MELISSA BLOCK, HOST:
This week was the deadline for insurers to file rates for 2018. And while most states are OK, there are some counties that may have no company selling plans on the health exchange. But this is just a step in the process, and some insurers may step in. As Alex Smith reports from Kansas City, nothing is set in stone.
ALEX SMITH, BYLINE: The insurance game is all about predicting the future. So the constant uncertainty in 2017 about what's next in health care has made insurance companies sweat, according to Washington University health economist Timothy McBride.
TIMOTHY MCBRIDE: 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.
SMITH: A Congress that's bent on ending the Affordable Care Act and a president who's threatened to cut some of the key subsidies for insurance companies have made many insurers very nervous.
MCBRIDE: We've been hearing a lot about - the insurers are saying, well, we're not whether we should even compete.
SMITH: And 47 counties in four states, Indiana, Missouri, Ohio and Washington, as of now have no insurer offering a plan on the exchange in 2018. That leaves about 34,000 people across the country without an exchange option out of the around 10 million people who have insurance on the exchange. Those exchange plans are the only ones that qualify for subsidies. And since the large majority of exchange customers get those, many of them simply won't be able to afford another insurance plan.
MCBRIDE: We may end up in a situation at some point where there are literally zero choices for people in certain counties of the state. We just haven't faced that yet in the ACA marketplaces.
SMITH: These areas are almost all rural. And Caroline Pearson of Avalere Health says that's because insurers face a lot of challenges crafting plans for those areas.
CAROLINE PEARSON: Enrollment in rural counties is smaller. 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.
SMITH: Meaning, with fewer doctors and hospitals in rural places, insurers have less leverage to keep prices down. But states do have some influence over their insurance markets. Some states have managed to avoid bare counties by encouraging insurance companies to stick it out. And in a few cases, states have gotten tough with insurers.
PEARSON: 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, you know, in that case the state is really using a little bit of its leverage to try to force plans to offer coverage.
SMITH: But in states that are less Obamacare-friendly like Missouri, action like that is unlikely. Missouri law prohibits any public agency from being involved in the exchange, which might actually make it illegal to step in when insurers decide to drop out. But the fact is summer is still negotiation time, and the insurers and rates for 2018 are still in flux. And some smaller insurers are moving in. St. Louis-based Centene recently announced it would sell exchange plans in Missouri, Nevada and Kansas. Centene already runs Medicaid plans. And Pearson says this kind of company could succeed in places where giants like Anthem and United have failed.
PEARSON: 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 pretty low rates. So they've really used their Medicaid experience to their advantage. And I do think they may fare better than some of their competitors.
SMITH: This week, the Senate is set to vote on its Obamacare repeal. Depending on how that goes, insurers may get all the certainty they need - or not. For NPR News, I'm Alex Smith in Kansas City.
BLOCK: The story is part of a reporting partnership with NPR, KCUR and Kaiser Health News.
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