Southeast to Take Brunt of ACA Pullouts

Meir Rinde
Published: Wednesday, Oct 05, 2016
Michael Roberts, MD

Michael Roberts, MD

First it was UnitedHealthcare, then Humana, then Aetna. One by one, major payers have announced they will withdraw from many Affordable Care Act (ACA) marketplaces at the end of this year, leaving residents of hundreds of counties with just one or two payers selling policies on the government-run exchanges. For a few weeks it appeared the marketplace for Pinal County, Arizona might have no plans at all, despite the law’s requirement that most Americans carry health insurance.

Exchange plans make up a small part of the overall insurance market, and the majority of counties will still have more than two payers, but this is little comfort to cancer patients in the affected areas who have such plans. They are already coping with ever-rising premiums, high deductibles and copays, narrow provider networks, and cumbersome preauthorization requirements. Now, they face the prospect of losing their insurance and possibly having to change their doctors in the midst of a course of treatment.

Michael Roberts, MD, of Arizona Oncology, a practice in The US Oncology Network, recently saw a patient in the Phoenix area who has multiple myeloma and was “more than ready” for a stem cell transplant. The approaching expiration of the man’s marketplace plan only added to the urgency of a speedy start to treatment, Roberts said.

“I was calling the transplanters to get him in sooner rather than later, because his insurance from this plan ends on November 1. I’m trying to make sure he gets on to his wife’s insurance, and he’s terrified,” Roberts said. “We spent a good chunk of a Friday afternoon trying to piece together what’s going on with him. I’m pretty sure at the end he’s going to get on the other insurance and be OK, but there was an hour when he was just kind of terrified.”

He noted that insurance plans are increasingly changing every year, or even more frequently, whether provided by a marketplace, employer, or Medicaid. Providers are added or subtracted, cost-sharing terms change, and new hurdles are imposed for treatment approvals. He described the new marketplace disruption as just the latest in the insurance market’s ongoing turmoil.

“This year’s going to be a little bit harder with the ACA plans because there are fewer of them and costs are going up, but honestly, I think each year it just gets more complicated,” Roberts said. “That’s been going on for quite a while.”

Oncologists like Roberts are having difficult conversations with their patients across the state and the country. In Arizona it appears that the marketplaces in every county but one will have plans from just a single carrier.1 Exchange offerings have not yet been finalized, but the Kaiser Family Foundation estimates that 31% of counties nationwide could have just a single marketplace payer in 2017, up from 7% this year, and a similar percentage will only have two, up from 12% in 2016.2 Open enrollment begins November 1.



Figure: Payer Participation in Health Exchanges Will Plummet

Source: Kaiser Family Foundation

Currently, only Wyoming has a single marketplace carrier in every county, but Alabama, Alaska, Oklahoma, and South Carolina will likely join that list in January, according to the foundation. Single-carrier marketplaces have been concentrated in rural states, including West Virginia, Utah, South Carolina, and Nevada, and will become much more prevalent in Arizona and several southern states, most significantly Florida, Mississippi, Missouri, North Carolina, and Tennessee.

The big payers that are pulling back cite the small market size, greater patient expense on the exchanges, and continuous financial losses from those plans. In addition, Aetna, which is dropping out of 546 counties in 11 states, had threatened to leave the exchanges if the Justice Department opposed the company’s proposed merger with Humana. In July, the government sued to block the deal.

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