Some of the Affordable Care Act’s insurance marketplaces are in turmoil as the fourth open enrollment season approaches this fall. What’s ahead for consumers depends very much on where they live.

Competition on some exchanges will be diminished next year when three of the nation’s largest health insurers — Aetna, UnitedHealthcare and Humana — will sell individual plans in many fewer markets. The departure of several Blue Cross and Blue Shield plans in various states will also hurt. These pullbacks also come on top of the closure of 16 nonprofit co-ops, another coverage option, since January 2015.

Aetna’s exit announcement Monday that blamed financial losses on its marketplace plans gave Obamacare opponents who have from the start predicted the health law’s failure a fresh chance to proclaim, “I told you so.”

That story line got more complicated Wednesday after the Huffington Post reported Aetna CEO Mark Bertolini sent a letter to the Justice Department on July 5 threatening to withdraw from the Obamacare marketplaces if the government sued to block his company’s planned merger with Humana. The Justice Department did just that a couple weeks later.

Still, most marketplace consumers won’t see any ill effects from insurers’ withdrawals, say the health law’s advocates and independent analysts.

“The effect on consumers is going to be mixed around the country,” said Katherine Hempstead, a senior adviser at the Robert Wood Johnson Foundation. “Most of these marketplaces are not dependent on” the large national carriers.

Also, the big insurers’ announcements apply generally only to the individual market. The much larger market of employer-sponsored insurance is not part of the health law exchanges.

Many major metropolitan areas, such as those in California, New York and Texas, will still have several insurers for individual health insurance consumers to choose from. In Texas, all major metro areas — including Austin, Dallas, Houston and San Antonio — will have at least three insurers after Aetna and UnitedHealthcare exit.

That’s true also for most urban exchange customers living in the Northwest, the Midwest and New England.

Most hurt will be marketplace consumers in Arizona, North and South Carolina, Georgia and parts of Florida, where only one or two insurers will be left when open enrollment season begins Nov. 1.

Remaining insurers might raise their monthly premiums as a result, but more than 8 in 10 consumers on the marketplaces who get government subsidies would be insulated. Subsidies increase as premiums rise.

One concern is that with less competition, insurers may tighten their provider networks and give these consumers fewer choices of hospitals and doctors. That trend started several years ago, and some states have responded with regulations requiring insurers to provide customers with reasonable access to doctors and hospitals in each county where they sell plans.

Nearly 13 million people signed up for Obamacare marketplace policies for 2016. Aetna, UnitedHealthcare and Humana have 2 million members in total, but their exit from certain states is predicted to affect between 1 million and 1.5 million people who will have to choose new carriers.

While changing plans can force people to find new doctors, it’s also the best way for consumers get the best deals on coverage.

Aetna will exit 11 of 15 states where it sells plans on the exchanges. UnitedHealthcare has said it will quit 22 of 34 states, and Humana will leave four of the 15 states where it operates.

In late May, the Kaiser Family Foundation estimated the number of rural counties at risk of having one insurer on the exchanges would triple in 2017. That was before Humana and Aetna detailed their plans. (Kaiser Health News is an editorially independent project of the foundation.)

“We could be looking at about 1 in 4 counties in the U.S. with just one exchange insurer next year, though this could change between now and open enrollment in November,” said Cynthia Cox, associate director for the Kaiser Family Foundation Program for the Study of Health Reform and Private Insurance.

Overshadowed by the big insurers’ withdrawals is the prospect that other carriers will enter markets the three giants are leaving. Smaller insurers Molina and Centene have said they’re doing fine on the exchanges. And Cigna, a larger insurer, has said it will move into some North Carolina counties for 2017.

North Carolina will be left with just one or two plans in most of the state after it loses UnitedHealthcare and Aetna plans. Health insurance analysts say three insurers are needed for a healthy competitive market.

“We’ve had a very robust enrollment under the ACA and hope consumers will still see benefits of having coverage even if they have fewer options,” said Ciara Zachary, health policy analyst for the North Carolina Justice Center’s Health Access Coalition.

Rural Americans had few health insurers to choose from even before Obamacare, but some suburban and urban parts of the Southeast will be in the same fix next year. In southeast Florida, consumers in counties near Naples and Fort Myers will have only one marketplace insurer — Florida Blue — next year, unless other insurers step in.

“There are some headwinds, but it’s not a question of whether the market will stabilize but how quickly and how well,” said Hempstead.

Strong winds are already blowing with hurricane force toward Arizona’s Pinal County, southeast of Phoenix, health care advocates say. Nearly 10,000 people enrolled in Obamacare marketplace policies this year and about 85 percent received a federal subsidy.

In 2017, Pinal stands to lose its only two insurers — UnitedHealthcare and Blue Cross and Blue Shield of Arizona. “Clearly this is a big concern for consumers,” said Allen Gjersvig, director of navigator and enrollment services for the Arizona Alliance for Community Health Centers. He said he is hopeful another insurer will step in, but not confident.

Neighboring Maricopa County, which includes Phoenix, is expected to have just two relatively small insurers in the area left on its marketplace next year. Gjersvig questions whether those two — Cigna and Phoenix Health Plan — will have enough doctors and hospitals under contract to handle their new members after larger rival Blue Cross and Blue Shield of Arizona gives up its 40,000 customers.

At least a dozen other counties in Arizona will be left with just one health insurer, he said.

Arizona had eight insurers operating in various parts of the state this year, but four are leaving entirely — Aetna, UnitedHealthcare, Humana and Health Choice. Two more, Blue Cross Blue Shield and Health Net, are scaling back their participation.

Despite the problems with the marketplaces, Gjersvig said thousands of people have gained coverage through them and he is confident they will survive. “We do not see this as a death knell for the marketplace,” he said.

Tammie King, an insurance agent in Columbia, S.C., is less sure how insurer departures will affect consumers in the Palmetto State. The pullouts by UnitedHealthcare and Aetna mean there will be only one carrier in the state in 2017 — Blue Cross and Blue Shield of South Carolina.

That’s a particular concern in Columbia, she said, because the Blue Cross plan does not include one of the biggest hospitals, Lexington Medical Center, and its affiliated physicians. “People will be left unable to see the doctors they are now using,” King said.

King said she worried the Blue Cross plan will use its monopoly power to further reduce the number of doctors and hospitals in its network and limit its choice of prescription drugs. “You can’t blame them because … they have to do something to control costs,” she said.

Kaiser Health News is an editorially independent news service supported by the nonpartisan Kaiser Family Foundation.You can follow Phil Galewitz on Twitter: @PhilGalewitz.

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It’s not often in the midst of an antitrust fight that the public gets a look at the gamesmanship that’s happening behind the scenes.

But thanks to the Huffington Post’s Jonathan Cohn and Jeff Young, we got a glimpse at how health insurer Aetna is making its case to acquire rival Humana — and new insight into Aetna’s decision announced Tuesday to pull out of Obamcare exchanges in 11 states.

The reporters obtained a copy of a letter from Aetna CEO Mark Bertolini to the Justice Department on July 5. The letter was written while the government was still deciding whether to oppose the insurance companies’ merger on the grounds that it (and another proposed deal between Anthem and Cigna) would hurt consumers and reduce competition.

The Bertolini letter was in answer to a Department of Justice request for information about how a decision on the Humana deal would affect Aetna’s participation in the health insurance exchanges created by the Affordable Care Act.

The letter is pretty direct: If the government moved to block the merger, then Aetna would begin to pull out of the health insurance exchanges.

Here’s the key paragraph (emphasis added):

“Our analysis to date makes clear that if the deal were challenged and/or blocked we would need to take immediate actions to mitigate public exchange and ACA small group losses. Specifically, if the DOJ sues to enjoin the transaction, we will immediately take action to reduce our 2017 exchange footprint. We currently plan, as part of our strategy following the acquisition, to expand from 15 states in 2016 to 20 states in 2017. However, if we are in the midst of litigation over the Humana transaction, given the risks described above, we will not be able to expand to the five additional states. In addition, we would also withdraw from at least five additional states where generating a market return would take too long for us to justify, given the costs associated with a potential breakup of the transaction. In other words, instead of expanding to 20 states next year, we would reduce our presence to no more than 10 states. We also would not be in a position to provide assistance to failing cooperative exchanges as we did in Iowa recently.”

The Huffington Post reporters calls the letter “a clear threat.”

A little more than two weeks later, on July 21, the Justice Department said it would sue to block the Aetna-Humana deal and the other proposed megamerger between Anthem and Cigna.

On Tuesday, Aetna said it would dramatically scale back its participation on the insurance exchanges in 2017. The company move would take it out of 546 counties in 11 states, leaving it active in 242 counties in four states: Delaware, Iowa, Nebraska and Virginia.

Aetna said the pullback was a business decision stemming from a loss in the second quarter on individual plans and uncertainty about the policy outlook for the exchanges.

In the company’s statement, Bertolini said, “As a strong supporter of public exchanges as a means to meet the needs of the uninsured, we regret having to make this decision.”

The statement made no mention of the company’s pending offer for Humana nor its recent correspondence with the government about how Aetna would likely respond if the feds moved to block the deal. Aetna didn’t immediately respond to a request for comment on how to reconcile Tuesday’s announcement with the July 5 letter made public by Huffington Post on Wednesday.

The change in tack for Aetna is also noteworthy because Bertolini was talking up the business potential of the exchanges as recently as April, when he said during a call with analysts and investors that the exchanges were “a good investment,” despite the losses incurred.

At the time, Bertolini said that Aetna was “committed to working constructively with the administration and lawmakers to find solutions that can improve this program, stabilize the risk pool, and expand product flexibility, all with the goal of creating a sustainable program that makes health care more affordable and accessible for all consumers.”

Now, the company appears to be taking its ball and going home.

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At 10 a.m. on a recent Wednesday morning, a line of parents pushing strollers filed into a conference room at the Sacramento County Courthouse in California. They sat at rows of narrow plastic tables, shushing their babies and looking up at a man in a black robe.

Hearing Officer Jim Teal sounded his gavel. “This is the time and place set for Early Intervention Family Drug Court,” he began, gazing sternly at the parents who sat before him. “Graduation from this court is considered a critical factor in determination that the children of participants will be safe from any further exposure to the danger and destructive impact of parental substance abuse.”

There has been a surge recently, across the U.S., in the number of children entering the foster care system after years of decline. Nationally, roughly 265,000 kids entered foster care in 2015 — the highest number since 2008, according to a recent government report.

Substance abuse is a factor in up to 80 percent of cases where a child is removed from a home. And there are signs that the opioid epidemic may be to blame.

Parents who receive addiction treatment are much more likely to get their kids back, but 4 in 5 parents fail to complete their treatment regimen.

The Early Intervention Family Drug Court aims to change that by helping parents with substance abuse problems to complete treatment before their children enter the foster care system. If the parents fail, they’ll be sent to a formal family drug court, where their children are taken away and given attorneys of their own.

But before that, the parents get this opportunity to enter recovery, through a mix of support, medication-assisted treatment and tough love.

Many parents participating in the early intervention drug court entered the system after having babies born dependent on opioids or other drugs. Others were reported to Child Protective Services by friends or family. All are at risk of losing custody of their children because of their drug abuse.

Emma, 20, a striking woman with long blond hair, approached Teal’s podium holding a baby. NPR is withholding her last name because her case is active with Child Protective Services.

“Good morning,” Teal said. “Who do you have with you there?”

“My daughter, Cailynn,” Emma answered proudly, bouncing the cooing child on her hip.

Emma started using drugs when she was 16. At first it was methamphetamines, she said, but she quickly transitioned to heroin. Then she got pregnant.

Her daughter Cailynn tested positive for opioids at birth. Child Protective Services came to the hospital and took the baby into custody.

“I regret every moment of it,” Emma said. “It’s hard. But I’ve got to keep my head up and keep going.” From the start, she wanted her daughter back.

A court booklet give parents inspiration to stay off drugs. They paste a photo of their child on the front and then write about their experiences inside. Robert Durell for Kaiser Health News hide caption

toggle caption Robert Durell for Kaiser Health News

Usually, Sacramento County has a three-month wait for people who need substance abuse treatment. But by volunteering to participate in the drug court, Emma was able to get treatment right away and her baby back.

“So Emma, it says here you’re 63 days compliant,” Teal said that day in court. “And 63 days in the program, so you’ve been good. You’ve been doing what you’re told. Congratulations.”

The other parents in the room burst into applause — this is a major accomplishment. The six-month program is rigorous. In addition to monthly sessions at the court, the parents must attend almost daily group meetings, submit to random drug tests and take parenting classes. Many, like Emma, go to inpatient rehab. Medication-assisted therapy for opioids is also available. And once or twice a week, they get a home visit from their social worker.

Emma attributed much of her success in the program so far to social worker Matthew Takamoto, whom she called “amazing.”

Takamoto has been a social worker for 20 years and has been part of the EIFDC since the program began six years ago. The program, he said, is an important change in way the county handles addiction.

“In the olden days, we were quicker to send them to court,” he said. Their approach was “more ‘blaming the addict,’ versus giving them the tools they need.”

In the afternoon following the court meeting, Takamoto drove to the inpatient residential facility where Emma lives with her daughter. In the back is a grassy yard with a small jungle gym, where several mothers sat, watching their children play. Emma was there, too, holding Cailynn in her lap.

Matthew Takamoto has been been a social worker with the early intervention program in Sacramento County from its start, and is pleased with its success. The hardest part, he says, is realizing that not every parent will be be able to quit drugs for good. Robert Durell for Kaiser Health News hide caption

toggle caption Robert Durell for Kaiser Health News

Takamoto seemed happy with Emma’s progress. “You take these clients from the very beginning, where they’re broken and it’s the worst day of their life,” he said. “And to see them slowly get back up as they have days of clean time — it’s been incredible.”

The hardest part of his job, he said, is realizing that not all the parents are going to make it. In fact, just a third end up graduating from the county’s program.

“If these parents aren’t successful, it’s the kids [who] pay the price,” Takamoto said. “The parents are doing what they want to do, but the kids don’t have a choice.”

Just 5 to 10 percent of families in the United States who could use family drug courts have access to them, according to Children and Family Futures, an organization that advises and evaluates family drug courts. Sacramento’s program is one of about 350 in the country; most of the rest work with families after their children have entered the foster system.

Sherri Z. Heller, director of Sacramento’s Health and Human Services Department, described family drug courts as a success story.

“People can overcome addiction if the motivation is strong enough, and this is the most effective motivation I have ever seen,” Heller said.

Just 10 percent of kids with families in the program end up being removed from their home, compared to 30 percent of children in families who do not participate. That represents a major savings to the county — about $21,000 dollars a year for every kid who doesn’t have go into the court and foster system, for an annual total savings of $7 million.

“The rush that comes with getting high is pretty spectacular,” Heller said. “And it’s very hard physically, once the addiction happens, to overcome. But if there is one thing that matters to people more than the thrill of getting high, it’s the thrill of doing the right thing for your children and keeping your family intact.”

Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation. You can follow Jenny Gold on Twitter: @JennyAGold.

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