Et Tu, Aetna?

What a difference ten months makes! In October 2015, after United Health announced its intention to minimize its participation in the online exchanges of the Affordable Care Act (ACA), Aetna vowed to continue its participation in them. Its CEO Mark Bertolini declared, “We view it still as a big opportunity.”

So how long did his view last? Not even a full year! Last week, Aetna reversed its position and announced its intention to follow United’s withdrawal strategy.

Why? Aetna claimed that, after reviewing its recent fiscal data, its executives decided that the firm could no longer afford the costs of care for members inside the ACA exchanges. And yet the insurance giant had previously announced that it had “achieved record annual operating revenue and operating earnings in 2015, and delivered full-year operating EPS that was above (its) most recent projection.” And they produced these results while participating in the exchanges.

Furthermore, Aetna had threatened the federal government that it might withdraw from ACA exchanges if regulators failed to approve its mega-merger proposal with Humana. After the Department of Justice refused to approve the merger, Aetna announced its exchange withdrawal plans.

For obvious reasons, some critics charge that Aetna’s withdrawal represented a decision to “make good” on an inappropriate threat. Whether or not you believe that the insurer acted appropriately, though, it might be helpful to ponder a more fundamental question.

Namely, why should we believe that any large, for-profit health insurer would remain committed to the ACA exchanges? Indeed, why would such firms find it profitable to sell policies to individuals at any time?

Think about it. Large health insurers were never eager to sell affordable policies to individual families before the ACA was passed into law. That’s why individuals who were unable to access health benefits through their employers were often forced to purchase extremely limited plans with very large premiums.

Then and now, major health insurers prefer to contract with large employers that maintain Departments of Human Resources. These Departments employ teams of professionals to help insurers manage their administrative and communications responsibilities with their enrollees, i.e. with corporate employees.

Thus, insurers can achieve significant economies of scale by insuring many employees through each group contract. They cannot possibly achieve such cost efficiencies in the individual market.

So was there ever any reason to believe that the ACA would alter this fundamental economic reality? It’s hard to understand why any large national insurer would maintain a long term commitment to the individual market under any regulatory system.

Of course, this doesn’t necessarily mean that the exchanges should be shut down immediately. For the eleven million individuals who obtain health insurance through the ACA each year, an insurance policy with a non-profit or small for-profit insurer is undoubtedly preferable to no insurance policy at all. Such insurers may remain interested in growth strategies that rely on the individual policy market.

Nevertheless, ACA supporters who are excoriating Aetna for its withdrawal decision may wish to hold their fire. Whether or not they have a point about the ethicality of Aetna’s choice, it may be difficult for them to dispute the inevitability of it.