The Affordable Care Act has helped reduce Indiana’s uninsured rate, and those who shopped for 2017 plans in Indiana’s federally facilitated exchange during open enrollment had more options and lower rate increases than consumers elsewhere. Nationally, health insurance premiums increased an average of 25 percent for 2017, and about one-third of U.S. counties have only one exchange insurer in 2017.
But most Indiana counties have three or more insurers offering coverage. And the state’s average benchmark plan premium actually dropped 3 percent for 2017. Overall, premiums in Indiana’s individual market increased by a weighted average of 18.9 percent.
Indiana’s Congressional delegation and the AHCA: Mostly in support
The American Health Care Act, introduced by House Republicans in March 2017 in an effort to repeal and change several provisions of the ACA, would have had significant consequences for the individual health insurance market. The Congressional Budget Office projected that premiums would have increased by 15 to 20 percent in 2018 and 2019 if the bill had been enacted. They also projected that 24 million people would have joined the ranks of the uninsured. According to an analysis by the Center for American Progress, 365,500 of them were in Indiana.
Less than three weeks after it was introduced, the legislation was pulled by GOP leadership before the House voted, due to lack of support. The AHCA was universally opposed by Democrats in Congress, and although many Republicans supported it, there were too many opposed for it to pass (Republicans could only afford to lose 22 votes, and there were at least 33 who were expected to vote against the bill).
Although the AHCA was pulled before it reached a full vote on the House floor, here’s how Arizona’s Congressional delegation felt about the legislation:
- Senator Todd Young (Republican): The AHCA was introduced in the House and never reached the Senate, but some Senators expressed opinions about it. Young did not say whether he supported or opposed it, but he has voted numerous times in the past to repeal or defund the ACA.
- Senator Joe Donnelly (Democrat): Opposed to the AHCA
- Democratic Representatives Peter Visclosky and Andre Carson: Opposed to the AHCA.
- Republican Representatives Jackie Walorski, Jim Banks, Todd Rokita, Susan Brooks, Luke Messer, and Larry Bucshon: Supportive of the AHCA (all were expected to vote yes; Brooks and Bucshon had already voted for the bill in committee)
- Republican Representative Trey Hollingsworth, new to the House in 2017, did not take a position on the legislation, but asked his constituents to weigh in, and said that Obamacare had “drastically failed to meet the promises that were made to the American people.”
Indiana health ratings
The state ranked in the third and fourth quintile for all categories: Access, Prevention & Treatment, Avoidable Hospital Use & Cost, Healthy Lives, and Equity. The state did not place in the top 10 for any one indicator; however, it never placed last either. See Indiana’s scorecard for more details on what makes up the overall ranking.
Indiana ranked 41st in America’s Health Rankings for 2015. As it did in The Commonwealth Fund Scorecard, Indiana earned lower marks for its percentage of uninsured individuals, coming in at 31st. The Hoosier State placed 48th for public health funding and 36th for policy, which includes the following measures: Lack of Health Insurance, Immunizations Children, Immunizations Adolescents, and Public Health Funding.
The 2016 edition of Trust for America’s Health also ranks various public health measures; see Key Health Data About Indiana.
If statewide data is too broad, get county-by-county health rankings for Indiana from the Robert Wood Johnson Foundation and the Population Health Institute at the University of Wisconsin.If statewide data is too broad, get county-by-county health rankings for Indiana from the Robert Wood Johnson Foundation and the Population Health Institute at the University of Wisconsin.
How Obamacare is helping Indiana residents: nearly 450,000 are receiving financial assistance with insurance
Under the ACA, Indiana has a federally facilitated exchange, which means its residents use HealthCare.gov to purchase health insurance plans that qualify for subsidies. The state initially did not expand Medicaid but later opted to do so, and expansion took effect in early 2015.
By January 2017, Indiana reported that 403,142 people had enrolled in expanded Medicaid. In most states where Medicaid has been expanded, enrollment has been tracking above expectations. But in Indiana, the state had projected that 427,702 people would be enrolled by January 2017, so enrollment is lagging behind projections. This is likely due to the complicated nature of the state’s expansion, and the premiums that enrollees must pay in order to enroll in HIP Plus.
174,611 people enrolled in private plans through the Indiana exchange during the 2017 open enrollment period, which was an 11 percent decrease from the year before. In 2016, 83 percent of enrollees were receiving premium subsidies. If that percentage is still roughly accurate in 2017, there are about 145,000 people in Indiana who are receiving premium subsidies. Combined with the 403,142 who are covered under expanded Medicaid, there are nearly 450,000 people who are receiving financial assistance with their health insurance coverage in Indiana as a result of the ACA.
2017 rates, plans available in Indiana
Competition among insurers through the marketplace was limited during 2014 open enrollment. MDWise, Coordinated Care, Physicians Health Plan of Northern Indiana and Anthem participated in the marketplace. However, only one or two insurers offered policies in about two-thirds of the state’s 91 counties.
But Indiana residents had many more choices on the federal marketplace for 2015. The number of insurers more than doubled, from four to nine. And the number of available plans increased from 278 to 975.
FOr 2017, however, Indiana’s exchange saw four insurers leave – All Savers (UnitedHealthcare, Southeastern Indiana Health Organization, Physicians Health Plan, and Indiana University Health Plans. The four remaining include:
- Anthem BCBS
- CareSource Indiana
Aetna had filed rate proposals to join Indiana’s exchange, but the carrier announced in August that it would not expand into any new exchanges for 2017.
Indiana’s individual market does not include any PPO options for 2017. With the exception of Celtic’s on-exchange EPO and Anthem’s on- and off-exchange POS, all other carriers are offering HMO plans.
Indiana state regulators approved an 18.9 percent weighted average rate increase for 2017 plans. However, average benchmark plan rates in the exchange dropped 3 percent. That means average subsidies are slightly smaller in 2017, and it was particularly important for Hoosiers to shop around during open enrollment to ensure that they enrolled in the plan that provided the best value for 2017.
Indiana enrollment in qualified health plans
According to the Kaiser Family Foundation, 132,423 of 525,000 potential market enrollees in Indiana – 25.2 percent – signed up qualified health plans (QHPs) through Indiana’s health insurance exchange during 2014 open enrollment. Nationally, 28 percent of potential enrollees signed up for QHPs.
On March 31, 2016, Indiana’s effectuated exchange enrollment was 168,884 – nearly 83 percent of these enrollees were receiving premium subsidies that averaged $259 per month.
Enrollment during the 2017 open enrollment period was 11 percent lower than it had been at the end of the 2016 open enrollment period. 174,611 people enrolled in private plans through the Indiana exchange during the 2017 open enrollment period. Nationwide, there was an average decrease in enrollment in states that use HealthCare.gov (although Indiana’s decrease was more than double that of other HealthCare.gov states). The drop-off was likely due to higher premiums, uncertainty about the future of the ACA, and the Trump Administration’s decision to pull back on advertising and outreach for HealthCare.gov in the final week of open enrollment.
The Affordable Care Act in Indiana
When the Affordable Care Act was passed in 2010, Indiana’s senators and representatives voted along party lines, with former Sen. Evan Bayh voting yes, former Sen. Richard Lugar voting no, and representatives voting 5-4 in favor of the measure. Currently, Indiana’s House delegation is dominated by Republicans, and its Senate seats are split between the parties. As described above, virtually all of the state’s Republican Representatives in the US House were in favor of the AHCA, which would have repealed or changed many of the ACA’s spending-related provisions.
Indiana uses the federally facilitated health insurance exchange HealthCare.gov. And while former Governors Mitch Daniels and Mike Pence both opposed the ACA, Pence did push for – and get – federal approval to expand Medicaid using a waiver to enhance the Healthy Indiana Plan. The federal government rejected the state’s first proposal, but a second proposal was approved in January 2015, and expanded coverage was in effect by February 2015. Former Gov. Pence became Vice President of the United States in January 2017. in the 2016 election.
Former Gov. Pence became Vice President of the United States in January 2017. in the 2016 election. In the 2016 election, Republican Eric Holcomb won the gubernatorial election in Indiana. Holcomb is opposed to the ACA, and supported House Republicans in their quest to pass the AHCA (the legislation was pulled before a vote, but would have frozen Medicaid expansion funding for new enrollees at the end of 2019, and would have resulted in smaller overall premium subsidies in the individual market, along with significantly higher premiums for people over the age of 50).
Medicaid expansion, as enacted by the ACA, extends Medicaid eligibility to low-income adults up to 138 percent of the federal poverty level. Indiana did not expand Medicaid in 2014, but their second waiver proposal was approved by CMS in January 2015, paving the way for Medicaid expansion to begin in February 2015.
Prior to that, 291,000 people with incomes up to 138 percent of the poverty level were excluded from the Medicaid program and 182,000 people were in the coverage gap.
From 2013 to June 2016, average monthly Indiana Medicaid/CHIP enrollment in Indiana increased by 31 percent – an increase of 349,336 enrollees. The left-leaning Center on Budget and Policy Priorities (CBPP) notes, however, that Indiana’s Medicaid enrollment is lower than it would be if the state had simply expanded coverage as called for in the ACA, without the modifications that are included in the state’s waiver.
Indiana has two levels of Medicaid coverage: HIP Basic and HIP Plus. HIP Plus includes dental and vision coverage, and no copays unless enrollees use the emergency room for non-emergency care. HIP Basic has copays and does not include dental and vision coverage. People with income above the poverty level enroll in HIP Plus, and must pay premiums. People with income below the poverty level can enroll in HIP Basic without premiums, or can pay premiums and enroll in HIP Plus.
But the complexity of the design, confusion about premiums, and some enrollees’ lack of financial resources mean that enrollment has lagged behind expectations. The CBPP analysis found that in any given month, there are about 30,000 people who have been determined eligible for Indiana Medicaid in the previous two months, but have not finalized their enrollment because they have not paid their premiums.
Other ACA reform provisions
The Affordable Care Act established the Consumer Operated and Oriented Plan (CO-OP) Program to encourage competition and consumer choice. Through this federal loan program, 23 CO-OPs were offering coverage as of the first open enrollment period. However, only five remained operational as of early 2017. No CO-OP plans were created in Indiana.
Does Indiana have a high-risk pool?
Before the ACA reformed the individual health insurance market, applications were medically underwritten in nearly every state, including Indiana. As a result, people with pre-existing conditions were often ineligible to purchase private plans, or were only able to get policies that excluded their pre-existing conditions or charged them significantly higher premiums for comprehensive coverage.
The Indiana Comprehensive Health Insurance Association (now terminated) was created in 1982 to provide an alternative for residents who were unable to obtain coverage in the private market because of their medical history.
Under the ACA, all new health insurance policies became guaranteed issue starting on January 1, 2014. This aspect of healthcare reform meant that plans in the individual market could be purchased regardless of medical history, making high-risk pools largely obsolete. ICHIA stopped enrolling new members at the end of September 2013. They had originally planned to cease operations and terminate all policies at the end of 2013, but the glitches in Healthcare.gov made it difficult for members to enroll in an exchange plan by mid-December.
The Indiana Insurance Commissioner extended ICHIA coverage until January 31, 2014, in order to give members another month to secure new plans. Coverage was extended until April 30, 2014, for members with HIV, and until the end of 2014 for the 12 members with end-stage renal disease.
Medicare enrollment in Indiana
In 2015, Indiana Medicare enrollment reached 1,150,553, about 17 percent of the state’s population and consistent with the percentage of people enrolled in Medicare across the U.S. 82 percent of those individuals qualified based on age alone, while the other 20 percent were eligible due to a disability.
As of 2009, Indiana ranked 15th in overall Medicare spending with $9.7 billion per year. Per Indiana enrollee, IMedicare spends about $9,141 per year – higher than the national average of $8,970.
Indiana Medicare recipients who want additional benefits beyond what original Medicare offers can instead select a Medicare Advantage plan. In Indiana, 24 percent of Medicare beneficiaries were enrolled in a Medicare Advantage plan in 2016 (instead of traditional Medicare), compared with 31 percent nationwide.
Medicare Part D plans are also available to Indiana Medicare enrollees who want stand-alone prescription drug coverage. More than half (53 percent) of Indiana Medicare enrollees have stand-alone Rx coverage compared with 45 percent nationwide.
Other recent health reform legislation at the state level includes: