Jayne O'Donnell, Ken Alltucker, Laura Ungar and Tony Leys

USA TODAY Network

Up to 2.1 million people will likely have to change plans for 2017 due to insurers leaving states' Affordable Care Act marketplaces, up from more than 1.2 million who had to find new insurers last year. That doesn't include the millions who bought new plans because they found a better deal.

The new estimates, from data expert Charles Gaba of ACASignups.net, come as another analysis shows five states are expected to have just one company selling insurance on the 2017 Obamacare exchanges. Consumers in most counties in nine other states won't find any competition for their exchange business either, according to the Kaiser Family Foundation.

These latest assessments show how leery insurers are of the costs and rules associated with selling on the ACA exchanges — the centerpiece of the health law — and the risks this reticence present to their future. Insurers including Aetna, UnitedHealthcare and many smaller insurers and cooperatives have either decided to leave states and counties or have failed. Julie McPeak, who was appointed insurance commissioner by the Republican governor, told The Tennessean that the ACA marketplace for the state was "very near collapse."

The turmoil is putting intense pressure on federal regulators to stabilize the system, lower costs for consumers and reduce risks for insurers — often conflicting challenges that create a Catch-22. Among other changes, the Centers for Medicare and Medicaid Services proposed Monday to have its risk adjustment program factor in prescription drug usage data and the people who drop their coverage before 12 months are up. Insurers complain too many sick people sign up to get health care and then drop plans after their treatments are complete.

Insurers need healthy people to buy insurance to offset the companies' costs of covering sicker ones, but healthy consumers who don't qualify for high subsidies won't sign up unless the prices are more affordable, says Paul Howard, director of health policy at the free market Manhattan Institute.

"It's important that enrollment continue to grow," so the ACA sign-up period that starts Nov. 1 will be critical, says Kaiser Family Foundation vice president Gary Claxton. Regulators also need to "work with industry to figure out what issues remain and what to do about them."

Although the health law hasn't become the hot button issue it was in the last presidential election, the Obama administration still must make changes against a backdrop of fierce partisan opposition to Obama's signature law. That means no one expects solutions requiring congressional action before the November elections.

"This is probably the most frustrating public policy dilemma we’ve got right now in the country," says Wayne Goodwin, North Carolina's Democratic insurance commissioner. "Businesses and health insurance companies have invested so much into the ACA, there is a tremendous urgency to having Congress and whoever the new president is fix the law."

South Carolina and Alabama are grappling with what will likely be no competition for the first time in 2017 after insurers Aetna and United Healthcare announced plans to leave the whole states. And the Kaiser's analysis shows 31% of counties will likely have just one insurer in 2017 and another 31% are expected to have only two.

Tennessee insurance commissioner: Obamacare exchange 'very near collapse'

Kevin Counihan, CEO of Healthcare.gov, which handles the exchange sales for 38 states, emphasizes that insurers are adjusting at different rates to selling on the exchanges.

"With high consumer satisfaction, more people getting care, and an improving risk pool, incoming data continue to show that the future of the Marketplace is strong.” he said after Aetna's announcement this month that it would stop selling on the exchanges for 11 states.

CMS also often notes that rate increases haven't been as "high as people were expecting, but it doesn't matter because people aren't buying" plans unless they are heavily subsidized, says Howard of the Manhattan Institute.

Aetna changes add consumer pain as health care costs to rise in 2017

Arizona is facing one of the country's most dramatic swings in insurance company participation on the ACA exchange with 80% of the counties served by just one insurer. Pinal County, Arizona's third most populous, is the only county in the United States currently without an insurer selling on the exchange for 2017.

Six insurers that sell plans directly to consumers are bowing out or scaling back on the Affordable Care Act marketplace in Arizona. Multiple insurers also are discontinuing "off-exchange" plans that middle- and upper-income Arizonans rely on for health coverage, too.

Arizona's upheaval ensnared Leah Sondergeld, whose daughter, Kate, was diagnosed in 2015 with epilepsy. Kate's condition made the families' need to change insurers for a third time this fall all the more upsetting now that Aetna is leaving the state.

After a battery of tests, several specialists and seven medications before they found one that worked without too many side effects, Sondergeld dreads the thought of possibly having to find a new neurologist to treat her daughter. After her first exchange insurer went out of business in late 2015, the Sondergelds switched to United Healthcare, but quickly dropped the plan when she says the company refused to cover a test and her medications.

"We are a good family. It’s not that we’re not trying," says Sondergeld, a former nail salon owner whose self-employed husband works in real estate. ''It'’s a struggle."

Only two marketplace insurers are poised to remain in Arizona’s largest county, Maricopa, and the exodus has left 10,000 people in Pinal County enrolled in exchange plans without a single insurer willing to offer an option for them. After Aetna said it was leaving the state's exchange market, Blue Cross Blue Shield of Arizona said it would reconsider its decision to exit the two counties for 2017.

Federal and Arizona officials caution that things can change between now and Nov. 1, the scheduled start of the three-month enrollment, citing efforts to woo at least one Pinal County insurance provider,



How consumers in other states are faring:

• In North Carolina, where the Kaiser analysis shows 90% of the counties will have just one insurer, Goodwin is bracing to find out whether even that insurer — Blue Cross Blue Shield — will be leaving the state. (Cigna is on the exchange for the area known as the Research Triangle.) He describes his job as a "balancing act" that involves protecting consumers from "excessive rates" and trying to keep insurers in the market so consumers have access to insurance coverage.

Margaret Brawner of Charlotte, a pet sitter who does some contract work, says the rates were already too high. She's paying the tax penalty and out-of-pocket for doctor visits rather than the "unaffordable premium and ridiculously high deductible" she faced in 2015 of $900 a month with a $5,000 annual deductible for a Blue Cross Blue Shield silver plan. She's in good health, so worries more for friends who are being hit harder by the lack of competition. "It's people who need frequent access to medical care with no subsidy that it really hurts," she says.

• In Kentucky, consumers are adjusting to the looming departure of Aetna and UnitedHealthcare, which will not offer plans on the exchange next year. Sarah Halfacre, 35, an occupational therapist and single mom of two young children, is worried that after struggling to find the right United Healthcare plan and working out an arrangement with her student loan lender so she could afford the $340 premium, her only choices may cost even more.

Tom Clements, vice president of Preferred Insurance Group in Louisville, downplayed the significance of the two departures from the ACA exchange, noting they weren't competitive enough to attract many customers. Still, he says, "it’s not a good sign for the trajectory of health reform.”

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• In Iowa, which in late 2014 was the first to have an Obamacare co-op go belly up, 2017 is shaping up to be fairly stable, especially compared to what other states are facing. Mara Deaton of Des Moines will get to keep her Aetna policy as Iowa is one of the four states the company will remain in. Deaton, 61, is "incredibly grateful" to have a plan as she was treated for a life-threatening breast cancer more than a decade ago.

“I think we’re definitely having growing pains, but I know for a fact that no one would want to insure me," she says.

Deaton also receives a monthly subsidy of about $170 toward her Aetna premium and pays the remaining $372 per month. Aetna notified her recently that her premium will jump 19% next year, if the increase is approved next month by state insurance commissioner Nick Gerhart. Gerhart has warned that if he rejects the proposed increases, the insurers could just pull out of the state.

The insurer drop outs and scale backs — along with rate-hike requests as high as 122% for remaining insurers — has left other Arizona consumers nervous too. Some are taking step to prepare for what they fear could be delayed care and long trips to doctors’ offices and hospitals.

Claburn Niven Jones, who owns a home in Scottsdale and a condo in the San Francisco Bay area, said the insurance shakeout has prompted him to decide to relocate full time to California in 2017. The 63-year-old cancer patient doesn’t think that there will be enough options for his county, Maricopa, next year.

Diagnosed with prostate and thyroid cancers, Jones envisions long waits for specialists with crowded appointment calendars.

More than 126,000 Maricopa County residents had selected health plans offered by eight insurance companies as of Feb. 1. Those marketplace customers will be funneled to two insurance providers as of Jan. 1, 2017 — Phoenix Health Plans and Cigna.

“If you add them all up and throw them into a network, you’ll never see a doctor,” said Jones, a retired certified public accountant .

Briggs, of the Arizona Department of Insurance, said that the agency uses formulas to make sure there are enough doctors, labs and hospitals to handle the projected number of enrollees. He acknowledged that the remaining insurers could face heavier customer loads after so many others have dropped out or scaled back.

Jones has an insurance plan through UnitedHealth Group that will expire Dec. 31. UnitedHealth won’t offer any individual plans next year in Arizona.

"We moved to Arizona for a quality of life and (lower) expense,” said Jones. “I can’t get insurance, so I will have to leave.”

Goodwin, North Carolina's insurance commissioner, sent a letter to Department of Health and Human Services Secretary Sylvia Burwell in February, saying that he worried some residents would have "no access to health insurance at all."

"This is what I had asked and that so many wondered out loud: What if the dominoes begin to fall?" Goodwin said Friday. "There's been no answer to that question."

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