The scorecard of how the biggest commercial health insurers—UnitedHealthcare Group, Aetna Inc., Anthem Inc. and Cigna Corp.—feel about further participation in the public exchange market is pretty much now filled in.

Earlier in this week UnitedHealthcare, Aetna and Anthem all confirmed once more or told Wall Street analysts on their year-end earnings calls that they intended to take a wait and see attitude about cutting back or pulling out altogether of the public exchange market.

Now Cigna is the latest big commercial carrier to put the brakes on a firm “yes” to staying in some or all of the seven states where it writes public exchange policies.

“We’ll have a lot of decisions to make as we get through the spring of the year, and we’ll assess our participation in the marketplace in totality with a fresh set of eyes based upon the rules, regulations and design for that marketplace that, as we sit here right now, is fragile at best,” Cigna CEO David Cordani told Wall Street analysts yesterday on the company’s year-end earnings call, based on a transcript from

Cigna didn’t break out specific numbers for its public health exchange business. For the year ended Dec. 31, total revenue grew year over year 4.4% to $39.49 billion from $37.81 billion. Income from operations was $2.10 billion compared with $2.30 billion in 2015 while the insurer’s commercial customer base grew year over year 1.4% to 14.6 million from 14.3 million.

There are a lot of factors coming to bear on the consumer market for health insurance, particularly the high cost of healthcare delivery and an aging population, Cordani told analysts.

“Aging populations, eroding health status and the rise of chronic conditions all pose challenges for health care consumers individually as well as society at large,” Cordani told analysts. “These forces in turn contribute to increasing demand for greater access to healthcare services and sense of security offerings that are both affordable and of high quality.”

In the future healthcare will be driven even more by consumer choice on a consumer level, he noted. “We see acceleration and demand for programs that offer more personalized solutions and are designed for local marketplaces,” Cordani told analysts.

Cigna’s approach to plan members is becoming much more focused on digital healthcare technology and analytics. “This year more than 1 million Cigna customers have access to One Guide, a multi-modal service experience powered by analytics that proactively engage consumers to stay healthy, eliminate surprises and save money, he told analysts. “One Guide combines the convenience of a smart integrated digital app with the expertise and empathy of human touch. This differentiated solution provides access to guided consultation via the phone, web, mobile app or chat.”