April 25, 2013; Stateline

You might recall earlier coverage of the slowing down of the federal and state health insurance exchanges where small employers might be able to purchase affordable health insurance, which may mean that those exchanges might not have as many choices for consumers as they were intended to.

In other states, however, it doesn’t appear that private insurers are coming to the plate to compete with the existing monopolies. For example, Blue Cross and Blue Shield of Alabama covers 89 percent of Alabamians. That’s a pretty uncompetitive health insurance market and tough for a potential new entrant to challenge. In fact, according to the American Medical Association, Alabama is the least competitive commercial health insurance market in the nation, followed, in rank order, by Hawaii, Michigan, Delaware, Alaska, North Dakota, South Carolina, Rhode Island, Wyoming, and Nebraska.

Under the Affordable Care Act, the insurance exchanges were meant to give employers and individuals a number of competing providers, busting the next-to-monopolistic dominion of entities like BCBS in Alabama. In theory, competition and choice would lead to lower costs for small employers and lower-income people. Will the exchanges offer a truly robust array of choices?

Even with operational exchanges, there might not be a lot of insurers willing to jump in. It might be because of the low incomes of potential customers (Alabama is 46th in median household income) who might not be able to afford premiums. It might be the long distances between the few health care providers in rural states. (Wyoming, for example, has only 18.7 physi