Health insurance provider Anthem announced Tuesday it is pulling out of Obamacare entirely in Ohio, a decision that could leave nearly 20 counties in the state without a single insurer on the exchanges.

Anthem’s move Tuesday marks its first exit from a state Obamacare exchanges, although the company has repeatedly warned it would exit from exchanges if conditions did not improve. Its exit from the Ohio exchanges is likely to leave consumers in 18 Ohio counties without the option of purchasing an Obamacare plan, The Wall Street Journal reports.

The insurer currently offers plans in 13 states and expects to continue offering plans on the exchanges through 2018. Anthem held its decision to continue to serve Obamacare consumers in Connecticut until the last minute, and could still choose to withdraw from any, or all, of the 13 states in 2018.

Like many insurers who have opted out of various state Obamacare exchanges in recent months, Anthem cited uncertainty and “volatility” in the Obamacare marketplaces as reason for its decision. The company believes the “increasing lack of overall predictability simply does not provide a sustainable path forward to provide affordable plan choices for consumers.”

Anthem will offer insurance plans in just one Ohio county, Pike, but they will not offer Obamacare plans in that county.

Anthem’s exit marks the second major insurance provider to opt out of state Obamacare exchanges in the region. Blue Cross Blue Shield of Kansas City announced in late-May that it will no longer offer or renew insurance plans on the city’s Obamacare exchange next year in Kansas or Missouri.

The problem isn’t localized, but spreading across the nation. Humana became the first insurance provider to completely opt out altogether in February, announcing it would no longer offer health insurance plans on state exchanges in 2018. Aetna announced in early-May that its exit from the exchanges nationwide.

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