If younger adults stay away and enrollment remains biased toward the older adults, insures may only hike future premiums by a couple percentage points, said Gary Claxton, a vice president with the Kaiser Family Foundation, a nonprofit that studies health care issues. He noted that companies can still vary their prices based on age, just not as much as they used to.
But insurers note that such an increase would be added to other cost hikes due to things like the rising cost of care.
The hit an insurer takes and the impact on future prices also may depend on how it approached the exchanges. Companies that saw them as a "land grab" for new customers and entered with low prices to attract as many people as possible may suffer a bigger blow than those that acted more conservatively, Lynch said.
The overhaul builds in safeguards to protect insurers during their first few years on the exchanges, when the new system is taking shape. A reinsurance fund will help insurers pay high claims, and another provision will help make up some of the difference in markets where an insurer's expenses exceed the premiums it collects.
Still, Axene and others say these programs will ease but not erase the impact of an insured population that skews older than an insurer expected.
"Those are important programs," said Robert Zirkelbach, a spokesman for the industry trade group America's Health Insurance Plans. "But that doesn't change the fact that if the young, healthy people chose not to participate, there still will be an impact on premiums."
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