Although it may be premature to perform last rites on insurance exchanges created under the Affordable Care Act (ACA), it's fair to say that they are on life support in many states.

“We continue to see a decline in issuer participation in the health insurance exchanges, leaving consumers with fewer and fewer insurance options,” Seema Verma, administrator of the federal Centers for Medicare & Medicaid Services, said in a report issued in late July. “I am deeply concerned about the crisis situation facing the individual market in many states across the nation.”

The agency projects that residents of 49 counties will have no options to choose from when they try to enroll in a plan through an exchange for 2018. Another 2.4 million exchange participants in 1,300 counties may have only one carrier option next year, according to the report (see chart on page 15).