Highlights and updates
- Looking ahead to 2019: Rate hikes expected to be small, CSR broad load expected to continue
- 2018 enrollment 95% of last year’s total, despite shorter enrollment period
- Humana’s exit leaves one insurer for 2018
- 47.3% average rate hike for 2018, including cost of CSR added to all premiums
- Highest percentage of CSR recipients in the country
Mississippi exchange overview
Mississippi uses the federally run exchange for individual market plans, so residents who buy their own health insurance enroll through Healthcare.gov. But the state runs One Mississippi, which is the SHOP exchange for small businesses.
Blue Cross Blue Shield of Mississippi has a strong presence in the Mississippi individual market, but they do not participate in the exchange. Magnolia/Ambetter is offering offer plans statewide in the Mississippi exchange in 2018, and is the only insurer offering exchange coverage after Humana exited at the end of 2017.
Looking ahead to 2019
In April 2018, the Mississippi Business Journal reported that Mississippi Insurance Commissioner, Mike Cheney, expects Ambetter/Magnolia to remain in the exchange in 2019 statewide. Cheney also expects rate increases for 2019 to be very modest, no more than 4 or 5 percent.
Cheney also indicated that the state might continue to have Ambetter add the cost of cost-sharing reductions (CSR) to premiums for plans at all metal levels, rather than just to silver plan premiums. As discussed below, Mississippi is one of just five states where the cost of CSR was added to premiums at all metal levels for 2018, after the Trump Administration cut off federal funding for CSR. And some of those states have already said that they’ll switch to adding the cost of CSR only to silver plan premiums for 2019. But Commissioner Cheney appears to favor the approach that the state used for 2018, saying that it’s fairer for everyone.
The Mississippi Insurance Department confirmed in early May that they were considering the issue and would provide guidance for Ambetter with regards to CSR loading for 2019 (Ambetter is expected to continue to be the only insurer offering coverage in the Mississippi exchange in 2019). At that point, the Insurance Department indicated that the general expectation was that the CSR approach would be similar to this year’s, but the Department clarified that they were still early in the process of deciding on a strategy for 2019. By late June, the Mississippi Insurance Department noted that they were still leaning towards having Ambetter add the cost of CSR to plans at all metal levels, but that nothing would be final until rates are filed in July.
When the cost of CSR is added to silver plan premiums, it results in much larger premium subsidies for anyone who get a subsidy. And people who don’t get a subsidy can either enroll in a bronze or gold plan (without the cost of CSR added to the premiums), or, if off-exchange-only plans are available, those can also be offered without the cost of CSR added in, even at the silver plan level. Adding the cost of CSR to only silver plan premiums is considered the approach that’s most beneficial to the most people.
2018 enrollment: Nearly 95% of last year’s enrollment, despite shorter enrollment period
The federal government reported that 83,649 people enrolled in coverage through the Mississippi exchange during the open enrollment period for 2018 coverage. That amounts to nearly 95 percent of 2017’s total, when 88,483 people enrolled. Nationwide, there was a similar drop in enrollment across all states that use HealthCare.gov, with enrollment in those states about 5 percent lower than it had been in 2017. The small reduction in enrollment came despite the fact that open enrollment was half as long for 2018, and despite the fact that the Trump Administration slashed funding for enrollment assistance and exchange marketing in the weeks leading up to open enrollment.
Open enrollment for 2018 coverage ended on December 15, 2017, but HHS announced in late September that residents of areas hit by 2017 hurricanes would have a special enrollment period (SEP) to sign up for coverage if they were in an area that FEMA designated as eligible for “individual assistance” or “public assistance.”
The hurricane special enrollment period was initially scheduled to run through December 31, 2017, but was later extended until March 31, 2018. There were seven counties in Mississippi (George, Hancock, Harrison, Jackson, Pearl River, Stone, and Greene County, which is on this map for disaster designation DR-3450) where residents had a special enrollment period due to Hurricane Nate.
And there was also a special enrollment period, through March 1, 2018, for people who involuntarily lost their 2017 coverage at the end of the year. This applied to anyone who had Humana coverage in Mississippi in 2017, since the insurer terminated those plans at the end of 2017.
Humana members who had coverage through the exchange were automatically mapped to a plan from Ambetter/Magnolia if they didn’t return to the exchange to actively pick a new plan. But Humana members with off-exchange coverage were uninsured as of January 1 if they didn’t actively pick a new plan by December 31. Those individuals had until March 1 to select a replacement plan.
One insurer offering plans for 2018
Two carriers offered plans in the Mississippi exchange for 2017: Magnolia/Ambetter offered coverage in all 82 counties. Humana offered coverage in 32 counties. Humana exited the individual market at the end of 2017, however, which means Mississippi has just one insurer in the exchange in 2018.
In April 2017, Centene (Magnolia/Ambetter in Mississippi) announced that they were planning to remain in the exchanges in 2018 in the states where they were already participating. According to Centene Chairman and CEO, Michael Neidorff, “Centene’s exchange experience continues to be favorable, and we are achieving margins at the higher end of our targeted range.”
Rate changes for 2018: Magnolia added the cost of CSR to premiums for all plans
Enrollees who had 2017 coverage with Humana needed to switch to a plan from Magnolia/Ambetter for 2018.
Magnolia/Ambetter initially proposed average rate increases of 18 percent for their standard individual market plans, and 21.4 percent for their plans that include adult dental and vision coverage. The rate filing was heavily redacted, but it did note that the proposed rates were based on the assumption that the federal government would continue to fund cost-sharing reductions (CSR), and that larger premium increases would be necessary if CSR funding were to end.
Ultimately, the Trump Administration did eliminate federal funding for CSR in October 2017, but Ambetter/Magnolia had already filed revised rates over the summer with the assumption that CSR funding would end. The revised rate proposal, which was approved by regulators, called for an average increase of 47.3 percent — more than two and a half times as large as the originally proposed increase.
The dramatic increase in the revised rates is because CSR is a larger expense in Mississippi than it is in other states. 80 percent of Mississippi exchange enrollees are receiving cost-sharing reductions — the highest percentage in the nation, and well above the national average of 57 percent. Eligible enrollees are continuing to receive CSR benefits in 2018, but the federal government is no longer reimbursing insurers for providing that benefit. So insurers in nearly every state added the cost of CSR to their premiums for 2018. In most states, the cost of CSR was added only to silver plans, which is beneficial for most enrollees, since premium subsidies are based on the cost of a silver plan, and larger silver plan premiums mean larger subsidies.
But in Mississippi, Ambetter/Magnolia’s revised rate filing notes that the cost of CSR was added to the premiums of all ACA-compliant plans, including those sold outside the exchange. Only a few other states took this “broad load” approach (Colorado, Delaware, Indiana, and West Virginia). Premium subsidies are much larger in Mississippi for 2018 than they were for 2017, since premiums increased by an average of 47.3 percent. But since plans at all metal levels are sharing the burden of the cost of CSR, the free or ultra-low-cost bronze plan premiums (after subsidies) that we’re seeing in some areas of the country are not available in Mississippi.
Mississippi residents who do not qualify for premium subsidies (ie, their income is above 400 percent of the poverty level on this chart, or they’re impacted by the family glitch or the Medicaid coverage gap) might have found that a Blue Cross Blue Shield of Mississippi plan outside the exchange may be available at a lower price than Magnolia (BCBSMS didn’t add the cost of CSR to their plans, since they don’t incur any costs for CSR because their plans are not available on the exchange). Magnolia’s ACA-compliant plans include the cost of CSR in the premiums regardless of whether they’re sold on or off-exchange.
Mississippi’s Insurance Commissioner, Mike Chaney, noted in mid-August that he didn’t think that CSR funding would continue, and that ultimately ended up being a prescient call, as CSR funding was eliminated two months later. Chaney’s office had initially directed Magnolia/Ambetter to file rates based on the assumption that cost-sharing reduction funding would continue, but noted that they’d be able to file new rates if CSR funding was not allocated (the revised were ultimately approved, based on the assumption that CSR funding would not continue).
2017 enrollment nearly 19 percent lower than 2016
88,483 people enrolled in private individual market plans through the Mississippi exchange (via HealthCare.gov) during the 2017 open enrollment period, which ended January 31, 2017. For perspective, 108,672 people enrolled during the 2016 open enrollment period, so enrollment for 2017 was almost 19 percent lower.
But a significant number of the 2016 enrollees didn’t pay for their coverage or dropped it early in the year (about double the nationwide percentage). By March 2016, total effectuated enrollment in individual market plans through the Mississippi exchange stood at 77,747.
Health insurance in Mississippi under the Trump Administration
In December 2016, HHS reported that 161,000 people had gained coverage in Mississippi from 2010 to 2015, as a result of the ACA. The Center for American Progress, a left-leaning organization, estimates that 289,500 people in Mississippi would have lost coverage under the American Health Care Act (AHCA) if it had passed (they used the CBO’s analysis, and broke it down by congressional district). The AHCA did pass the House, but three different versions of the bill failed in the Senate in late July, and the Graham-Cassidy Amendment, a last-ditch effort to repeal the ACA, was pulled in September when it didn’t have enough GOP support in the Senate.
Despite the prospect of those coverage losses, Mississippi Governor, Phil Bryant, endorsed the American Health Care Act. And while ACA repeal has thus far failed in Congress, it’s still a possibility in future legislative sessions. And the tax bill that the Senate passed in early December (in the middle of the night, with a bill that had been finalized just hours earlier and which still had handwritten revisions in the margins) calls for the elimination of the ACA’s individual mandate, which would significantly weaken the ACA if it’s eventually enacted.
Mississippi is one of the least-healthy states in the country. It’s one of 11 states where three of every ten non-elderly adults residents has a pre-existing condition that would make it difficult or impossible to get new individual market health insurance if the ACA and its guaranteed-issue provision were to be repealed. The AHCA called for pre-existing condition protections to technically remain in place, but lawmakers added an amendment in late April that would have given states the option to allow insurers to charge higher premiums when people have pre-existing conditions and a gap in coverage, and to also offer plans that don’t cover the ACA’s essential health benefits. Those changes would have essentially gutted the ACA’s protections for people with pre-existing conditions, although if a bill like that were to be implemented it would be up to the state to decide whether to seek a waiver.
Because Mississippi hasn’t accepted federal funding under the ACA to expand Medicaid, the impact of ACA repeal wouldn’t be as significant as it would be in other states. That’s because Mississippi’s poorest residents are already suffering in the coverage gap, unable to realistically obtain any sort of health insurance. Repealing the ACA won’t change their situation, but it will continue to be dire.
However, it could end up being worse than just keeping the status quo in Mississippi with regards to Medicaid. Republicans in Congress have pushed to switch Medicaid from its current open-ended federal matching to a per-capita allotment system of federal funding (this was included in the AHCA and the Senate bills that failed in July). A move to a per-capita or block grant system would result in less federal funding over the long run, and some of the almost 680,000 people who are already covered by Medicaid in Mississippi might be in danger of losing their coverage if these proposals were to be implemented.
Mississippi residents already struggle with the cost of care, and 40 percent of the under-65 population in state owes money to hospitals or doctors.
UnitedHealthcare exited individual market, Humana following them out the door
Mississippi is one of 31 states where UnitedHealthcare exited the individual health insurance market at the end of 2016. That left Humana and Magnolia/Ambetter as the only carriers offering plans in the exchange.
Although Humana exited the exchanges in several states at the end of 2016, they stayed in Mississippi. That decision was short-lived, however, as Humana announced in February 2017 that they would no longer offer individual market plans in any state after 2017.
United was the only carrier in the Mississippi exchange that offered coverage in all 82 counties in the state in 2016, although Magnolia has expanded statewide in 2017. For 2018, Magnolia is currently the only insurer slated to offer coverage in Mississippi’s exchange.
2017 rates and carriers
Two carriers are offering plans in the Mississippi exchange in 2017. In late August 2016, Mississippi Insurance Commissioner Mike Chaney reported that a third health insurer had proposed joining the exchange state-wide, but had been rejected by HHS due to “lack of an adequate network and specialists in each county.”
In 2016, Humana offered exchange plans in 46 counties in Mississippi, but but has reduced their coverage area to 32 counties in 2017. Magnolia/Ambetter offered plans in 52 counties in 2016, but has expanded state-wide for 2017. So 32 counties have two carrier options, while 50 counties have just one carrier in the exchange in 2017.
The following rate increases were proposed and approved for the Mississippi exchange in 2017, although they apply to unsubsidized premiums, and subsidies offset the rate hikes as long as enrollees were willing to be flexible about possibly needing to switch plans in order to get the best rate (94 percent of Mississippi exchange enrollees received subsidies in 2016 — the highest percentage in the country):
- Humana: 43 percent (Humana had about 13,000 exchange enrollees in 2016)
- Magnolia/Ambetter: 7 percent (Magnolia had about 40,000 exchange enrollees in 2016)
Blue Cross Blue Shield of Mississippi is a major carrier in the state, but they have thus far not participated in the exchange (more details below). They had an average rate increase of 16.12 percent for 2017, for their off-exchange plans. At ACA Signups, Charles Gaba calculated an average rate increase of 15.82 percent for the two exchange carriers, which is very similar to the rate hike for BCBSMS off-exchange plans.
During the 2016 open enrollment period, private plan enrollment in Mississippi’s exchange reached 108,672 people. This included renewals and new enrollees, and also accounted for early attrition through February 1. For perspective, 103,600 people enrolled in coverage through the Mississippi exchange during the 2015 open enrollment period.
Effectuated enrollment stood at 77,747 by March 31, 2016. That’s an attrition rate of 28 percent, which is more than double the national average rate of attrition during the first quarter.
Effectuated enrollment in Mississippi stood at 80,011 on March 31, 2015. Nationwide, effectuated enrollment was almost 9 percent higher in March 2016 than it had been in March 2015, but there are a handful of states where enrollment declined, including Mississippi (to clarify, enrollment at the end of the 2016 open enrollment period was higher in Mississippi than it had been at the end of the 2015 open enrollment period, but a larger number of people cancelled or didn’t pay for their coverage in 2016, resulting in a lower effectuated enrollment by March).
At the end of open enrollment, 90 percent of Mississippi exchange enrollees were receiving premium subsidies. By the end of March, however, 94.2 percent of the enrollees with effectuated coverage were receiving premium subsidies; the people who weren’t receiving subsidies dropped their coverage (or never paid for it in the first place) at a higher rate than those who were receiving subsidies. The average premium subsidy as of March was $306 per month in Mississippi.
Open enrollment for 2016 is now over. You can still enroll in a plan for 2016 if you experience a qualifying event, and Native Americans can enroll year-round. In addition, Medicaid and CHIP enrollment continue year-round. Open enrollment for 2017 is tentatively scheduled to begin November 1, 2016.
Legislation introduced to block Obamacare
In February 2016, Republican State Senator Michael D. Watson Jr. introduced SB2543, which would effectively block all Mississippi agencies and employees from having any part in enforcement or implementation of the ACA. The legislation would also prohibit the state from creating a state-based exchange or expanding Medicaid. Neither of those have been done in Mississippi, but legislation blocking them would make it more difficult for a future governor to set a new course for Mississippi.
SB2543 was referred to the Senate’s Medicaid committee as soon as it was introduced, and ultimately died in committee. The legislation did not include any language in terms of how Obamacare should be replaced or any sort of alternate structure to make health insurance affordable and accessible to the people of Mississippi; it would merely have blocked the state from taking any part in the continued implementation of the law.
2016 rates: lower than they were in 2015
Once all of the plan selections for 2016 had been finalized, 90 percent of Mississippi exchange enrollees qualified for premium subsidies. Their average pre-subsidy premium is $388 per month (a little lower than the $396/month average across all states that use Healthcare.gov), and their average after-subsidy premium is $91/month (the average after-subsidy premium across all Healthcare.gov states is $106/month).
In 2015, 93 percent of Mississippi exchange enrollees qualified for subsidies; their average pre-subsidy premium was $405/month, and their average after-subsidy premium was $52/month.
So while average pre-subsidy premiums declined in Mississippi from 2015 to 2016, average after-subsidy premiums increased. That could be a result of more people with higher average incomes enrolling in 2016, or it could be a result of enrollees selecting more robust – and more expensive – coverage.
Three carriers offer plans through the Mississippi exchange: Humana, Ambetter/Magnolia, and UnitedHealthcare. According to the Mississippi Business Journal, average rate changes for 2016 were:
- Magnolia Health/Ambetter: average decrease of 2.9 percent (18,000 enrollees as of November 1, 2015)
- Humana: average decrease of 0.2 percent (16,915 enrollees as of November 1)
- UnitedHealthCare: average increase of 6.6 percent (26,000 enrollees as of November 1)
But only Humana’s rate filing (which was approved as-proposed) was displayed on Healthcare.gov’s rate review tool. For 2016, average rate changes for Humana plans in the Mississippi exchange ranged from a 2.5 percent decrease to a 2.4 percent increase. Rate filings for Magnolia/Ambetter and UnitedHealthcare don’t show up on Healthcare.gov’s rate review tool, even after the data was adjusted to show all rates, as opposed to only rate increases of ten percent or more (as was the case from June through October).
The Mississippi Business Journal obtained the above enrollment numbers from the Mississippi Insurance Department. They indicate significant attrition from July 2015 through October, as the exchange had 73,223 people with in-force private plan coverage at the end of June, and the total as of November 1 was only about 61,000.
Based on the enrollment as of November 1, the weighted average rate change in the Mississippi exchange was only about 1.9 percent for 2016 – and that came on the heels of an average rate decrease in 2015.
Statewide, the average benchmark (second-lowest-cost Silver) plan premium is 8.2 percent less expensive in 2016 than it was in 2015. Out of the 37 states that used Healthcare.gov in 2015, only four have lower average benchmark premiums in 2016, and Mississippi is one of them. In Jackson, the average benchmark premium for a 30 year old decreased by 9.2 percent – from $305/month to $277/month. Those are unsubsidized premiums; for people who qualify for subsidies, the after-subsidy monthly premium is lower. And as of mid-2015, more than 95 percent of Mississippi’s exchange enrollees were receiving premium subsidies – the highest percentage in the nation (unsurprising, since subsidy eligibility is based on income, and Mississippi has the lowest average household income in the US).
The benchmark plan isn’t necessarily the same plan from one year to the next, so the changes in benchmark premiums don’t really tell us much about how premiums on specific plans are changing. But premium subsidies are tied to benchmark premiums, so average subsidies in Mississippi are lower in 2016 than they were in 2015, highlighting the importance of shopping around during open enrollment as opposed to letting plans auto-renew.
Off-exchange carriers — 2016
Outside the exchange, Blue Cross Blue Shield of Mississippi requested an average rate increase of more than 25 percent, but their final approved rate increase was 16.5 percent. Also off-exchange, Enterprise Live and Freedom Life both ended up with average rate increases of 9.9 percent. UnitedHealthcare was also listed in the rate review tool with a rate increase of 21.1 percent, but only for off-exchange plans that have a total of 513 enrollees.
Blue Cross Blue Shield had the lion’s share of the market in Mississippi prior to 2014 (roughly 80 percent), but they have not participated in the exchange. Their substantial rate increase for 2016 may have been a driving factor in the increase in enrollments for the Mississippi exchange, since premium subsidies are only available through the exchange. For a 50 year-old non-smoker in Hinds County (Jackson), the cheapest plan available from BCBS of Mississippi was $436/month in 2016. The plan had a $5,000 deductible, $6,500 maximum out-of-pocket, and no subsidies were available since it was only sold outside the exchange.
That same applicant – with an annual income of $40,000 and no dependents – could get a plan through the exchange in 2016 for $285/month with a $6,800 deductible. For a plan with a $5,500 deductible, $6,500 maximum out-of-pocket, and copays for office visits and prescriptions (which the BCBS plan did not offer), the price was $330/month through the exchange. And it’s important to note that if the person’s income was lower than $40,000, the premium was lower as well. As opposed to a plan outside the exchange, which doesn’t include any premium relief, regardless of how little the applicant earns.
According to an analysis published by The Commonwealth Fund, average premiums in Mississippi were 19 percent lower in 2015 than in 2014. The weighted analysis looked at premium amounts, differences in premiums between urban/suburban/rural areas within states, and insurer participation. But a similar analysis from PricewaterhouseCoopers found an average rate decrease of 9.3 percent from 2014 to 2015 – still a significant rate decrease, but not as substantial as the Commonwealth Fund’s result.
In 2014, Mississippi’s pre-subsidy average premium was $438/month – the fifth-highest among the 36 states that used Healthcare.gov.
2015 enrollment data
About 103,600 Mississippi residents selected health plans through HealthCare.gov during 2015 open enrollment. While that’s 42,000 more signups than during 2014 open enrollment, it is still just 37 percent of those eligible to enroll according to Kaiser Family Foundation estimates.
And attrition was particularly high in Mississippi in 2015. By the end of March, just 80,011 people had effectuated exchange coverage in place, and that had dropped to 73,223 by the end of June. That’s 71 percent of initial enrollments; nationwide, 85 percent of enrollees had effectuated coverage by the end of June, so Mississippi was well below average in that regard.
The Kaiser Family Foundation estimated that 28 percent of Mississippi’s eligible population had enrolled in coverage through the exchange by the end of March – a little lower than the national average of 36 percent, but higher than twelve other states.
Mississippi’s exchange population tended to be relatively low-income, with 89 percent having incomes under 250 percent of the poverty level. Those enrollees were eligible for cost-sharing subsidies, and 85 percent of them selected silver plans, meaning that they obtained coverage that included the cost-sharing subsidies (cost sharing subsidies are only available if you purchase a silver plan). In all, more than 77 percent of the 73,223 people who had coverage at the end of June were enrolled in plans that included cost-sharing subsidies.
Participating insurers – a timeline
UnitedHealthcare joined the Mississippi marketplace for 2015, bringing the total number of insurers on the individual exchange to three in the state. Humana and Magnolia Health Plan were part of the marketplace in 2014 and returned for 2015. All three insurers continued to participate in 2016, but for 2017, United has left the state, and Mississippi’s exchange is back to just Humana and Magnolia.
United’s entry brought welcome competition to Mississippi in 2015 and 2016. In 2014, residents of some counties had access to just a single insurer’s plans through the exchange. In 2011 and 2012 – back when Mississippi was in the process of creating it’s own State-run exchange – Blue Cross Blue Shield of Mississippi (which had more than 80 percent of the market share in Mississippi) had told Insurance Commissioner Mike Chaney that they would participate in the exchange. But due to conflicts among the state’s leadership, HHS rejected Mississippi’s exchange application (more details below), and at that point, BCBS of Mississippi pulled out.
That left Humana and Magnolia Health Plan as the only two carriers for 2014. But leading up to the federally-run exchange’s fall 2013 debut, Mississippi had a problem. The two carriers had selected the counties in which they wanted to operate, and 36 of the state’s 82 counties had no participating carriers at all. Humana ultimately decided to go ahead and offer coverage state-wide in 2014, but only four of the state’s counties had plans available from both carriers in 2014.
In 2015, when UnitedHealthcare joined the exchange, every county in Mississippi had at least two participating carriers, and 13 counties had coverage options available from all three carriers.
For 2016, Humana’s plans were not available in all areas of the state. But UnitedHealthcare expanded to offer coverage state-wide, so every county in the state still had at least two carriers from which to choose, and 32 counties had plans available from all three carriers.
In 2017, there were 32 counties that had two carriers (Humana and Magnolia), and 50 counties where the only carrier offering plans in the exchange was Magnolia.
For 2018, Magnolia is the only insurer participating in the Mississippi exchange.
King v. Burwell: Chaney had a plan in case SCOTUS ruling had been different
In June 2015, the Supreme Court ruled that subsidies are legal in every state, regardless of whether the exchange is run by the state or the federal government. That was great news for Mississippi residents, insurers, and healthcare providers; 95 percent of the people who are enrolled in private plans through the Mississippi exchange are receiving premium subsidies.
The Mississippi Business Journal reported that Insurance Commissioner Mike Chaney had a contingency plan to protect subsidies for state residents if the Supreme Court had eliminated them. Rather than creating a state-run exchange, “it would entail funneling federal money through the existing Mississippi Comprehensive Health Insurance Risk Pool Association to private insurers.” But the Journal noted that the plan would be contingent upon approval from the Governor, Lt. Governor, and the Speaker of the House (Chaney had worked to establish a state-run exchange back in 2011 – 2012, but was foiled by the Governor and the legislature).
Politico also reported that the state had a back-up plan, but they explained that Chaney wanted “Mississippi to use existing private health insurance exchanges to enroll people, qualifying for subsidies while avoiding the federal government’s technology.”
The Mississippi Comprehensive Health Insurance Risk Pool is the state-run high-risk pool that pre-dates the ACA. Private health insurance exchanges are not run by the government – rather, they’re set up by health insurance carriers, brokers and benefits managers to provide a platform for people to shop for coverage. Mississippi’s Insurance Department did not return phone calls to clear up the discrepancy, but it did appear that in early 2015, the state was working on a back-up plan that could have been put in place if the Supreme Court had eliminated subsidies. In many states, there were no such contingency plans, and enrollees would have had few options but to terminate their coverage if subsidies had been eliminated.
The University of Mississippi Medical Center got the majority of the Navigator grants that were awarded by the federal government in August 2013 to fund enrollment efforts in Mississippi for 2014. Of $1.1 million that Mississippi received, $832,000 went to UMMC. Oak Hill Baptist Church got the remaining Navigator funding that year, but by 2015, Oak Hill had become the primary Navigator grant recipient in Mississippi, receiving $547,867 to assist with enrollment efforts for 2016 (another $415,224 was awarded to the University of Southern Mississippi in September 2015).
Small business marketplace
Mississippi began operating its own Small Business Health Options Program (SHOP) exchange — which is called One, Mississippi — in May 2014. One, Mississippi is open to employers with 50 or fewer full-time employees.
How many Mississippians enrolled in 2014?
Mississippi was 33rd in terms of the percentage of eligible individuals who enrolled in a qualified health plan (QHP) through the marketplace in 2014. According to the Kaiser Family Foundation, 61,494 people signed up for health plans, and another 13,779 people qualified for either Medicaid or the Children’s Health Insurance Program (CHIP) under existing eligibility criteria.
Among Mississippi residents enrolling in QHPs, 94 percent qualified for financial assistance, compared to 85 percent nationally. A report released in June by the U.S. Department of Health and Human Services showed the average monthly premium, after tax credits, for Mississippi consumers was just $23. That’s the lowest average in the nation.
Eight percent of Mississippi residents selected a bronze plan (20 percent nationally), 79 percent selected a silver plan (65 percent nationally), 5 percent selected a gold plan (9 percent nationally), 7 percent selected a platinum plan (5 percent nationally) and 1 percent selected a catastrophic plan (2 percent nationally). Thirty-one percent of Mississippi enrollees were between the ages of 18 and 34.
40,000 of the state’s 61,000 exchange enrollees in 2014 selected a plan from Humana (in all but four counties, Humana was the only carrier available in 2014).
Exchange creation battle in Mississippi
State Commissioner of Insurance Mike Chaney clashed with two governors as to what form a health insurance exchange should take in Mississippi. Chaney, current Gov. Phil Bryant, and former Gov. Haley Barbour are all Republicans and on record as opposing the Affordable Care Act. However, Chaney consistently maintained that the state would be better off running its own exchange.
Chaney pushed hard for a state-run exchange. In 2011, he announced that the Mississippi Comprehensive Health Insurance Risk Pool Association would operate an exchange. The Risk Pool Association developed a plan in which the exchange would be developed in four phases, with work outsourced.
Early exchange planning was carried out by the board of directors of the Risk Pool Association and an advisory board appointed by Chaney. The Risk Pool Association, the advisory board, and the insurance department continued working throughout 2012, and in November, Chaney notified the U.S. Department of Health and Human Services (HHS) that Mississippi intended to implement a state-run exchange. However, Bryant told HHS in December 2012 that Chaney had overstepped his authority.
It was also in 2012 that anti-ACA influences from outside Mississippi (including the Koch Brothers and the Cato Institute) began pressuring Cheney to give up his push for a state-run exchange. But OneMississippi, the state-run exchange that Cheney created, opened in October 2012, a year before the ACA-sanctioned exchanges nationwide. OneMississippi didn’t have any premium subsidies (those wouldn’t be available until the first ACA open enrollment period began in October 2013), but it did have coverage for sale. The task at that point switched to obtaining federal approval to have OneMississippi be the state’s official ACA exchange.
But ultimately, Governor Bryant’s opposition to the exchange was its downfall. In February 2013, HHS rejected Mississippi’s exchange blueprint, telling Chaney that it simply wouldn’t work without the Governor’s support. The exchange would have needed to work with the Mississippi Medicaid program – overseen by a Bryant appointee – and there were too many concerns that Bryant would be able to derail the exchange via funding or hiring decisions. The federal government said at the time that they “didn’t feel that [they] should get involved in a battle between two elected state officials.”
Mississippi was the only state whose exchange blueprint was rejected by the federal government, and in February 2013, OneMississippi shut down. The federal government runs the individual exchange in Mississippi, but OneMississippi opened back up as the state-run SHOP exchange in the spring of 2014, offering health insurance options for small businesses.
Several factors constrain marketplace enrollment in the Magnolia State. Political opposition to the Affordable Care Act is very strong, many residents are distrustful of government assistance, and outreach efforts are limited. In a state with a 22 percent poverty rate, many people find premiums too expensive — even with subsidies factored in. And the Medicaid coverage gap is significant in Mississippi: Kaiser Family Foundation estimates that 108,000 of Mississippi’s 359,000 uninsured residents are in the coverage gap – ineligible for Medicaid (because the state has refused federal funding to expand Medicaid) and ineligible for subsidies in the exchange because their income is under the poverty level.
Mississippi health insurance exchange links
State Exchange Profile: Mississippi
The Henry J. Kaiser Family Foundation overview of Mississippi’s progress toward creating a state health insurance exchange.
Health Help Mississippi
Assists people insured by private health plans, Medicaid, or other plans in resolving problems pertaining to their health coverage; assists uninsured residents with access to care.
(877) 314-3843 / firstname.lastname@example.org
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.