As a microcosm of American health insurance markets, with both old and new regulations and business trends, one corner of the country offers a window into the future.
In Idaho, Oregon, Washington, and Utah, Cambia Health Solutions' Blue Cross and Blue Shield companies are among more than a dozen insurers trying to innovate in the transition to consumer-based health insurance.
The four states all have their own dynamics but share the emergence and growing importance of individual shoppers in both public and private exchanges, said Chris Blanton, a former Cigna executive who joined Cambia as president last year to head up the Bridgespan Health exchange plans.
In the first open enrollment for public exchanges, "consumers were very confused," Blanton said. "They struggled with all of the moving parts and the changing dates, and what was occurring in one state not necessarily happening in other states."
In the public exchanges, Cambia sells Bridgespan plans statewide in Idaho, Oregon and Utah, but in only seven of 39 counties in Washington -- which is emerging as a proving ground of sorts for healthcare competition and transparency.
Across Washington, 10 insurers are selling 90 individual exchange plans for 2015 -- up from eight insurers this year. One insurer, another Blue licensee, however, is bound to keep its large foothold. Premera Blue Cross controlled about 60 percent of the pre-Affordable Care Act market and sold more than 60 percent of the exchange plans in Washington.
Group Health Cooperative sold more than 15 percent of exchange plans, while Centene, a newcomer to Washington, sold about as many. While Regence had a nearly two-thirds hold on Washington's pre-ACA individual market, BridgeSpan only sold 2 percent of all the state's exchange plans in the first open enrollment.
"Our goals for year-one were listening and learning, getting into the exchange and seeing how it worked, the questions consumers asked, less so getting any large membership," said Blanton. "Year two, we're expanding our product portfolio and redesigning our website."
Some 30 Bridgespan plans will be available in five more counties in Washington -- the most of any insurer and double Premera's offerings. In addition to PPOs, there will be accountable care plans in the four county region around Seattle featuring health systems like UW Medicine and the Everett Clinic.
"This a long-term play in terms of improving quality, lowering costs and improving access," Blanton said. In Washington, "having new networks approved by the insurance commissioner is a difficult process."
Insurers selling in the state exchange, Washington Healthplanfinder, sought to increase premiums for next year by an average of 8 percent, but the state commissioner brought those down to just under 2 percent.
The rate change for Bridgespan is a decrease on average of about 3 percent, while Premera got an okay to increase premiums by 2.6 percent. With two new insurers and numerous changes to pricing, though, the next open enrollment period could be confusing for both new and returning customers -- in Washington and elsewhere.
"This idea that your subsidy could change based on changes in the benchmark, or new plans coming in, or those leaving, may not be understood by consumers," Blanton said. "Rate changes before subsidies are not good indicators of changes after subsidies, and this is something we've been talking with the Marketplace and educating brokers about."
Health insurance exchanges are, at least in their early iterations, bound to be confusing, in part because of technology, legal requirements and traditional practices among big healthcare institutions, said Ron Sims, chair of the Washington Health Benefit Exchange Board.
"I can shop for anything online -- books, raisins -- and know the price," Sims said in a keynote address to the Maine Health Management Coalition, in a visit to Portland, in October. "The biggest battle we have in our area is the people who want to keep that secret."
Washington State is making inroads in transparency, but the extent of what consumers know in insurance, medical and hospital care, still lags along with the overall experience, he said.
For instance, while insurers are required to digitally publish and explain certain provisions in their drug formularies, exchange shoppers have to go insurers' websites and can't necessarily make meaningful comparisons between so many complex requirements and co-sharing features. "When our website is as good as Fantasy Football, we'll have the best site," Sims said.