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Anthem Inc., the nation’s No. 2 health insurer, said Wednesday that it may curtail its participation in the government-run health exchanges in 2018, saying its decision will hinge on whether it loses money on Obamacare plans next year.

A decision to withdraw would be a blow to Missouri and 13 other states where Anthem sells Blue Cross Blue Shield plans on HealthCare.gov.

Competitors Aetna Inc. and UnitedHealth Group Inc. already have largely pulled out of the on-exchange individual market, leaving just a handful of major insurers offering plans for next year.

In the St. Louis area, only Anthem and Cigna Corp. have plans available on HealthCare.gov. Online enrollment for 2017 began on Tuesday.

The market for individual health insurance created under President Barack Obama’s signature Affordable Care Act drew fewer than half the enrollees expected — 12.7 million enrolled at the beginning of 2016 — and those who enrolled were sicker and had higher medical costs than foreseen.

This has led to losses at Anthem and its rivals, some of which plan to stop selling these plans in 2017.

Anthem said it needed to see profits next year and new regulations to stabilize the market before it commits to a 2018 strategy.

“We are going to be very surgical” in looking at both regions and states for 2018 participation, Chief Executive Joseph Swedish said in a conference call to discuss the company’s third-quarter earnings.

Regulatory adjustments Anthem wants include changes in the risk payments it gets for its sickest customers, more-flexible plans and a change in the health insurance tax due to come online in 2018.

News that Anthem may withdraw from the exchanges sparked concern Wednesday from health care policy experts.

“That’s certainly a problem,” said Tim Greaney, health law and antitrust expert at St. Louis University. “I just don’t know what the back-up options are for the government.”

Anthem currently sells exchange plans in 84 Missouri counties plus the city of St. Louis, according to a Post-Dispatch analysis. Anthem is the sole carrier selling exchange plans in 73 counties, so if Anthem were to leave any of those counties, consumers would be left with no insurance carrier.

“I’m not surprised,” Bill Hill, a local health insurance broker, said of the Anthem news.

Hill said the costs and limited networks had made exchange plans unpopular with his clients.

In general, Cigna covers BJC HealthCare and its doctors and facilities. Anthem covers SSM Health doctors and facilities but not BJC.

Sabrina Corlette, research professor and lawyer at Center on Health Insurance Reforms at Georgetown University’s Health Policy Institute, said it was not time to “hit the panic button.”

She said it was difficult to tease out what was posturing.

“I don’t want to suggest they (the insurers) haven’t struggled in a number of places, but a lot of them got really big price increases approved for 2017,” Corlette said, which will help cover costs.

But she also said they were facing multiple conflicts with the federal government and needed to maximize their negotiating position.

Aetna said Wednesday that it was committed to fighting the U.S. government’s lawsuit to block its acquisition of Cigna because of concern about reduced competition and higher prices for consumers.

Aetna and Humana Inc. are facing, and contesting, similar litigation.

Insurers also are insisting that the federal government make good on financial protections they thought would be available to them if they enrolled a sicker-than-expected population.

Anthem is not the Blue Cross Blue Shield provider in Illinois.

Reuters contributed to this report.

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Samantha Liss • 314-340-8017

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sliss@post-dispatch.com