Iowans shopping for 2017 health insurance in the state’s exchange saw some changes from previous years: UnitedHealthcare exited Iowa’s exchange at the end of 2016, as was the case in 33 other states where they had previously offered exchange plans. Meanwhile, Wellmark Blue Cross and Blue Shield began selling individual coverage on Iowa’s exchange for the first time during the 2017 open enrollment period.
Despite president Trump’s promise to repeal and replace Obamacare, nothing has changed for 2017, and it’s unclear whether Republican lawmakers will ultimately have the votes to repeal and replace the ACA. 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 in terms of health care reform remains to be seen. You can follow the process in our Repeal & Replace section.
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 16th overall in 2016, up from 22nd in 2015. 22nd overall in 2015. The state’s low percentage of uninsured individuals bolstered Iowa’s placement in this ranking as well – for the lack of health insurance measure, Iowa placed 5th in both 2015 and 2016. According to U.S. Census data, only four states and the District of Columbia had lower uninsured rates than Iowa in 2015.
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, Gallup data indicated that Iowa’s uninsured rate had fallen 3.4 percentage points since 2013, from 9.7 to 6.3 percent. U.S. Census data put the uninsured rate even lower, at 5 percent in 2015.
Exchange rates, carriers for 2017 enrollment
Many exchanges saw carriers exit at the end of 2016, and Iowa was no exception with the loss of UnitedHealthcare. However, Iowa’s exchange includes new carriers for 2017 – Avera, and Wellmark Blue Cross and Blue Shield.
- 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 for 2017 ended on January 31, 2017. But people who experience a qualifying event can still enroll in 2017 coverage. Medicaid and CHIP enrollment are year-round, and Native Americans are eligible to enroll in private plans in the exchange year-round.
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.
Enrollment dropped by about 6 percent for 2017, with 51,573 people enrolled in private plans during open enrollment. Across all of the states that use HealthCare.gov there was an overall enrollment decline of about 5 percent. This is due in part to the uncertainty surrounding the future of the ACA, and the Trump Administration’s decision to scale back advertising and outreach in the final week of open enrollment.
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. Both Grassley and Ernst are opposed to the ACA, and both voted yes on the January 2017 budget resolution to begin the process of drafting reconciliation legislation to repeal the ACA.
In 2009, 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. The Grassley Amendment was included in the final bill; Congress and their staffers use the DC small business exchange to sign up for health insurance coverage (as opposed to the FEHBP plans that they used to have). 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. Three of the four remaining representatives are Republican, and one is a Democrat.
Within the Iowa legislature, Republicans control both chambers after taking over control of the Senate in the 2016 election and retaining control of 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 was the so-called “private option,” with Medicaid funding 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 expanded Iowa’s existing Medicaid program, which is called the Iowa Wellness Plan, to nonelderly adults with incomes up to 100 percent of FPL.
By 2015, however, Iowa had abandoned their private option waiver in favor of standard Medicaid expansion as called for in the ACA.
Iowa Medicaid/CHIP enrollment
Iowa is among the states that have accepted federal Medicaid expansion. The state initially received a waiver from CMS allowing it to take a slightly different approach and still receive federal funding.
In 2014 and 2015, Iowa’s alternative to ACA Medicaid expansion involved a program called the Iowa Health and Wellness Plan in which residents with household incomes below the federal poverty level were enrolled in a state-run health plan called the Iowa Wellness Plan; some paid modest premiums. Those with incomes of 101 to 138 percent of the federal poverty level purchased marketplace coverage through a program called the Iowa Marketplace Choice Plan and their premiums were 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.
In 2015, the state announed that they would switch to regular Medicaid expansion as outlined in the ACA. But they also obtained a waiver that allowed them to switch Medicaid enrollees to Medicaid managed care plans (most states were already using Medicaid managed care plans at that point). The switch to managed care was slated to happen as of January 2016, but was delayed until April 2016.
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 grew by 128,556 people from 2013 through December 2016, an increase of 26 percent.
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 operated in Iowa and Nebraska, received $112.6 million.
But 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, but membership has steadily declined since 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 were 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.
Medicare Advantage offers Iowans additional health benefits through private plans instead of Original Medicare. 17 percent of Iowa Medicare recipients chose a Medicare Advantage plan in 2016. 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: