Aug 29, 2017 - Health

No more empty ACA counties, but not problem-free either

Sam Jayne / Axios

The threat of counties with no Affordable Care Act insurance options next year has faded, now that the Ohio Department of Insurance has found a health insurance company to serve the last county that was at risk. Roughly 23% of people buying plans on the ACA marketplaces will have one insurer to pick from next year, and the rest will have at least two choices, according to Bloomberg.

But filling the "bare counties" doesn't solve all of the shortcomings for people who get their health coverage outside the employer system. Here are pros and cons of the ACA marketplaces as they stand now.


  • People who buy coverage in the individual market won't be left out in the cold.
  • People who have incomes up to 400% of the federal poverty level can still get premium subsidies if they get a plan on the exchange.
  • Cost-sharing subsidies also help people who make less than 250% of poverty, assuming they get paid.
  • ACA plans still must cover preventive services and cannot turn away people based on pre-existing medical conditions. "It's certainly better than the world we had before, and it's certainly better than zero choices," said JoAnn Volk, senior research fellow at the Georgetown University Center on Health Insurance Reforms.
  • For insurers, it makes "profitability within the bare county extremely probable," said David Anderson, a health researcher at Duke University. They get to set the lone price, and they get to cover the healthy and sick.
  • Premiums could go down for people, depending on how insurance companies price their products.


  • A minimum of one health insurance carrier isn't much of a choice. Consumers have to take it or leave it.
  • The monopoly insurer can set whatever price it wants, since there is no other competition. That means the federal government will have to spend more on premium subsidies. "It really is an expensive way to do this," Volk said.
  • There might not be wide networks of hospitals and doctors available at any price. The lone insurer may decide to offer only cheaper, narrow-network plans. "This matters the most for fairly sick people who have complex care needs with multiple providers," Anderson said.
  • People who buy individual coverage outside of the marketplaces still don't get subsidies and will feel the full brunt of rising premiums.
  • Deductibles and other out-of-pocket expenses remain unaffordable for many low- and middle-income people.
  • People in rural areas will have fewer choices than people in suburban and urban areas (although this problem is not unique to the ACA markets).

The ultimate caveat: All counties are filled, but those are verbal commitments. Health insurers still have to sign contracts in September to lock them into offering coverage next year. "If nothing else, we've learned that things are quite fluid," Volk said.

The bottom line: The ACA exchanges still are not imploding as President Trump and Republicans claim, and it will take active undermining from the administration to put them in a tailspin. The bare counties turned out to be short-term problem, as many companies and insurance commissioners found ways to plug the holes. But Congress will have to find ways to make ACA markets more stable and affordable to avoid bare county threats every year.

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