Rising insurance premiums, lack of access, uncertainty, and commotion around Affordable Care Act (ACA) repeal, have all contributed to the growing discontent and unease surrounding health care reform. Pressure to act continues to mount. Insurance titans Humana, United Healthcare, and Aetna have all rolled-back participation on the ACA Marketplaces. Anthem recently announced that it would exit the Ohio health insurance Marketplace, potentially leaving at least 18 counties without an exchange plan next year. Missouri and Washington State are also facing similar Marketplace participation issues. States such as Alabama, Arizona, Illinois, Kansas, Minnesota, Oklahoma, Pennsylvania, and Tennessee have seen individual market exchange premiums increase more than 45 percent since 2016. Furthermore, participating exchange plans are asking for steep rate increases for next year—averaging between 11.1 percent and 44.7 percent.
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These events have contributed to an economic and political climate ripe for disruptive legislation. While Congress and the current administration pursue solutions to address premium and access issues, more states are inserting themselves in the conversation. More than a dozen states have explored options to leverage federal 1332 and 1115 waivers, which would provide flexibility to develop market stabilizing programs and regulatory changes to their respective individual and Medicaid markets. More recently, a few state legislatures have leap-frogged one-off programs such as reinsurance or high-risk pools, and sought to create a truly different market structure. Three states’ legislatures, California, New York, and Nevada, have developed high-profile state-driven solutions to address consumer access and price-related concerns. While state-led waiver initiatives such as those from Alaska and Oklahoma are meant to provide an incremental stabilizing force to their respective markets, the models that California, New York, and Nevada legislatures proposed could fundamentally reshape the framework of state health markets more akin to what Massachusetts did 11 years ago.