker as a whole," he added. "It is also a mostly rural state, which means very little market power, pricing power for insurers, when there may be only one hospital covering two counties."
In addition, the state's only insurer, Medica, is offering very few plans, including just one silver, the benchmark for subsidies.
"There are no good deals for healthy people," Anderson said. "This is a deliberate choice because the company offers multiple plans elsewhere.
"The application for a waiver was withdrawn when state looked at the numbers and realized the federal government was going to give them much less money than expected."
It was also a big and complex proposal, and only submitted in August, not enough time for it to be assessed and approved, Anderson argued.
Overall, Anderson said a key problem with the exchanges nationwide comes down to communication, of which there has been a significant change since the new administration took charge in January.
Individuals may not bother signing up because the message they are receiving is that the ACA is dead, the health policy analyst said, adding that those who are relatively healthy may just flip a coin on whether to enroll.
The estimated number expected to enroll is 10-11 million, down from 12.2 million this year. Dramatically decreased federal support to encourage enrollment likely will make a difference.
Anderson predicts a likely marked difference between those states that run their own exchnges, including Washington, California, New York, and Idaho, and those where it is organized by the federal government.
Those running their own exchanges are invested in making them work, Anderson said.
The average enrollee has a total of 25 specific plans to choose from — down from 30 last year and 51 during the first enrollment period.
The Centers of Medicare and Medicaid Services (CMS) released its county by county analysis of participation in Obamacare’s exchanges. For the upcoming plan year, Americans residing in more than half of the nation’s counties will have only one issuer offering plans.
While President Trump has stopped cost-sharing reduction payments to insurers – which were aimed at offsetting company losses for providing lower priced insurance to low and middle income consumers – most of those enrolled will continue to receive subsidies and/or tax credits.