I

n June, Nevada suddenly found itself in quite a jam — 14 of its 17 counties had zero insurers offering plans on the Obamacare exchanges.

Insurance officials in the state scrambled, wooing and cajoling insurers to return. Two weeks ago, those efforts paid off. Centene Corp., a Missouri-based insurer, agreed to provide coverage in all the bare counties.

A similar relief has played out nationwide: From a high of 49 counties left bare in late June, it was announced last week that every county in the country had at least one insurance carrier for 2018.

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But in states across the country, coverage remains extremely tenuous and thin, especially in rural pockets far removed from the debate in Washington.

So what happens next?

To answer that question, STAT spoke with Heather Korbulic, executive director of Nevada’s insurance exchange, about the challenges facing her state what lies ahead in the individual insurance market:

Prices are skyrocketing

The cost of individual coverage is certain to rise significantly in Nevada next year — right now, a projected 38 percent average premium increase.

But that increase is outdated, and it reflects a whopping 62 percent hike Anthem had requested before it pulled out of the market altogether. The federal government has given insurers, including Anthem’s replacement — Centene Corp. — until Sept. 5 to file updated requests, and the state will make the final numbers public on Oct. 2.

Still, Korbulic said, the numbers won’t be pretty, noting that many counties only have one insurer. “People who are not eligible for subsidy assistance are going to be unable to afford health care plans,” she said. “As a nation, we need to start talking about solutions for making sure there’s more competition.”

A shrinking open enrollment period

Despite the lingering uncertainty over pricing — and sudden changes among insurance carriers in many states — the Trump administration is cutting in half this year’s open enrollment period from 90 days to 45 days.

Korbulic said the timing of the change is terrible for Nevada. “There’s never been a more important time for our consumers to sit with an enrollment professional, choose plans, and actively shop the market,” she said. “It gives me heartburn all the time. I’m worried it’s not going to be enough time for a lot of people.”

It’s also unclear whether the Trump administration will help states to market plans to consumers. In years past, she said, states already had information at this point about federal marketing efforts and other key details. “Right now, we really don’t have any clarity,” she said. “It’s just kind of crickets.”

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Exorbitant costs to use Healthcare.gov

Nevada pays $5.5 million to lease Healthcare.gov’s eligibility and enrollment system from the federal government to run its exchange. Korbulic said the cost is expected to increase to $7.2 million in 2018, a level of expense the state cannot afford.

So far, she said, the federal Centers for Medicare and Medicaid Services, which operates Healthcare.gov, has not responded to her complaints that the leasing rate is too high, or to her request that the state be allowed to transition to a new digital system. If a solution is not reached soon, she said, the leasing cost alone will swallow her department’s entire budget.

“It would be hugely embarrassing for CMS to allow our exchange to fail by continuing to charge an amount that’s exorbitant and unaffordable for us,” she said, adding that the agency has also refused, dating back to the Obama administration, to provide data about people who are buying plans on the exchange.

“If we understood who our consumers are, we would be able to more efficiently spend our marketing and advertising dollars … and keep people on the exchange,” she said.

No clarity on cost-sharing subsidies or the individual mandate

Korbulic said Anthem was clear about its reasons for pulling out of Nevada: “They said it was related to ongoing federal instability around cost-sharing reductions and enforcement of the individual mandate.”

Although Centene Corp. has stepped in to fill the void, the uncertainty over those issues persists. The lack of clarity on the cost-sharing reductions — which support coverage for low-income people — makes it exceedingly difficult for insurers to price their policies.

Korbulic said enrollment in the Nevada exchange has continued to grow, and she and other officials are brainstorming ways to stabilize the market. But without a major change in federal policy, Nevada could easily find itself trying to plug holes in its coverage map again this time next year.

“We’re still sort of at the whim of Washington, D.C.,” she said.

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