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The Affordable Care Act and federal regulators tried to give the ACA public exchange system a dominant position in individual major medical major medical insurance distribution.
But, as of 2016 — the third year of the ACA public exchange system's operation — the exchange plan system accounted for only 57% of U.S. individual major medical enrollment, according to new data from the U.S. Government Accountability Office (GAO).
(Related: 3 Off-Exchange Health Market Changes)
The GAO is an arm of Congress that helps lawmakers monitor what's going on in the federal government.
Congress developed the ACA public exchange system in an effort to give consumers a simple way to shop for coverage from commercial insurers, and to use federal subsidies to pay for the coverage.
The GAO prepared the new report to show members of Congress how competition in the ACA public exchange system has evolved since 2014, and especially in 2016 and 2017.
At that point, the administration of former President Barack Obama was giving the exchange system enthusiastic support, but technology problems and resistance from Republicans in the U.S. House had crippled one of the major ACA public exchange issuer support programs, the ACA risk corridors program. Issuers were starting to flee from the exchange system.
GAO investigations have informed lawmakers that, between 2015 and 2017, the state of competition in the ACA exchange system individual market grew weaker.
"Each year during this time period, for the 49 states for which we had complete data, on average, between three and five issuers participated in the individual market exchanges across the states' rating areas," John Dicken, a GAO director, wrote, in an account of the GAO investigators' findings. "Further, each year, the three largest issuers held 80% or more of the exchange market, on average, across the states' rating areas, in at least 46 states. For example, in Wisconsin in 2017, the market share of the three largest issuers ranged from 75% in two of the state's 16 rating areas to 100% in six rating areas; on average, the three largest issuers held 92% market share across the 16 rating areas."
The number of highly concentrated markets stayed about the some, but, during the period from 2015 through 2017, "market share was increasingly concentrated among a smaller number of issuers in many states, as fewer issuers participated in the exchanges," Dicken wrote.
Individual Market Numbers
The GAO has also included what may be some of the first state-by-state federal government data on the size of the non-exchange individual major medical market.
Non-exchange enrollees include people who still have "grandfathered coverage," or health insurance purchased before March 23, 2010, when Obama signed one of the two bills that created the ACA into law; people who still have "grandmothered coverage," or coverage purchased between March 23, 2010, and Dec. 31, 2013, before the first ACA public exchange plan coverage sold took effect; and people who have off-exchange coverage purchased on or after Jan. 1, 2014.
Consumers must meet strict federal and state rules to keep grandfathered and grandmothered coverage in place.
Consumers who buy individual major medical coverage outside of the ACA public exchange system must buy the coverage without help from the ACA premium tax credit subsidy.
In spite of those challenges, non-exchange coverage continued to be a powerful force in many states' individual major medical markets in 2016, according to the new GAO figures.
