Depending on the ranking factors, Iowa is a state with top-10 to average health ratings. It also boasts a relatively low rate of uninsured, which has been significantly helped by Medicaid expansion.
This brief summary compares Iowa to the rest of the states in terms of health status, uninsured rates, and approach to health care reform. It is a helpful place to start gathering information if you are considering a move to Iowa or just want to compare healthcare and health across states.
Iowa health ratings
Iowa rounds out the top 10 in the Commonwealth Fund’s 2014 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. Since 2009, Iowa’s overall health ranking fell two positions. Review Iowa’s Scorecard to learn more about Iowa’s State Health System Ranking.
America’s Health Rankings look at a somewhat different set of measures, and Iowa ranked 24th overall in 2014 – slipping from 18th in 2013. This may have been impacted by an increase in smoking and pertussis in the past year – pertussis increased by 636 percent. Iowa scores well for having high rates of immunization coverage among children and high school graduation, along with a low rate of drug deaths. Public health challenges in Iowa include a high prevalence of binge drinking and infectious disease, as well as limited availability of primary care doctors.
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.
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.
Obamacare’s impact in Iowa
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.
Iowa, along with Kansas and Virginia, saw an increase in its uninsured rate between 2013 and mid-2014. Iowa’s rate increased 0.6 points – from 9.7 percent to 10.3 percent. Nationally, the uninsured rate dropped 4.6 points to 13.4 percent between 2013 and mid-2014.
By mid-2015, Iowa’s uninsured rate had dropped to 5 percent, remaining well below the national average of 11.7 percent.
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 2015 open enrollment period, 45,162 Iowans selected a QHP. By June 30, that number had dropped to 39,347 after some enrollees failed to make premium payments or cancelled their coverage. Of these remaining enrollees, 85.5 percent had selected a plan with an advanced premium tax credit and 49 percent were receiving cost-sharing reductions.
Iowa’s partnership-exchange added four carriers to its exchange for the 2016 coverage period, bringing the total to five companies offering individual plans through the marketplace:
- Avera Health Plans
- Gunderson Health plan
- UnitedHealthcare of the Midlands
Previously, Coventry and CoOportunity Health, a CO-OP started with ACA funds, sold exchange-based coverage in Iowa as well as Nebraska. However, CoOportunity stopped selling plans in late December 2014 and is among the nine failed CO-OPs.
Wellmark Blue Cross and Blue Shiled will join Iowa’s exchange for 2016. The largest carrier in Iowa’s individual market has sold only off-exchange coverage.
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 21 percent from pre-ACA to July 2015.
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 folded in late 2014 and no longer sells plans in Iowa or Nebraska
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.
Iowa’s state-based reform legislation
Here’s what’s happening legislatively in Iowa with healthcare reform at the state level:
Iowa lawmakers have introduced state legislation to convert Iowa’s partnership exchange to a state-run exchange; however, these bills have never advanced.
Medicare in the state of Iowa
In 209, Iowa Medicare enrollment was 17.3 percent of the state’s total population – 16 percent of the U.S. population is enrolled in the program. Of Iowa Medicare beneficiaries, 85 percent qualify based on age and 15 percent as a result of disability.
Medicare spends about $8,461 per enrollee in Iowa each year. There are about 20 states that spend $20,000 or more. 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. Fourteen percent of Iowa Medicare recipients chose a Medicare Advantage plan in 2014. Nationwide, that figure was 30 percent.
Iowans can also select stand-alone prescription drug plans called Medicare Part D. Forty-seven percent of the state’s Medicare beneficiaries selected this Medicare prescription drug coverage in 2014, which is consistent with the national average.