Iowa health insurance

Exits, entrances in motion as IA exchange enrollees look toward 2017

This open enrollment season, Iowans shopping for 2017 health insurance plans through the state’s exchange will notice some changes when it comes to carrier options. UnitedHealthcare will exit 34 exchanges, including Iowa’s at the end of 2016. Meanwhile, Wellmark Blue Cross and Blue Shield will sell individual coverage on Iowa’s exchange for the first time.

Carrier options and rate increases may seem like old news following the 2016 election results. Despite president-elect Trump’s promise to repeal and replace Obamacare, people are encouraged to enroll in ACA-qualified health insurance plans as usual. As of now, Iowa boasts top-10 to average health ratings and a relatively low rate of uninsured, which has been significantly helped by Medicaid expansion.

What the future holds remains to be seen, and we’ve addressed some common concerns here.

Iowa health ratings

Iowa moves up one spot to number nine in the Commonwealth Fund’s 2015 Scorecard on State Health System Performance, which evaluates the performance of the 50 states and the District of Columbia on more than 40 health measures. The state is a top-performer when it comes to healthcare access, prevention and treatment.

Iowa’s scorecard includes a 5th and 2nd place ranking for its percentage of uninsured adults and children. To improve to the level of the best-performing state, just 54,070 more adults would need to gain insurance.

America’s Health Rankings look at a somewhat different set of measures, and Iowa ranked 22nd overall in 2015. Its low percentage of uninsured individuals bolstered Iowa’s placement in this ranking as well – for the lack of health insurance measure, Iowa placed 5th. Among the state’s biggest areas of improvement, according to this analysis: the number of primary care physicians and dentists per 100,000 residents as well as public health funding.

Another source for Iowa public health information is the Trust for America’s Health; see Key Health Data About Iowa. Finally, you can zoom in and get county-by-county health rankings for Iowa from the Robert Wood Johnson Foundation and the Population Health Institute at the University of Wisconsin.

Obamacare’s impact in Iowa

Iowa is one of the states that fully embraced implementing healthcare reform. Although the state’s pre-ACA uninsured rate was relatively low, with a state-partnership exchange and Medicaid expansion in effect since 2014 open enrollment, its uninsured rate continues to drop.

A Kaiser Family Foundation report estimated that, as a result of the Affordable Care Act, 71 percent of Iowa’s 301,000 nonelderly uninsured residents would qualify for either Medicaid or tax subsidies to help pay for coverage purchased through the marketplace.

By late 2015, Iowa’s uninsured rate fell 3.4 percentage points from 9.7 to 6.3 percent.

Exchange rates, carriers for 2017 enrollment

Many exchanges will see carriers exit at the end of 2016, and Iowa is no exception with the loss of UnitedHealthcare. However, Iowa’s exchange will include new carriers for 2017 – Avera and Wellmark Blue Cross and Blue Shield.

Four carriers are offering plans through Iowa’s exchange during 2017 open enrollment – their rate increases are also included below.

  • Aetna (formerly Coventry) – Iowa is among the few states where Aetna will continue to offer ACA plans: 22.58 percent
  • Gunderson (merging with Unity Health Insurance): 19.8 percent
  • Medica: 19 percent
  • Wellmark (new to the exchange): 42.6 percent

Open enrollment runs through January 31, 2017. Those who want coverage effective January 1 will need to enroll by December 15, 2016.

Iowa enrollment in qualified health plans

About 29,000 Iowans of an estimated market of 224,000 eligible residents enrolled in a qualified health plan (QHP) through Iowa’s exchange during the 2014 open enrollment period. That’s just 13 percent, below the national average of 28.0 percent. Among Iowa residents who signed up for a QHP for 2014, 84 percent qualified for tax subsidies to help offset the premium cost.

During the 2016 open enrollment period, 55,089 people bought private plans through Iowa’s exchange. As of March, effectuated enrollment was 48,949 – 25 percent higher than last year at the same time.

Iowa and the Affordable Care Act

Iowa Sen. Thomas Harkin (D) voted yes and Sen. Charles Grassley (R) voted no when the Affordable Care Act was passed in 2010. Sen. Grassley remains in office; however, Sen. Harkin retired and was replaced by Joni Ernst (R) in 2015.

Grassley proposed an amendment to require members of Congress and their staffs to use the health insurance marketplace – even though the marketplace was intended for individuals and small businesses. Confusion over the amendment led to charges that Congress was exempting itself from Obamacare.

Three Iowa House members – all Democrats – voted in favor of the ACA, while two Republicans voted against it. Iowa has since lost a seat in the House through the reapportionment process, and its four remaining representatives are evenly split between the Democratic and Republican parties.Within the Iowa legislature, Democrats hold a slim majority in the Senate, and Republicans control the House.

Republican Gov. Terry Branstad is not supportive of the Affordable Care Act. In 2011, Branstad signed Iowa onto Florida’s lawsuit challenging the ACA. Branstad stated a preference for a state-based insurance marketplace, but said the federal government had not provided enough information for Iowa to proceed with that option. Iowa currently operates a state-partnership marketplace.

The federal government approved two Iowa waiver applications to expand Medicaid under the ACA. One waiver is the so-called “private option.” Medicaid funding is used to pay for the purchase of private health insurance through the marketplace for residents with incomes between 100 and 138 percent of the federal poverty level (FPL). The other waiver expands Iowa’s current Medicaid program, which is called the Iowa Wellness Plan, to nonelderly adults with incomes up to 100 percent of FPL.

Iowa Medicaid/CHIP enrollment

Iowa is among the states that have accepted federal Medicaid expansion. However, the state received a waiver from CMS allowing it to take a slightly different approach and still receive federal funding.

Iowa’s alternative to ACA Medicaid expansion involves a program called the Iowa Health and Wellness Plan in which residents with household incomes below the federal poverty level are enrolled in a state-run health plan called the Iowa Wellness Plan; some pay modest premiums. Those with incomes of 101 to 138 percent of the federal poverty level purchase marketplace coverage through a program called the Iowa Marketplace Choice Plan and their premiums are paid by the federal government.

Two waiver amendments approved in Dec. 2014 allow the state to continue not providing non-emergency transport and also charge a monthly premium for those with incomes under 138 FPL – those who complete a wellness exam and health-risk assessment could reduce or eliminate these premiums.

Forty-seven percent of Iowa’s 301,000 nonelderly uninsured residents qualify for Medicaid or the Children’s Health Insurance Program (CHIP), according to the Kaiser Family Foundation. The average monthly enrollment for Iowa Medicaid has increased 25 percent from pre-ACA to June 2016..

More information about Iowa Medicaid is available at the Iowa Department of Human Services.

Other ACA reform provisions

The ACA’s Consumer Operated and Oriented Plan (CO-OP) Program encourages the creation of nonprofit, consumer-run health insurance issuers. Twenty-four CO-OPs received loans totaling $1.98 billion as of January 2013. CoOportunity Health, which operates in Iowa and Nebraska, received $112.6 million.

CoOportunity Health stopped selling plans in both states as of late December 2014 and is among the nation’s many failed ACA CO-OPs.

Does Iowa have a high-risk pool?

Before the ACA reformed the individual health insurance market, coverage was underwritten in nearly every state, including Iowa.  Applicants with pre-existing conditions were often unable to purchase private coverage, or found themselves with very limited options that didn’t cover their pre-existing conditions.

The Iowa Comprehensive Health Association (otherwise known as Health Insurance Plan of Iowa, or HIPIOWA) was established in 1987 to give people an alternative if they weren’t eligible to buy private plans because of their medical history.

Under the ACA, all new health insurance policies became guaranteed issue starting on January 1, 2014. As a result of this reform provision, there is no longer a pressing need for high-risk pools. HIPIOWA is still operational, however, and had 3,002 members as of Dec. 2013.

At a Jan. 2014 board meeting, there was discussion about the need to inform members of their options under the ACA and the fact that legislation would be needed for HIPIOWA to cease operations. At that same board meeting, it was noted that a large number of members had terminated their coverage in January, likely because they had found a better option in the newly guaranteed-issue individual market. But four new applications for HIPIOWA coverage had been received that month, and there are no immediate plans to terminate coverage.

Medicare in the state of Iowa

In 2015, Iowa Medicare enrollment was 571,596, about 18 percent of the state’s total population. 86 percent of the state’s Medicare beneficiaries qualified based on age and 14 percent as a result of disability.

At $7,727, annual per-enrollee Medicare spending in Iowa falls well below the nation’s average of $8,970. When it comes to total overall spending, Iowa ranks 32nd and spends $4.3 billion annually.

Medicare Advantage offers Iowans additional health benefits through private plans instead of Original Medicare. 15 percent of Iowa Medicare recipients chose a Medicare Advantage plan in 2015. Nationwide, that figure was 31 percent.

Iowans can also select stand-alone prescription drug plans called Medicare Part D. 63 percent of the state’s Medicare beneficiaries selected this Medicare prescription drug coverage in 2015, higher than the national average of 45 percent.

Iowa’s state-based reform legislation

Here’s what’s happening legislatively in Iowa with healthcare reform at the state level: