There are no more counties without any Obamacare plans

Paulding County, Ohio, come on down!

The last empty Obamacare county, where 380 customers on the individual marketplaces were at risk of having no insurance options at all next year, has been filled. CareSource, which had filled other bare counties in Ohio and Indiana this summer, agreed to sell coverage there in 2018.

With that, every county in the country will have at least one insurer for its Obamacare market in 2018.

It’s a sharp reversal for the law. In June, when Republicans were still working to repeal and replace Obamacare while President Trump threatened to deal it a devastating blow, there were 47 counties, with 38,000 customers, without insurers. At one time or another this year, 82 counties were at risk, according to the Kaiser Family Foundation.

So Obamacare didn’t implode. Why? I walked through some of the reasons earlier today. More briefly, I’d break it down like this:

Insurers see a solid business opportunity in bare counties. They can set prices to recoup their costs, knowing that most customers who receive subsidies through Obamacare will be insulated from premium increases. The feds will pick up the tab.

State officials worked hard behind the scenes — and had ample leverage, as the still-predominant regulators of insurance — to bring carriers on board. We saw this play out in Nevada and Ohio, where governors flew in insurance executives for meetings and insurance officials got into nitty-gritty negotiations matching different insurers to different counties.

Republicans failed to repeal and replace Obamacare, and Trump hasn’t followed through on his threat to cut off the law’s payments to insurers. I wouldn’t say things are stable or certain, but they are more so than they looked over the summer — and now Congress is turning explicitly to shoring up the markets, not overhauling them.

A few companies — namely Centene, which filled 45 of these empty counties — specifically invested in helping the law. Sarah profiled the former Obama administration executive now in a leadership role at that company.

This isn’t a perfect solution, especially for people who don’t receive subsidies and therefore aren’t protected from premium increases in a monopolized market. It’s also possible that Trump does something in the next few weeks to disrupt the market again — insurers have until the end of September before they are truly locked into selling plans in 2018.

We’re still likely to hear a lot about counties with only one insurer. There are 1,340 of them, with 2.7 million Obamacare customers, according to our estimates.

That’s a real issue. But I thought I’d share a couple of observations from Craig Garthwaite, a health economist at Northwestern University.

First, he pointed out that the problem is not that insurers will charge exorbitantly high premiums in a monopoly — there is little evidence of that happening, he said, and we know from aggregate data that insurers aren’t exactly making a killing in the Obamacare markets.

“We should be careful about why exactly we care about the monopoly,” he said. “As long as there are meaningful opportunities for entry, I don’t think we should worry that much.”