PERSPECTIVE 910 Success and Failure in the Insurance Exchanges n engl j med 376;10 nejm.org March 9, 2017 insurers that remained in the ex- change market had a greater lo- cal market share of fully insured products. In supplementary analyses, we also compared characteristics of insurers and plans entering the exchange market in 2017 and found that new plans had sub- stantially lower premiums than their local competitors (premiums are $30 per month lower for a 35-year-old enrollee). Moreover, issuers of these new plans were more likely to have experience with Medicaid managed care but less likely to have direct experi- ence in the markets they entered. This finding is consistent with the existence of a functioning market in which firms that were initially successful are moving into new geographic areas. Taken together, our estimates demonstrate that the insurers par- ticipating in the exchange market in 2017 are systematically differ- ent from the firms that have ex- ited it. Furthermore, the dimen- sions on which they differ, such as experience in pricing premiums and managing risk for low-income populations, may be those most likely to contribute to commercial success in a reformed nongroup market. It is possible that the ex- perience of insurers operating in the 17 state-based marketplaces we did not examine could be dif- ferent; further work examining those marketplaces would be use- ful. But claims that the failure of certain insurers is evidence of un- workable policies seems misguid- ed. The available data reveal pat- terns of market entry and exit that are consistent with natural competitive processes separating out firms that are best suited to adapt to a new market. We be- lieve that efforts to reform or re- place the ACA should therefore proceed with the knowledge that highly publicized market exits are a poor and probably inaccurate signal of a failing market. Disclosure forms provided by the authors are available at NEJM.org. From the Kellogg School of Management, Northwestern University, Evanston, IL (C.G.); and Vanderbilt University School of Medi- cine, Nashville (J.A.G.). This article was published on February 1, 2017, at NEJM.org. 1. Levitt L, Claxton G, Damico A, Cox C. Assessing ACA marketplace enrollment. Kaiser Family Foundation issue brief. March 2016 (http://files.kff.org/attachment/issue -brief-assessing-aca-marketplace-enrollment). 2. Johnson CY. UnitedHealth Group to exit Obamacare exchanges in all but a ‘handful’ of states. Washington Post. April 19, 2016 (https://www.washingtonpost.com/news/ wonk/wp/2016/04/19/unitedhealth-group -to-exit-obamacare-exchanges-in-all-but-a -handful-of-states/). 3. Tracer Z. Anthem threatens Obamacare retreat if results don’t improve. Bloomberg Businessweek. November 2, 2016. 4. Wilde Matthews A. Molina outperforms rivals in ACA marketplaces. Wall Street Jour- nal. October 6, 2016. DOI: 10.1056/NEJMp1614545 Copyright © 2017 Massachusetts Medical Society. At Risk for Serious Mental Illness — Screening Children of Patients with Mood Disorders or Schizophrenia Michel Maziade, M.D. A 10-year-old boy has cogni- tive deficits, and his school performance and social skills have been deteriorating gradually since he was 7. Neither his 12- year-old brother nor his 14-year- old sister has similar problems. Their mother, a 37-year-old school- teacher, has been treated for bi- polar disorder since she was 28 and has had stable periods inter- rupted by acute episodes for which she was hospitalized. Recogniz- ing that she shares cognitive dys- functions with her younger son and reminded by his difficulties of the similar ones she had at his age, she consults her family doc- tor, worried about her son’s future mental health. Her doctor reas- sures her that her son still exhibits no seriously problematic behavior but adds that if the deterioration persists until adolescence, a psy- chiatric consultation could be con- sidered. Unfortunately, most clini- cians would similarly defer clinical investigation in this case. There are situations in which current medical practice does not reflect the relevant science, and the lack of attention to the mil- lions of children born to a parent with schizophrenia, bipolar dis- order, or recurrent major depres- sion is a case in point. This ne- glect is out of phase with the massive need in primary care and the available scientific evidence. Children with a parent who has serious mental illness can no longer be regarded as an extreme and isolated subpopulation. An estimated 4% of the populations of the Group of Seven (G7) indus- The New England Journal of Medicine Downloaded from nejm.org at BIBLIOTHEQUE UNIV LAVAL SEC ACQ on March 9, 2017. For personal use only. No other uses without permission. Copyright © 2017 Massachusetts Medical Society. All rights reserved.