"At this point, I don't know how much value it's going to bring to small businesses," he said. "I feel like small businesses have been pushed to the side or into a holding pattern. And for a state like New Hampshire, that has so many small businesses, it's really preventing us from realizing the full scope of benefits that were the intention of the Affordable Care Act."
The law requires each state to have a Small Business Health Options Program, or SHOP exchange, through which employers can offer workers a choice of qualified health plans from several insurers. But the employee choice provision has been delayed until 2015, meaning Baetz wouldn't be able let his workers choose policies that meet their diverse needs next year even if companies other than Anthem were participating.
"It's disappointing we're not going to realize the full breadth of benefits," he said. "And my fear is it may never be realized because we seem to be continually pushed back."
For individuals, the new markets will offer a choice of private health plans resembling what workers at large companies already get. The government will help many middle-class households pay their premiums, while low-income people will be referred to safety-net programs for which they might qualify.
Like Baetz, Lisa Kaplan Howe also was disappointed that uninsured individuals won't have as much choice as she had hoped. She is the policy director at Voices for Health and represents consumers on the advisory board.
"We were hopeful that there would be an opportunity for people to compare costs across carriers," Howe said. "But it's always a delicate balance. One thing we were concerned about was having a huge number of plans because having an overwhelming number of choices is not a meaningful choice."
Some insurers may be waiting to see how things play out the first year, she said, noting that New Hampshire was slower than many states in deciding whether to set up its own marketplaces or let the federal government run things. And the state could explore strategies to bring more carriers in, such as requiring all carriers with a certain presence in the state to participate.
Anthem is one of four companies licensed to sell individual plans outside the new marketplaces in New Hampshire and one of six licensed to sell small group policies. In the new marketplaces, enrollment starts Oct. 1 with coverage taking effect Jan. 1. After that, virtually everyone in the country will be required by law to have health insurance or face fines.
Elsewhere in the country, a bit of a pattern has emerged, with New England states tending to have fewer participating insurers, said Caroline Pearson, vice president of the health consulting company Avalere Health. Vermont, for example, has two companies participating; Rhode Island will have two carriers in the individual exchange and three in the small group exchange. That stands in contrast to the rest of the country, where there has been a fairly large turnout in most states, she said.
"Exchanges draw new carriers to the market in a broader way than they have operated before, but they're being very strategic about where they go. So we're seeing the bigger states that have more meaningful population attracting new health plans, and the small states, not surprisingly, are being left with the plans that are already there."