Leading up to open enrollment, New Hampshire became a favorite 2014 exchange punching bag.

Its partnership exchange beat enrollment estimates, with more than 40,000 people picking plans (HHS statistics, accessed May 2, 2014). But all its enrollees had only one insurer choice, Anthem Blue Cross and Blue Shield in New Hampshire. New Hampshire and West Virginia were the only states where exchange shoppers faced monopolies of a dominant Blue plan.

In 2015, New Hampshire will look drastically different. Nowhere will the exchange landscape shift more. The exchange will usher in four new competitors Assurant Health, Harvard Pilgrim Health Care, and two Consumer-Operated and Oriented Plans, Minuteman Health and Maine Community Health Options (MCHO). The jump to five plans makes it the most competitive individual exchange market in New England outside Massachusetts.

If there are no market contractions elsewhere, every exchange in the United States will have at least two competitors in 2015 (West Virginia will retain Highmark and add the Kentucky Health Cooperative).

CO-OPs will play a major role a year after none operated in New Hampshire. Minuteman Health had little luck in Massachusetts, enrolling just 1,435 people as of April 15 (Congressional Committee figures, accessed June 13, 2014). It could find greener pastures in New Hampshire, since Massachusetts had a smaller pool of available enrollees because of its own health reforms.

MCHO's 2014 experience could benefit it in a suddenly crowded market. Pitted against Anthem Blue Cross and Blue Shield of Maine, MCHO signed up 80 percent of Maine's 44,000 exchange enrollees in 2014. The Maine exchange was a battle of rates and networks With MCHO offering a broad network next to Anthem's narrow network built around Maine Health. The nonprofit plan will bring this approach to the four New Hampshire counties that border Maine, but will have a network with all 26 hospitals.

With New Hampshire raising some uproar over Anthem's narrow network, the strategy could be fruitful. MCHO will not be the only insurer casting a broad network. The state's second-largest insurer, Harvard Pilgrim, plans to offer a narrow-network product with coordinated care, and a broader network.

In states with fewer providers, cutting a few hospitals to lower premiums can leave plan members with few options. The loss of a single hospital can push acute-care access an hour or more away. In Maine and New Hampshire, exchange shoppers are more aware of provider networks. Every hospital counts.

The Granite State could also be more attractive to carriers due to the closing of its coverage gap. In July, New Hampshire will begin enrollment in a private model for Medicaid expansion, with members initially enrolled in the state's Medicaid managed care program. However, in 2016 the expansion population will shift to the exchange.

New Hampshire proves one year can reshape a health exchange. We have yet to see the opposite, with insurers fleeing a market en masse. It could still happen if the exchange populations don't attract enough young, healthy people or enrollment lags, but for now, no one will scoff at New Hampshire's exchange market again.

Follow Bill Melville on Twitter @BillMelvilleDRG

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