Iowa operates a partnership exchange with the federal government. Iowa residents use the federal marketplace, HealthCare.gov, to compare and purchase coverage. The state is responsible for plan management, consumer assistance, and Medicaid eligibility determination.
Iowa’s plan management functions include selecting and monitoring the qualified health plans (QHP) that offer policies on the exchange. Iowa’s role in consumer assistance is education and outreach, coordinating the in-person consumer assisters, and overseeing the Navigator program. The federal government manages the exchange website and call center, and funds the Navigator program.
A market in turmoil
Iowa has four insurers offering coverage in the exchange in 2017: Wellmark, Aetna, Medica, and Gunderson. The Iowa Division of Insurance confirmed that there are no additional insurers offering new individual market plans only outside the exchange.
Wellmark and Aetna have already announced that they will not offer ACA-compliant individual market plans in 2018 (on or off-exchange). Medica, which is the only insurer that offers coverage statewide in 2017, has said that they will not be able to remain in the exchange “without swift action by the state or Congress to provide stability to Iowa’s individual market.” (the most direct action the Trump Administration or Congress could take would be to commit to funding cost-sharing subsidies through at least the end of 2018).
Gunderson only offers plans in five counties (Allamakee, Clayton, Fayette, Howard, and Winneshiek) in the northeastern part of the state, and hasn’t said whether they’ll continue to offer Iowa plans in 2018.
There is currently no backup system in place if some areas of the country end up with no participating exchange insurers (or no individual market insurers at all). That situation has not yet occurred, although Pinal County, Arizona came close to it for 2017, and the Knoxville, Tennessee area is currently facing that situation for 2018. Due to technology glitches, Massachusetts had to use a workaround in 2014 that involved temporarily putting 325,000 people on MassHealth (Medicaid), but a solution like that would require a waiver from HHS in order to use federal Medicaid funding.
In March 2017, Senator Lamar Alexander (R, Tennessee) introduced S.761, which would allow people to use ACA premium tax credits towards the purchase of off-exchange plans in areas where no exchange insurers offer coverage. The bill has not advanced out of committee yet. Even if it were to be enacted, it would not be of use to people in an area — like most of Iowa — facing the possibility of no individual market insurers offering coverage on or off the exchange.
Wellmark exiting Iowa’s ACA-compliant individual market at the end of 2017
Wellmark joined the exchange in Iowa for 2017, after offering only off-exchange plans for the first three years of ACA implementation. But on April 3, 2017, the insurer announced that they would exit the ACA-compliant individual market (both on and off-exchange) at the end of 2017. Wellmark said that the planned exit will mean that roughly 21,400 people will need to secure new coverage for 2018.
The insurer noted that they have lost $90 million in the ACA-compliant individual market over the last three years. They explained that younger, healthy people have been slow to enroll, leaving an older, sicker pool of insureds — a situation that is not sustainable over the long term. Wellmark in Iowa also has a uniquely expensive enrollee, whose claims total $1 million per month, and who accounted for a quarter of their total rate increase (across all members’ plans) in 2017.
Wellmark reported that 1.64 million members in the state will not be impacted by the exit. This includes people who have grandfathered and grandmothered individual market Wellmark plans (ie, people whose plans took effect prior to 2014). People with employer-sponsored plans (including ACA-compliant small business plans) and Medicare supplement plans will also not be impacted.
Wellmark’s exchange plans are narrow-network HMOs, and are not available statewide in 2017. They are available in 40 of the state’s 99 counties, with the carrier’s Mercy Health Network HMO (Wellmark Value Health Plan) the available exchange option in 36 of those counties.
And Wellmark announced in late September 2016 that they would no longer offer Gold plans in the individual market, nor would they “promote” individual market PPOs. But they noted that people with existing off-exchange Bronze and Silver PPOs in Iowa would be able to keep those plans in 2017. The switch away from PPOs and towards HMOs and EPOs has been a nationwide trend over the last few years.
Iowa is one of the states that is allowing grandmothered (transitional) health plans to remain in force per the Obama Administration’s transitional relief, which now permits states to allow grandmothered plans to continue to renew until October 1, 2018, and remain in force as late as December 31, 2018. Iowa had initially opted to make October 1, 2016 the latest date these plans could remain in force, but ultimately went along with the guidance that CMS issued in February 2016. An additional extension was issued by the Trump Administration HHS in February 2017, allowing grandmothered plans to remain in force throughout 2018. Iowa has agreed to that extension as well.
A significant number of Wellmark’s pre-2014 enrollees have opted to keep their non-ACA-compliant plans. The Des Moines Register reported that roughly 55,000 people still had 2016 Wellmark plans in Iowa that had been in effect since before the ACA was enacted, and that’s in addition to people with grandmothered plans.
Wellmark had 137,000 individual market members in Iowa in 2015, but the majority of them had non-ACA-compliant health plans. HealthCare.gov’s rate review tool indicates that about 33,000 Wellmark insureds (3,046 plus 29,975) had ACA-compliant plans in 2015, although the Iowa Insurance Division’s August notice regarding Wellmark’s rate increase stated that there were roughly 23,000 members on ACA-compliant plans at that point. Despite expanding onto the exchange for 2017, total enrollment in the insurer’s ACA-compliant plans is slightly lower in 2017 than it was in 2015.
Aetna also out at the end of 2017
On April 6, just days after Wellmark’s announcement, Aetna also said that they would stop offering individual market plans in Iowa at the end of 2017. Aetna had 42,000 enrollees in individual market plans as of 2016. People who currently have Aetna coverage will need to switch to a new plan for 2018. Medica is the only insurer that will be left in most of the state unless other insurers join, and it’s still unclear what Medica plans to do.
Medica considering a market exit
Medica is the only insurer that offers exchange plans state-wide in Iowa in 2017, and there are 13 counties where they are the only insurer participating in the exchange. If they remain in the exchange and no new insurers join, they will be the only insurer in all but five counties in 2018.
But on May 3, Medica released the following statement: “Without swift action by the state or Congress to provide stability to Iowa’s individual insurance market, Medica will not be able to serve the citizens of Iowa in the manner and breadth that we do today. We are examining the potential of limited offerings, but our ability to stay in the Iowa insurance market in any capacity is in question at this point.”
There is no doubt that the most pressing concern for insurers in terms of market stability is the ongoing funding of cost-sharing subsidies, which Congress and the Trump Administration had not yet clarified as of early May. In Iowa, however, some of Medica’s concern could also be related to the single very high-cost insured described in Wellmark’s 2017 rate filing. With Wellmark and Aetna exiting, Medica would become the insurer of last resort, and there isn’t currently an adequate risk sharing mechanism for addressing claims like that, particularly in a market as small as Iowa’s.
51,573 people enrolled in private plans through the Iowa exchange during the 2017 open enrollment period (November 1, 2016 through January 31, 2017). That’s a little more than a 6 percent decline from the 2016 open enrollment period, when 55,089 Iowa residents enrolled.
Across all the states that use HealthCare.gov, enrollment dropped by about 5 percent in 2017. This is due in part to the uncertainty surrounding the future of the ACA, and the Trump Administration’s move to cut back advertising and outreach in the final week of 2017 enrollment.
HHS estimated that there were 41,000 people in Iowa with off-exchange coverage in 2016 who would be eligible for subsidies if they switched to the exchange. And Kaiser Family Foundation data indicated that just 20 percent of eligible Iowa residents had enrolled in coverage through the exchange by 2016, the lowest percentage in the country. That may be due in part to the lack of marketing for the exchange in the state, or the fact that Wellmark sat out the first three years of exchange operation (they’re offering exchange plans in 2017; details below).
The Iowa exchange and the Trump Administration
Although the future of the Affordable Care Act has been uncertain under the Trump Administration, nothing has changed for now. Republican lawmakers considered the American Health Care Act in March, but ultimately pulled it before it reached a vote in the House, leaving the ACA intact for the time being. Some members of the party want to push forward with ACA repeal, while others have called for moving on to other priorities on the agenda. It’s unclear at this point whether additional legislation will be pursued.
But even if Republicans don’t take legislative action, the future of the ACA is still uncertain. The Trump Administration has taken some actions aimed at stabilizing the individual markets, but other actions have essentially served to destabilize the market. And the House v. Price (formerly House v. Burwell) lawsuit to determine the legality of the ACA’s cost-sharing subsidies has created a great deal of uncertainty among insurers.
This uncertainty, combined with significant losses, led to Wellmark opting to exit the ACA-compliant individual market at the end of 2017. The other insurers that offer individual market plans in Iowa have not yet said what they’re planning to do. Rate and plan filings will be submitted in May/June for insurers that wish to continue to offer coverage in 2018.
HHS reported that from 2010 to 2015, the number of Iowa residents with health insurance grew by 132,000 as a result of the ACA — a number that has continued to climb since 2015, largely due to Medicaid expansion.
If the ACA were to be repealed, ACA Signups estimates that 189,000 people in Ohio could lose their health insurance if the law were either not replaced (possible, given the political division in Congress), or replaced with something less robust. 150,000 of them are currently covered under Iowa’s expanded Medicaid coverage. Total net Medicaid enrollment in Iowa grew by 128,556 people from 2013 through December 2016.
UnitedHealthcare exited at the end of 2016
In November 2015, UnitedHealthcare announced that they were experiencing significant financial losses in the exchanges, and that they weren’t certain whether they would continue to sell plans in the exchanges after the end of 2016. In April 2016, they confirmed that they would exit most of the 34 exchanges where they offered plans in 2016.
Iowa is one of the states where UnitedHealthcare exited the individual market (on and off-exchange) at the end of 2016. According to The Gazette, there were about 9,000 people who needed to secure new coverage during the 2017 open enrollment period. That included 8,700 Iowa residents who had coverage through UnitedHealthcare of the Midlands Inc. and 328 people who had coverage through UnitedHealthcare Life Insurance Co.
In 2016, United offered plans in 76 of Iowa’s 99 counties, and in 71 of those counties, United offered at least one of the two lowest-cost silver plans in the exchange. In 66 counties, the benchmark plan for a 40-year-old would have been between $25 and $100/month more expensive in 2016 if United hadn’t participated. However, the impact of United’s exit is likely to be buffered by the fact that Wellmark has joined the exchange in 2017.
United exited the SHOP (small business) exchange in Iowa, but is continuing to offer small group plans outside the exchange. The company is not offering plans in the Iowa individual market at all in 2017, including outside the exchange.
2017 rates and carriers
Four carriers are offering on-exchange plans in Iowa for 2017. But Medica is the only carrier offering exchange plans in all 99 counties in Iowa. In 13 of the state’s counties, Medica is the only carrier offering plans in the exchange.
According to the Iowa Insurance Division, the following average rate increases were approved for carriers that are offering exchange plans in 2017:
- Aetna (formerly Coventry): 22.58 percent; Aetna had roughly 42,000 policyholders in Iowa in 2016.
- Gunderson (merging with Unity Health Insurance): 19.8 percent; Gunderson had 88 policyholders in 2016. Their 2017 Iowa plans are available only in four counties in the northeast corner of the state (Allamankee, Clayton, Fayette, and Howard).
- Medica: 19 percent; Medica had 1,367 policyholders in 2016.
- Wellmark (new to the exchange for 2017, but exiting the ACA-compliant individual market at the end of 2017): Average rate increase for 2017 was 42.6 percent for existing Bronze and Silver PPOs, and 37.8 percent for HMOs. There were about 7,800 policyholders with Wellmark’s HMOs in 2016, and about 22,000 policyholders who had plans for which the average 42.6 percent rate increase applied. All of them had off-exchange plans in 2016, but were able to transition to Wellmark’s on-exchange plans in 2017 if they so chose.
Aetna is not offering exchange coverage in 2017 in most of the states where they participated in 2016. But they’re continuing to offer coverage in the exchanges in four states, including Iowa (the others are Delaware, Nebraska, and Virginia). At the end of 2017, they are exiting Iowa’s individual market, although they have not said what they plan to do in the other three states.
Avera did not offer health insurance in the Iowa exchange in 2016 (their plans were all off-exchange), but they had initially filed rates for on-exchange plans to be available in 2017. That’s no longer the case however, and their individual market plans are now only available in South Dakota (they are continuing to offer small group plans in Iowa).
The Iowa Division of Insurance held public hearings about the proposed rates in late July, and consumers expressed their frustration with the size of the proposed rate hikes. But Insurance Commissioner Nick Gerhart noted that there was little the state can do to reign in rate increases if they’re justified by medical spending. Iowa regulators do not have the authority to reject rate increases outright, but can negotiate with carriers. Ultimately, the rates were approved as-filed for 2017.
For people enrolled in plans through the exchange and willing to shop around during open enrollment, premium subsidies mitigate much of the rate increase for the majority of Iowa exchange enrollees who receive subsidies (in 2016, 87 percent of Iowa exchange enrollees were receiving subsidies). Premium subsidies are available in 2017 for the first time for Wellmark enrollees, as long as they switched to a Wellmark plan offered through the exchange. And subsidies are significantly larger in 2017 than they were in 2016, since the average benchmark plan (second-lowest-cost silver plan, upon which subsidy calculations are based) is 25 percent more expensive in 2017.
55,089 people in Iowa enrolled in private plans through the exchange during the 2016 open enrollment period, including renewals and new enrollees. For perspective, dring the 2015 open enrollment period, 45,162 people enrolled in private plans through the exchange in Iowa.
2016 average premiums
Kaiser Family Foundation data indicates that there were still 188,000 uninsured residents in Iowa in 2015, and 47 percent of them were eligible for the state’s expanded Medicaid coverage. Another 16 percent were eligible for subsidies to help purchase private health insurance coverage, as long as they buy a plan through the Iowa exchange.
Of the people who initially enrolled in plans through the Iowa exchange for 2016, 85 percent were eligible for premium subsidies. Their pre-subsidy premium averaged $425/month (a little higher than the $396/month average across all Healthcare.gov states), but their average after-subsidy premium was just $122/month (also a little higher than the $106/month average across all Healthcare.gov states).
For comparison, 85 percent of enrollees also qualified for subsidies in 2015 in the Iowa exchange, but their average pre-subsidy premiums were $371/month, and their average after-subsidy premiums were $111/month.
By March 2016, 87 percent of Iowa exchange enrollees were receiving subsidies that averaged $307 per month.
Consumers had more choices in 2016
The Iowa Insurance Division announced in May 2015 that five carriers had submitted proposals to sell individual coverage in the exchange for 2016 — up from one that offered plans in 2015. Ultimately, four carriers offered exchange plans in Iowa in 2016.
Early in the 2015 open enrollment period, Coventry and CoOpportunity Health both offered plans in the Iowa exchange. But CoOportunity stopped offering policies in late December 2014. CoOportunity was a CO-OP health insurer formed with funding through the Affordable Care Act. CoOpportunity got into financial difficulty after higher than expected enrollment and claim costs in 2014, and was subsequently liquidated, leaving Coventry as the only marketplace insurer available in Iowa.
But for 2016, Coventry and Medica offered plans state-wide, while two other carriers offered plans in select areas. United Healthcare of the Midlands, and Gunderson offered plans in various areas of the state (although that chart indicates that Avera was also offering plans in the Iowa exchange in 2016, Avera’s 2017 rate filing memo (which has since been deleted, since they’re not offering individual market coverage in Iowa in 2017) noted that they did not participate in the exchange in 2016, and Avera’s website also confirmed that Avera plans were not available in the Iowa exchange in 2016).
Two additional carriers offered small group plans through the exchange in 2016.
For the three carriers that offered individual health insurance in 2015 (two of which were off-exchange only), the approved average rate changes for 2016 were:
- Wellmark = 17.6 to 28.7 percent increases, across ACA-compliant, transitional, and grandfathered plans. (137,000 members, OFF-EXCHANGE ONLY; rate hike for ACA-compliant off-exchange plans is 24.5 percent)
- Coventry = 19.8 percent increase (47,000 members)
- Gunderson = 9.4 percent (60 members, all off-exchange in 2015, but on-exchange plans are available in 2016)
At ACAsignups, Charles Gaba put the weighted average rate increase market-wide at a little over 22 percent. But for people who already had a plan through the exchange, it was 19.8 percent, since those plans were all from Coventry.
However, the average benchmark premium increased by 12.8 percent in Iowa, which was less than the overall average rate increase for on-exchange plans (in Cedar Rapids, the average benchmark premium is 15.4 percent more expensive in 2016). The benchmark plan is just the second-lowest-cost Silver plan in each area – it’s not necessarily the same plan from one year to the next, or even from the same carrier. Iowa is a good example of a new carrier taking over the benchmark position in at least some areas of the state.
With the addition of new carriers and plans in the Iowa exchange, it was extremely important for 2015 enrollees to shop around during open enrollment for 2016 plans. Subsidies are higher in 2016 than they were in 2015, but the increase in subsidies isn’t enough to fully offset the average rate increases on Coventry plans for 2015 enrollees who let their coverage auto-renew.
More than 45,000 Iowans singed up for qualified health plans during the second open enrollment period. While an improvement over 2014, the 2015 total was just 20 percent of the estimated 225,000 Iowans who were eligible to sign up on HealthCare.gov. Nationally, about 40 percent of those eligible actually enrolled during the 2015 open enrollment period.
And as expected, not everyone who enrolled ended up keeping their coverage. Some people never paid their initial premium, and others cancelled their coverage early in the year for one reason or another. By the end of June+, there were 39,347 people with in-force coverage through the Iowa exchange.
Iowa expanded Medicaid under the ACA, but with a waiver that called for using Medicaid funds to purchase private health plans for eligible residents. But in June 2015, the state announced that they were abandoning their alternative “private option” for Medicaid expansion, and switching Medicaid enrollees to regular Medicaid managed care plans instead. The switch to managed care was initially scheduled for January 2016, but was pushed back to March 2016.
Iowa’s uninsured rate decreased 3.1 percentage points, from 8.1 percent in 2013 to 5 percent in 2014 according to U.S. Census Bureau data. Iowa’s Medicaid/CHIP enrollment grew by 25 percent – about 125,500 people – from 2013 to August 2016, which is no doubt a significant factor in the reduction in the uninsured rate.
2015 premiums up 11 percent on average
A study by The Commonwealth Fund found that 2015 marketplace premiums in Iowa increased by 11 percent on average compared to 2014. The Commonwealth Fund’s study was weighted for differences in premiums between urban/suburban/ rural areas and insurer participation.
2014 enrollment metrics
In total, 29,163 people enrolled in qualified health plans (QHPs) during the 2014 open enrollment, and an additional 36,891 people qualified for Medicaid or the Children’s Health Insurance Program (CHIP).
Just 11.1 percent of Iowa residents eligible to enroll through the marketplace did so in 2014. Iowa tied with neighboring South Dakota for the lowest percentage of eligible enrollees signing up. A Kaiser Health News article attributed the low enrollment in both states to Wellmark Blue Cross & Blue Shield’s decision against participating in the states’ marketplaces rather than a boycott of the Affordable Care Act. In addition, the fact that transitional (pre-2014) plans were allowed to renew meant that overall enrollment in ACA-compliant plans was lower than expected.
A U.S. Department of Health and Human Services report showed the 2014 average, post-subsidy premium for Iowa consumers was $108 per month. The national average in states using HealthCare.gov $82 per month after subsidies. In 2015, the average after-subsidy premium in Iowa increased to $117 per month, and the national average increased to $105 per month (in the 37 states that used Healthcare.gov in 2015). It’s worth noting, however, that variations in after-subsidy premium are a function of income and plan selections – in an area where people have higher average household incomes, average after-subsidy premiums will be higher. That will also be the case in an area where people gravitate to more comprehensive plans. The ACA’s subsidies ensure that for people with equal income, the second-lowest-cost silver plan will be the same price in every area of the country (the exception is areas where the second-lowest-cost silver plan is actually priced so low that subsidies aren’t necessary in order to ensure that the plan isn’t more than the percentage of income cap imposed by the ACA).
Twenty-six percent of Iowa residents selected a bronze plan (20 percent nationally), 57 percent selected a silver plan (65 percent nationally), 12 percent selected a gold plan (9 percent nationally), 4 percent selected a platinum plan (5 percent nationally) and 2 percent selected a catastrophic plan (2 percent nationally). Twenty-six percent of Iowa enrollees were between the ages of 18 and 34.
Iowa’s approach to the marketplace
Iowa operates a partnership exchange with the federal government. The state has occasionally mentioned as a state that may transition to a different model for its exchange. In February 2014, Gov. Branstad floated the idea of a regional exchange in conjunction with South Dakota, Nebraska and Kansas. Bills to convert to a state-run exchange were introduced in Senate committees in both 2013 and 2014, but neither advanced. And as time goes by, it becomes less likely that the state will branch out into its own exchange, or create a regional exchange, due to the start-up costs.
Iowa health insurance exchange links
State Exchange Profile: Iowa
The Henry J. Kaiser Family Foundation overview of Iowa’s progress toward creating a state health insurance exchange.
Consumer Advocate Bureau
Provides consumers with assistance in navigating the health care system, assistance programs, and other issues related to health insurance benefits.
1-877-955-1212 / firstname.lastname@example.org