As uncertainty swirls around the future of the Affordable Care Act, insurers interested in continuing to offer plans on the exchanges may seek to cap enrollment in an effort to stay financially afloat.
Insurers have retreated from the exchanges in the past few years, and those that have remained are seeing their enrollment increase. But the influx of members hasn't led to rising profits, as many exchange enrollees are saddled with ailments that are expensive to treat.
The issue is only expected to worsen next year as 36 counties in Indiana, Ohio and Nevada are at risk of having no marketplace insurers, according to the Kaiser Family Foundation, which tracks insurer participation. The CMS projected that as many as 1,200 counties, nearly 40% of counties nationwide, could have only one issuer in 2018.
Community Health Choice, a Houston-based insurer, has seen its exchange enrollment explode over the past few years, said Karen Love, the plan's executive vice president and chief operating officer. Community now enrolls 145,000 exchange members, up from 40,000 two years ago.
Community, Blue Cross and Blue Shield of Texas and Molina Healthcare were the only three insurers in Houston to offer plans on this year's exchange, down from seven insurance companies in 2016.
Love said she is worried about reports that plans that dropped out of HealthCare.gov last year are also planning to end their off-exchange individual market plans as well.
"Those people are going to need somewhere to go," Love said at the Association for Community Affiliated Plans CEO summit in Washington, D.C. on Friday.
Given the federal and state requirements of risk-based surplus funds her plan must keep on hand, Love said Community Health Choice can't handle many more sign-ups. The funds that plans must set aside are taken from the profit margin, which has not increased as new members have enrolled.
"We can't financially take another big influx of members," Love said. "We would like to very much stay on the marketplace and keep our current members, but not take on many new members in 2018."
To that end, her plan is considering asking the CMS to allow them to cap their 2018 enrollment. Her state insurance commissioners would also have to sign off on the request. If approved, her health plan would still be considered on the marketplace and thus eligible for federal financial subsidies. However, uninsured consumers searching HealthCare.gov would not see her plan listed.
While rare, the request is not unprecedented. In Minnesota, HealthPartners, Medica and UCare all had enrollment caps this year. Medica also had a cap on its Kansas plan on HealthCare.gov.
If Community Health Choice requests a cap for 2018, it won't be alone. Other plans are also planning to seek such permission, according to Scott Weltz, a principal and consulting actuary at Milliman.
He wouldn't disclose which plans are seeking caps, due to client privilege, but said that like Community, they are smaller regional plans in markets where other plans have dropped out.
"Small regional plans don't have the capacity to suddenly jump from 10,000 to 100,000 members," Weltz said. "They are requesting these enrollment caps so they can manage their growth."
Advocates are concerned about what the trend could mean for access to care. The upcoming open enrollment is already shortened from three months to six weeks and it's unclear what other options consumers would have if their enrollment is denied because of a cap, said Sandy Ahn, an associate research professor at Georgetown's Health Policy Institute.
"Between the shortened time and all the policy changes, this was already going to be a very confusing open enrollment period," she said.