Health insurance in Iowa
- Iowa operates a partnership exchange so residents use HealthCare.gov to enroll.
- Open enrollment for 2019 coverage in Iowa ended on December 15, but enrollment is still possible for Iowans with qualifying events.
- Short-term health plans are available in Iowa with initial plan terms up to 364 days.
- Two insurers are offering individual market plans for 2019.
- Premium subsidies in Iowa’s exchange are larger than they were in 2019, and some enrollees can get free plans.
- Farm Bureau’s “non-insurance” plans became available for healthy applicants to purchase as of November 2018.
- About 53,000 Iowans enrolled in 2018 coverage through the Iowa exchange, but total enrollment in ACA-compliant plans stood at 39,000 as of late 2018.
- Iowa has far more enrollees in grandmothered and grandfathered plans than in ACA-compliant plans.
- Iowa implemented ACA’s Medicaid expansion fully in 2015.
Iowa’s health marketplace
Iowa operates a partnership exchange with the federal government, which means that residents use HealthCare.gov to compare and purchase individual coverage, while the state is responsible for plan management, consumer assistance, and Medicaid eligibility determination.
For 2019 coverage, open enrollment ended on December 15, but enrollment is still possible for Iowans with qualifying events.
Two insurers – Medica and Wellmark– are offering 2019 individual health plans through Iowa’s exchanges. In 2018, Medica was the only insurer in the exchange, but Wellmark rejoined the exchange for 2019 and both insurers are offering plans statewide.
Premium subsidies are generally larger in Iowa for 2019 than they were in 2018, so some enrollees can get free bronze plans and gold plans that only cost a few dollars a month, after their premium subsidies are applied.
Iowa is permitting Farm Bureau to sell “non-insurance” (ie, not regulated as insurance by the state) health plans that are medically underwritten. Sales began in November 2018, although they will continue to be available year-round, as eligibility is based on an applicant’s medical history. This is how individual market health insurance worked in most states (including Iowa) prior to 2014.
Iowa enrollment in qualified health plans
During the open enrollment period for 2014 coverage, 29,163 people enrolled in a qualified health plan (QHP) through Iowa’s exchange. Although enrollment had grown by 2018, it was still just 17 percent of the estimated eligible population, which was well below the national average of 34 percent of eligible individuals enrolled. Iowa residents were far more likely (compared with the national average) to maintain grandmothered and grandfathered plans, which has resulted in lower-than-expected enrollment in the exchange.
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 was 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.
For 2018 coverage, enrollment grew by about 3 percent in Iowa’s exchange. But off-exchange enrollment in ACA-compliant plans plummeted, due to insurer exits from the market and much higher premiums for the remaining Medica plans, which can’t be offset by subsidies outside the exchange. As of November 2018, only about 39,000 people had ACA-compliant individual market coverage in Iowa, including on- and off-exchange enrollees. Virtually all of them had on-exchange coverage, as the off-exchange market (where subsidies are not available) has dwindled to almost nothing.
But far more people — about 68,000 — had individual market coverage under grandmothered and grandfathered plans. Iowa is fairly unique in terms of having such a large population on grandmothered and grandfathered plans, relative to their enrollment in ACA-compliant plans.
Read more about Iowa’s health insurance marketplace.
Iowa and Medicaid expansion
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, but that approach was abandoned in 2015 in favor of straight Medicaid expansion as called for in the ACA.
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 announced that it would switch to regular Medicaid expansion as outlined in the ACA. But it also obtained a waiver that allowed Iowa 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.
Initially, there were three insurers offering managed care plans in IA Health Link, but that dropped to two in last 2017, and one of them stopped enrolling new members for a few months in late 2017 and early 2018. By the spring of 2018, new enrollees were once again able to select from two managed care providers — Amerigroup and UnitedHealthcare
Forty-seven percent of Iowa’s 301,000 nonelderly uninsured residents were expected to 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 187,603 (38 percent) from 2013 through August 2018.
More information about Iowa Medicaid is available at the Iowa Department of Human Services.
Read more about Medicaid expansion in Iowa.
Short-term health insurance in Iowa
Iowa currently follows federal rules regarding short-term plans. That means plans for sale in the state can have initial durations of up to 364 days and renewals up to 36 months.
The state’s insurance division had proposed new rules for plans with durations longer than three months, but the state’s rules committee did not approve them.
Read more about short-term health insurance in Iowa.
Iowa health ratings
Iowa was ranked 6th place in the Commonwealth Fund’s 2017 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 & treatment, and equity. In 2019, Iowa’s ranking dropped slightly, to 8th place.
Iowa’s scorecard includes high rankings in terms of access to care, including a low percentage of residents who went without care due to cost. However, the uninsured rate has undoubtedly climbed over the last couple of years, as more than 20,000 people have left the individual insurance market in Iowa in 2018, due to skyrocketing premiums for people who don’t get premium subsidies. Some may have obtained coverage elsewhere, but many have likely joined the ranks of the uninsured.
America’s Health Rankings look at a somewhat different set of measures, and Iowa ranked 15th overall in 2017, up from 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 2017, the same as they scored 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 2016, and the uninsured rate was just 4.3 percent. But as noted above, that’s likely to have increased in 2018.
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 embraced health care reform for the most part, but crucially, the state allowed grandmothered plans to continue to exist in Iowa, and Wellmark didn’t join the exchange until 2017 (and then left at the end of 2017, although they’ve returned for 2019). In November 2018, the Iowa Insurance Division reported that about 39,000 people had ACA-compliant individual market plans in Iowa, while 68,000 people had coverage under grandmothered and grandfathered plans. This is far different from most states, where enrollment in ACA-compliant plans is far greater than enrollment in pre-ACA plans.
The continuation of Wellmark’s grandmothered plans, combined with the fact that Wellmark stayed out of the exchange in the early years, meant that Iowa’s ACA-compliant individual market has been less stable than it would otherwise have been. But 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 continued to drop through 2016, to a low of just 4.3 percent. The uninsured rate started to rise again in 2017, reaching 4.7 percent. But that’s still well below the national average of 8.7 percent.
Premium subsidies in the exchange and Medicaid expansion have made coverage affordable and realistic for many Iowans, but people who purchase their own coverage and aren’t eligible for premium subsidies often find that coverage is entirely unaffordable. Iowa had the dubious distinction of having the nation’s highest average pre-subsidy premiums in 2018: A staggering $988/month per enrollee, versus a national average of $597/month.
Premium subsidies are correspondingly huge in Iowa, but there’s no relief for people who aren’t eligible for subsidies. That’s a big part of the reason the state has begun to allow Farm Bureau to sell medically underwritten plans that aren’t regulated by the state as insurance and are thus exempt from ACA rules. The idea is to allow people to have access to cheaper plans, but this is only a solution for people who are healthy. Those who aren’t can’t get through the medical underwriting, and are stuck in the ACA-compliant market. Average ACA-compliant premiums are a little lower for 2019, but still well out of reach for an average enrollee with income just a little too high for premium subsidies.
Iowa and the Affordable Care Act
Iowa’s Senators, Chuck Grassley and Joni Ernst, are both Republicans and both are opposed to the ACA. Sen. Both voted yes on the January 2017 budget resolution to begin the process of drafting reconciliation legislation to repeal the ACA. They also both voted yes on all three measures that the Senate considered in 2017 to repeal the ACA (the BCRA, “skinny repeal” and the Obamacare Repeal Reconciliation Act), although all three of those measures failed to pass.
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.
As of 2018, three of Iowa’s four US House representatives are Republican, and one is a Democrat. But that’s changing significantly after the 2018 election. As of 2019, Iowa’s House delegation will include three Democrats and just one Republican. Dave Loebsack, the incumbent Democrat, won re-election. And Abby Finkenauer (Dubuque) and Cindy Axne (West Des Moines) each defeated incumbent Republicans.
So as of 2019, Iowa’s Congressional delegation will be split 50-50, with three Democrats (all in the House) and three Republicans (two in the Senate and one in the House).
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. The governor is also a Republican, and this GOP trifecta remains in place after the 2018 elections.
Former Gov. Terry Branstad, a Republican, was 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.
Current Gov. Kim Reynolds, elected in 2016, is also a Republican, and supported the Graham-Cassidy bill to repeal the ACA in 2017 (that measure did not pass). Reynolds expressed disappointment when the state was forced to withdraw its 1332 waiver proposal that would have radically changed the ACA within Iowa. Reynolds won re-election in 2018.
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. But the state switched to a managed care program (IA Health Link) for most Medicaid enrollees as of 2016.
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. It was the first of the nation’s CO-OPs to fail, but almost all of the others failed in 2015 and 2016, leaving just four CO-OPs operational as of 2018.
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 a 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.
The program had 3,002 members as of Dec. 2013, and just 391 members as of September 2016. Operating costs for HIPIOWA were $11.9 million in 2016. Of that amount, about 30 percent was covered by members’ premiums, and the rest was covered by an assessment on insurance companies operating in Iowa. Premiums are based on 150 percent of the average premiums charged by the top five insurers in the individual market in the state, although Medica is the only individual market insurer offering plans in 2018. HIPIOWA premiums for 2018 are available here.
Medicare in the state of Iowa
In 2018, Iowa Medicare enrollment was 611,497, about 19 percent of the state’s total population. 87 percent of the state’s Medicare beneficiaries qualified based on age and 14 percent as a result of disability.
At $8,185 in per-enrollee spending in 2016 (for those enrolled in Original Medicare), annual per-enrollee Medicare spending in Iowa falls well below the nation’s average of $9,533.
Medicare Advantage offers Iowans additional health benefits through private plans instead of Original Medicare. 18 percent of Iowa Medicare recipients chose a Medicare Advantage plan in 2017. Nationwide, that figure was 33 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 (this makes sense, given the relatively small percentage of people enrolled in Medicare Advantage; Medigap plans are used by people who don’t have Medicare Advantage, which is a larger than average percentage of Iowa’s Medicare population).
Iowa’s state-based reform legislation
Scroll to the bottom of the page to see what’s happening legislatively in Iowa with healthcare reform at the state level
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.