Even after narrow passage of the American Health Care Act in the House this month, we don’t fully know what Trumpcare will become. But we do know what Obamacare has produced—broken promises, disappointment, government overreach and dysfunctional health insurance markets around the country. And we do know that after the Senate has its say on the issue, the final version will be better than Obamacare, even though that’s admittedly setting a pretty low bar. What’s ahead for GOP health care reform? Cautious steps in a different direction to re-balance our investments in health care and hopefully better health.

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Of the 498 rating regions in the United States, 146 had only one insurer selling nongroup coverage through its state marketplace in 2017; 125 had just two insurers. Markets with one insurer include the entire states of Alaska, Alabama, North Carolina, Oklahoma, most of Arizona, and rural areas of several states. Markets with only one or two marketplace insurers tend to be much less populated than areas with more competing insurers.

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Health insurance giant Aetna said Wednesday that it will not be participating in any Obamacare exchanges in 2018.

“Our individual commercial products lost nearly $700 million between 2014 and 2016, and are projected to lose more than $200 million in 2017 despite a significant reduction in membership,” T.J. Crawford, Aetna spokesman, said in an email.

The reason for the losses, he said, came from structural issues within the exchanges “that have led to co-op failures and carrier exits, and subsequent risk pool deterioration.”

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