In just a few weeks, Connect for Health Colorado will commence its fifth year with the launch of  open enrollment, which will begin Nov. 1 and end Jan. 12, 2018.

The bill establishing the state’s health insurance marketplace was signed by Gov. John Hickenlooper in   summer 2011, following the passage of the Affordable Care Act the year before.

The marketplace — like the health care industry as a whole — carries both victories and setbacks with substantial challenges ahead. And while the small group marketplace has always been more stable, the individual marketplace still experiences its fair share of turbulence.

Mission accomplished?

The mission of Connect for Health Colorado, according to its website, “is to increase access, affordability and choice for individuals and small employers purchasing health insurance in Colorado.”

Luke Clarke, director of communications for Connect for Health Colorado, said the marketplace has been largely successful, especially when it comes to increased access and affordability.

“It’s healthier than a lot of people want to say it is,” Clarke said. “We’re really happy Colorado has seven carriers in the individual market and all are returning next year. Some have had to adjust their service area — some are going bigger, some smaller. But we don’t have any barren counties in Colorado. There will be at least one carrier in every county with the choice of various plans those companies offer.”

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Despite the Division of Insurance approving nearly 27 percent premium increases in Colorado next year, the marketplace is growing more affordable. He said the average net reduction in premiums paid by individuals in 2017 was 11 percent.

“An analysis commissioned by the state Division of Insurance found that our current customers will see an average decrease in net premiums of 18 percent in 2018 because of the increase in the Advanced Premium Tax Credit they are eligible to receive,” Clarke said, explaining that as the cost of premiums increase, so do the tax credits.

About 60 percent of those insured through the marketplace receive some sort of subsidy, he said, adding that number will likely climb in 2018.

“When rates go up, more people qualify,” he said.

The average subsidy in the state amounts to $369 a month, but can climb to more than $700 in some rural counties along the Western Slope because the cost of care can be so much higher.

There are thousands of Coloradans buying their own insurance at full cost who would otherwise qualify for subsidies, Clarke said.

“One reason we discovered is people assume they’re not eligible,” he said. “You can make $48,000 a year as an individual and qualify for a tax credit. And that number is $98,000 for a family of four. That’s a middle-class income in most, if not all, of Colorado.”

Costs must be addressed

Vincent Plymell, communications director with the Colorado Division of Insurance, said the marketplace has been successful in reducing the number of uninsured. That population dropped from 14 percent in 2013 to 6.7 percent in 2015 and is now holding steady at about 6.5 percent. The state also recently, and for the first time, passed the 5 million mark for insured Coloradans.

Plymell added that health care-related bankruptcies nationally have been cut by more than half, thanks to the ACA.

“That means, hopefully, fewer people are going to go broke paying their health care costs,” he said. “And with more people covered there’s less uncompensated care — especially at hospitals — so they’re not passing that cost onto everybody else.”

Plymell said the growing cost of health care is what’s driving up premiums, and those escalating costs are a “thorn in the side” of Colorado Insurance Commissioner Marguerite Salazar.

“We need to shift the conversation to health care costs,” Plymell said. “The Affordable Care Act was about providing more coverage to those who are underserved or shut out of market because of affordability issues or pre-existing conditions. But it didn’t do anything to address health care costs — what doctors and hospitals are charging.”

Holly Kortum is executive director for Kaiser Permanente’s southern Colorado service area. The nonprofit health plan has been part of Colorado’s exchange since its inception.

She said the marketplace has evolved.

“There have been a few carriers leaving the market, but generally things have smoothed out,” she said, adding carriers now have access to several years worth of data and true cost analysis.

Increasing choice has not been one of the marketplace’s strong suits, Kortum said, and Kaiser Permanente would like to see more carriers offering services through the exchange.

“We believe [the market is] more stable if there are more carriers and competition,” she said. “We support having more carriers in the marketplace. Short of that, I think the carriers that are in the market are trying to be thoughtful and creative in the products they offer. We’ve tried to create [customizable] plans that reduce the cost in the individual marketplace.”

Not all good news

For all its victories, the marketplace has also seen upheaval. The system underwent a rocky roll out and technical issues during its initial enrollment period, and Connect for Health Colorado has since witnessed the disintegration of the first health insurance co-op, Colorado HealthOP, in late 2015.

“The DOI took this action as the financial viability of the HealthOP came into question after learning it would receive considerably less money than expected from a federal, risk-based reimbursement program known as ‘risk corridor,’” Plymell said in 2015.

Earlier that year, the Centers for Medicaid and Medicare announced it would only reimburse the nation’s health insurers 12.6 percent of what they were entitled to under the program — $362 million out of the $2.9 billion promised. Colorado HealthOP was expecting around $16.2 million in 2015 from the federal government, but received about $2 million.

Financial help from the feds has continually been a sticking point for Colorado’s providers and others throughout the country. Reacting to repeated threats from President Donald Trump and his administration to do away with cost-sharing reduction subsidy payments, Salazar called out the president in June.

“ … [I]t remains pivotal that the Trump administration commits to funding the cost-sharing reduction subsidy payments in 2018,” Salazar said. “As I said in a letter to the Colorado Congressional delegation in April of this year: ‘Using the CSRs as a bargaining chip is tantamount to gambling with Coloradans’ access to health care.’”

The Trump administration agreed the next month to fund those subsidy payments.

And while every Colorado county will have a carrier in 2018, that was nearly not the case.

For 14 of the state’s 64 counties, Anthem Blue Cross/Blue Shield was the only available carrier through Connect for Health Colorado. In fact, there were fewer carriers in 2017 than in any previous year.

Is the declining number of providers a concern?

“It’s always a concern and we want more,” Clarke said. “We’re very happy when Bright Health, a startup, chose Colorado to test its business model. But we always want more. That was part of the mission the legislature gave us — to increase choice. We do that by having more carriers. But we have to give them more certainty about the market. The same things that are affecting rates affect their decision to continue in the market or leave.”