Across broad swaths of the Midwest, the fate of the Affordable Care Act increasingly rests on the shoulders of a small nonprofit health insurance plan headquartered in suburban Minneapolis.
Medica is not a household name. It provides health insurance to 700,000 people scattered across Iowa, Minnesota, North Dakota, Nebraska, Kansas, and Wisconsin. The plan's enrollment is dwarfed by that of big health plans like UnitedHealth (47 million patients) and Aetna (20 million).
Medica stuck around the Obamacare marketplaces as big for-profit plans fled, scared away by dismal financial returns and uncertainty wrought by the Trump administration.
"We may find ourselves with a large number of lives in many of these states that we didn't earn in the traditional sense of the word, by beating the competition," says Geoff Bartsh, Medica's vice president of individual market business. "We just happen to be the last person standing."
The plan is currently undecided as to where it will stick around in 2018. Executives say they would hope to remain with the marketplaces, but much of their decision-making rests on getting more certainty and stability about the law's direction from the Trump administration and state regulators.
It is suddenly the case that if Medica were to quit Obamacare, the impact would be huge. The company's exit would leave 187 counties without any Obamacare insurers. This would be in addition to 47 counties in Missouri, Ohio, and Washington that are already down to zero Obamacare plans.
An estimated 137,000 Obamacare enrollees live in the areas where Medica is currently the only Obamacare provider.
That a small health plan can play such a linchpin role in the Affordable Care Act's future speaks to the marketplace's fragility. Obamacare's drafters expected marketplaces with health insurance plans competing against each other. Increasingly, markets are held by just one plan.
It now falls to Medica to figure out whether a small health plan can, quite suddenly, play a very large role in shoring up the Affordable Care Act marketplaces.
"We certainly think there is a role for us in all the markets we're in right now," Bartsh says. "In all these states we have a statewide presence, and I don't know if we'll be able to continue that. But I certainly know we're working to stay in as many areas as we can."