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Rebecca Zisser / Axios

The recent report from Standard & Poor's detailing why Obamacare is not in a death spiral has made a lot of waves, especially in liberal circles. Don't overlook the linchpin of the S&P analysis — the financial reports of the not-for-profit and mutual Blue Cross Blue Shield insurers.

Why focus on the Blues? Simply put, they hold a lot of market power, and the exchanges would struggle to function without them. "Traditionally the Blues have been the main players in the individual market," Dan Polsky, the executive director at the University of Pennsylvania's Leonard Davis Institute of Health Economics, told me. "They are kind of the default, the last man standing."

Here's the evidence of the Blues' importance:

  • Five states (Alabama, Alaska, Oklahoma, South Carolina, Wyoming) had only one insurer for 2017. In each of those instances, the lone insurer is a Blue Cross Blue Shield affiliate.
  • Many other states (Arizona, Delaware, New Jersey, North Carolina, Vermont, West Virginia) had only two insurers for 2017. In each of those instances, the Blues are a dominant player.
  • Blues are major competitors in California, Florida and other big-state exchanges.

It's not all rosy for the Blues: The Obamacare markets vary widely from state and depend heavily on other factors, such as Medicaid expansion, whether pre-Obamacare plans are still around, and the state's risk pool.

  • Many Blue Cross Blue Shield plans still offer broader networks of hospitals and doctors. But the Blues in Illinois, Minnesota and Texas scrapped those plans in favor of narrow networks.
  • The Blues affiliates in Mississippi and Nebraska only sell plans off the exchange, and Wellmark just decided to abandon its half-hearted attempt on the Iowa exchange.

What we're watching: Anthem, the largest of all the Blue Cross Blue Shield companies. The for-profit Anthem has a massive Obamacare business that has hovered around break-even and slight profitability, and its decision to stay or exit in 2018 will be a bellwether for the marketplaces.

"They're kind of caught between theses two different psychologies of how one might embrace the marketplace," Polsky said, noting Anthem will either choose its shareholders or its legacy mission of covering those in need. "It's very unpredictable."

Go deeper

57 mins ago - Health

CDC says some immunocompromised people can get fourth COVID shot

Photo: Noriko Hayashi/Bloomberg via Getty Images

The Centers for Disease Control and Prevention said in updated guidelines Tuesday that some immunocompromised people who have received either Pfizer or Moderna's COVID-19 vaccines will be able to get a fourth shot.

Details: People over 18 who are "moderately to severely immunocompromised" and have received three doses of an mRNA vaccine may get a fourth shot (of either the Pfizer, Moderna, or Johnson & Johnson vaccines) at least six months after getting their third Pfizer or Moderna dose, per the CDC.

2 hours ago - Politics & Policy

Scoop: Biden plan expected to include at least $500B for climate

Photo: Stephanie Keith/Bloomberg via Getty Images

The White House is privately telling lawmakers the climate portion of President Biden's roughly $2 trillion social spending plan is "mostly settled" and will likely cost more than $500 billion, two sources familiar with the talks tell Axios.

Why it matters: A pricetag of $500-$555 billion is a huge number and, if it holds, would likely be the single biggest component of the sweeping package. It also isn't far off from the roughly $600 billion proposed when the bill was expected to cost $3.5 trillion.

2 hours ago - World

U.S. presses Gulf countries to help resolve Sudan coup crisis

Jake Sullivan briefs the press. Photo: Chip Somodevilla/Getty

The Biden administration has asked its partners in the Gulf and elsewhere to press the Sudanese generals who carried out a coup on Monday to release captives including Prime Minister Abdallah Hamdok and to reinstate the civilian government, White House National Security Adviser Jake Sullivan said in a press briefing on Tuesday.

Why it matters: The U.S. has limited influence over coup leader Gen. Abdul Fattah al-Burhan and other military leaders, many of whom have close ties to Saudi Arabia and the United Arab Emirates.

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