One of the Midwest's largest Blues is winning in the new insurance market under the Affordable Care Act, without yet selling a public exchange plan.
On January 1, Wellmark Blue Cross and Blue Shield, the largest insurer in Iowa and South Dakota, celebrated the opening of Des Moines' new $32 million YMCA, the Wellmark YMCA, for which the company charitably donated land in exchange for naming rights.
The fact that the region's newest recreation and fitness center bears Wellmark's name suggests that the mutual insurer's power is going strong, with well over 50 percent market share, a CEO of 18 years and a vision for the future.
Wellmark, serving 1.8 million Iowans and 300,000 South Dakotans, has been sitting out the start of the ACA's exchanges, as many other state Blues embraced the new market. Wellmark has approximately 75 percent market share in Iowa across commercial segments and more than 50 percent in South Dakota.
An unlikely competitor, the startup nonprofit CoOportunity Health, ended up embracing the exchanges and grabbed most of the new business in Iowa.
It seems, though, that a significant proportion of CoOportunity's membership have been at-risk individuals with existing health conditions and pent-up demand for healthcare -- leaving the company bankrupt. Iowa insurance commissioner Nick Gerhart took the co-op under state receivership to try to rehabilitate it, but ultimately decided it could not be saved, and now is set to oversee its liquidation.
Wellmark actually sold the most ACA-compliant health plans in 2014, in both Iowa and South Dakota, off-exchange plans that is. It also continued underwriting thousands of individuals on pre-ACA plans that Iowa regulators allowed be renewed. Among those were some relatively healthy individuals, who might have otherwise purchased new ACA plans through exchanges.
Cliff Gold, CoOportunity's CEO and a former Wellmark marketing executive, estimated that as many as 200,000 Iowans kept their coverage in renewed pre-ACA plans. As Gold and some others saw it, Wellmark's decision not to sell exchange plans was a strategy of letting the "bad risk" flock to the public exchanges, where in Iowa CoOportunity was selling alongside Aetna's Coventry in the first year.
Wellmark will not be able to keep offering those pre-ACA plans forever, and is likely to start selling on the public exchanges in 2016, in the next open enrollment period.
Regardless of CoOportunity Health not being around to sell health plans, Wellmark will be insuring the high-risk membership that purchase its exchange plans, or otherwise helping pay for other insurers' high-risk membership through the risk adjustment program. Either way, there will be competition statewide from Coventry, possibly CoOportunity and regionally from provider-owned plans issued by the health systems Avera and Gundersen.
During CEO John Forsyth's 18-year tenure, Wellmark's membership has grown 60 percent. Formerly the CEO of the University of Michigan Health System in the 1980s, Forsyth is now eligible for Medicare. But regardless of how long he continues as chief executive, Wellmark will be in the position of trying to grow where it can and protecting its already massive business.
Wellmark's LEED platinum certified headquarters in Des Moines.
According to a 2011 state report, prior to the ACA Wellmark sold more than 80 percent of the individual health plans in Iowa, about 200,000 lives or 12 percent of the company's total membership. It had a more than 60 percent share of the small group market and 78 percent share of the large group market.
An unknown but likely significant percentage of those individual and small group members are owners and workers of Iowa's 90,000-plus farms. Wellmark "maintains a strong affiliation with the Iowa Farm Bureau, a distribution system which exclusively markets Wellmark insurance products to individuals and small groups in rural areas," the company said in its 2012 annual report.
Iowa's farming communities are aging, however, and younger, urban consumers buying individual insurance are a different demographic. Likewise, Iowa's businesses are by and large Wellmark customers, but they may not always remain so. Before going into state receivership CoOportunity reported fairly bustling group sales, signing up more than 1,500 organizations.
Not that Wellmark is resting on its laurels. The company has a range of initiatives aimed at serving members with affordability, prevention and wellness, and building its public image as Iowa's best health insurance option.
A new health plan, called Blue Rewards, features wellness incentives, a network based on the UnityPoint Health system and Hy-Vees pharmacies, with lower co-pays and deductibles. Available to individuals and small groups in 31 of Iowa's 99 counties, the plans come with Hy-Vee gift cards of $100, FitBit tracking bracelets and other rewards for members who take steps to improve their health, like getting an annual physical and consulting a dietician.
Beyond its health plans, Wellmark has also been an advocate for healthy and active lifestyles, trying to encourage its membership on social media like Twitter and through its philanthropic foundation. 
Wellmark is spending $25 million over five years helping Iowa's "Blue Zones" communities, a part of the global wellbeing and longevity project, to coincide with Iowa's goal of becoming the healthiest state by 2016, as ranked by Gallup-Healthways.
The basic goal is making "the healthy choice the easy choice" -- making it easier to bike or walk to work, or to drink water while at work rather than soda, Wellmark said in 2012. "Improving overall health and well-being is really the best health insurance."
The company's foundation has also made numerous grants supporting pedestrian and bike paths in Iowa and South Dakota. Many Wellmark employes and Des Moines residents have some pretty good bicycle commuting options, with a network of trails extending into the suburbs and dedicated lanes downtown, including along Wellmark's Grand Ave headquarters.