Nebraska’s uninsured rates were relatively low prior to the Affordable Care Act’s implementation. However, The Cornhusker State has not expanded Medicaid, which means that about 27,000 Nebraska residents are in the coverage gap, ineligible for Medicaid and also ineligible for premium subsidies — and mostly still uninsured.
Nebraska was one of 10 where health insurance premiums increased by at least 30 percent in 2017, and the rate increase for 2018 is shaping up to once again be more than 30 percent.
Two companies — Aetna and Medica — offer plans through the state’s federally facilitated exchange in 2017, down from four in 2016. And for 2018, there will be just one.
Medica is the only insurer that will continue to offer coverage in Nebraska’s individual market for 2018 (on or off-exchange), and their proposed average rate increase is 31 percent. A large portion of that rate hike is on silver plans, to cover the cost of cost-sharing reductions (CSR), since it’s unclear whether the federal government will continue to pay for CSR in 2018.
Enrollment in Nebraska’s exchange reached 84,371 people enrolled during the 2017 open enrollment period, which was about 4 percent lower than it had been the year before. This was consistent with the overall average drop across the states that use HealthCare.gov for enrollment, due in part to higher premiums for unsubsidized enrollees, insurer departures, and the nascent Trump Administration’s decision to scale back on advertising and outreach in the final week of open enrollment.
Nebraska health ratings
The Commonwealth Fund’s Scorecard on State Health System Performance 2017 rated Nebraska 15th among the 50 states and District of Columbia — tied with four other states for 15th place, but down from 9th in 2012/13.
The Cornhusker State ranked in the second quintile for four out of five measures: Prevention & Treatment, Avoidable Hospital Use & Costs, Healthy Lives, and Equity. The state ranked in the third quintile for Access and Affordability.
Nebraska’s 2015 Scorecard ranked the state 18th for uninsured adults (13 percent) and 15th for the number of adults who skipped care due to cost in the past year (12 percent)
The state earned a Top 10 spot in the 2014 edition of America’s Health Rankings. At 10th overall, Nebraska ranked performed well in many measures, including poor physical and mental health days, childhood immunizations, dentists, primary care physicians, and lack of health insurance. But in the 2016 report, Nebraska fell two spots, to number 12.
For more details on overall public health in Nebraska, check out the 2016 listing of Key Health Data About Nebraska, compiled by Trust for America’s Health. A county-by-county comparison provided by the Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute is also available.
How has Obamacare helped Nebraskans?
Nebraska opted for a federally facilitated health insurance exchange and did not accept federal funding to expand Medicaid under the Affordable Care Act. Both tend to be indicators of reluctance to the health reform law.
However, the state was already performing better than most in the nation as far as pre-ACA uninsured rates go, and once the law’s key provisions took effect, it continued to do so.
Prior ACA implementation, the uninsured rate in Nebraska was 11.3 percent, according to US Census data. By 2016, it had fallen to 8.6, which was equal to the national average — despite the fact that the state hadn’t expanded Medicaid.
2018 individual health insurance in Nebraska
The Nebraska exchange includes just one insurer — Medica — for 2018, and that will also be the only insurer offering plans outside the exchange. Medica has proposed a 31 percent average rate increase (as of their revised rate filing dated August 15, 2017, which is based on the assumption that CSR funding will not continue in 2018). The additional cost to cover CSR has been added to silver plans.
94 percent of Nebraska exchange enrollees received premium subsidies in 2017 to help lower their monthly premiums. For 2018, the subsidies available to eligible exchange enrollees will increase with the cost of benchmark plans (i.e., the second-lowest-cost silver plan in each area). Since the additional cost to cover CSR has been added to silver plans, the premium subsidies will be larger than they would have otherwise been. The subsidies can be applied to other metal level plans in the exchange, even those that don’t include the added cost to cover CSR. That will make bronze and gold plans a relatively better value than they are in 2017 for subsidized enrollees.
Nebraska enrollment in qualified health plans
In November 2013, the Kaiser Family Foundation estimated that the potential market for Nebraska’s exchange was 239,000 residents and that 122,000 of them would qualify for premium subsidies to lower the cost of their coverage. By mid-April 2014, when the first open enrollment period ended,42,975 people had finalized their enrollment in qualified health plans (QHPs) through Nebraska’s health insurance exchange. HHS reported that 87 percent of them received subsidies to lower their premiums.
By the end of 2016 open enrollment, the third ACA enrollment period, Nebraska’s exchange had enrolled 87,835 people. As of March 31, nearly 90 percent of the 80,213 effectuated enrollments were receiving subsidies that averaged $296 per month.
But enrollment declined in 2017, as was the case in most states that use HealthCare.gov. 84,371 people enrolled in private plans through the Nebraska exchange during the 2017 open enrollment period. By February 2017, effectuated enrollment stood at 74,582, and 94 percent of them were receiving premium subsidies.
Nebraska and the Affordable Care Act: Lawmakers’ approach
In 2010, Nebraska’s U.S. senators were split on the health reform law. Mike Johanns voted no, while Ben Nelson voted yes. All three members of the House voted no – Jeff Fortenberry, Lee Terry, and Adrian Smith.
Ben Nelson is no longer in the Senate, and his successor, Deb Fischer, is opposed to Obamacare and has said she supports a full repeal of the law.
Currently, all five congressional delegates from Nebraska are ACA opponents. Sen. Benjamin Sasse has replaced Mike Johanns. Sasse voted yes in 2015 to repeal the Affordable Care Act. Both Fischer and Sasse voted yes on all three ACA repeal measures that the Senate considered in July 2017: The Obamacare Repeal Reconciliation Act, the Better Care Reconciliation Act, and “skinny” repeal.
In the House, all three Nebraska Representatives supported the American Health Care Act (AHCA), an ACA repeal effort that passed the House in May but stalled when the Senate was unable to pass any of their versions of the bill.
Gov. Ricketts is also opposed to the ACA, and favors many of the reforms preferred by the GOP: tort reform, expanded HSAs, and tax credits to help purchase insurance. He is opposed to Medicaid expansion and has vowed to continue Gov. Heineman’s rejection of expanding the program.
Nebraska participates in the federally facilitated health insurance exchange.
Nebraska Medicaid/CHIP enrollment
Republicans in the Nebraska legislature filibustered a Medicaid expansion bill in 2013, and former Gov. Heineman also opposed Medicaid expansion. Current Gov. Ricketts continues to oppose it. As a result, Nebraska is one of 19 states that has not yet expanded Medicaid, leaving about 27,000 people in the coverage gap, with no access to financial assistance with their health insurance.
They would be eligible for Medicaid if the state were to use federal funds to expand coverage under the ACA. But for now, there is no financial assistance available for people with incomes below the poverty level who do not qualify for Medicaid under the state’s existing guidelines (Medicaid is not available in Nebraska for non-disabled childless adults, and is only available for parents of dependent children if their household income is under 57 percent of poverty).
Nebraska Senator John McCollister, a Republican, introduced LB1032 in January 2016, in an effort to expand Medicaid in Nebraska using a privatized model, like the system Arkansas uses. But the legislation did not advance out of committee. LB472, another Medicaid expansion bill, failed in the 2016 session aswell. 2016 was the fourth year in a row that lawmakers in Nebraska rejected Medicaid expansion.
When Donald Trump’s won the White House in the 2016 election, McCollister indicated that state lawmakers would not push for Medicaid expansion in the 2017 legislative session, noting that “until we get some clarity from Congress and the president, I don’t think it’s useful to spend much time on it.” That position was reiterated in April 2017, when the Nebraska legislature noted that they would take no action on the Medicaid expansion issue in 2017, waiting instead to see what would happen at the federal level. Ultimately, all of the measures that federal GOP lawmakers considered to repeal the ACA were unsuccessful. So Medicaid expansion is still an option for states that want to pursue it.
During the 2015 enrollment period, 7,218 people had enrolled in Nebraska Medicaid through the state’s exchange, qualifying under the existing guidelines. But the state’s monthly Medicaid enrollment had actually decreased 2 percent from 2013 to July 2017.
Medicaid enrollment is open year-round, which means the numbers can fluctuate. More information on Nebraska’s Medicaid and CHIP coverage and eligibility is available here.
Does Nebraska have a high-risk pool?
Before the ACA, individual health insurance was underwritten in nearly every state, which meant that pre-existing conditions could prevent a person from obtaining a policy, or could result in significantly higher premiums or policy exclusions. The Nebraska Comprehensive Health Insurance Pool (NCHIP) was created to give people an alternative if they were unable to obtain individual health insurance because of their medical history.
Now that the ACA has been implemented, all health insurance plans are guaranteed issue, making high-risk pools largely obsolete, and NCHIP closed on December 31, 2013. The program is now only available for people who are under 65 and on Medicare due to a disability.
Medicare enrollment in the state of Nebraska
Nebraska Medicare enrollment reached 313,703 in 2015 – 17 percent of its population, the same as the percentage enrolled in Medicare nationwide. As of 2013, about 86 percent of Nebraska Medicare enrollees qualified for coverage based on age alone, while the remaining 14 percent were eligible Medicare due to a disability.
Nebraska Medicare recipients can select a Medicare Advantage plan instead of original Medicare if they wish to gain some additional benefits, and about 12 percent of the state’s Medicare enrollees did so in 2016, up from 11 percent in 2015. This percentage is far lower than the 31 percent of Medicare beneficiaries who select a Medicare Advantage plan nationwide.
However, about 60 percent of the state’s Medicare beneficiaries are enrolled in Medicare Part D plans, which provide stand-alone prescription drug coverage. Of all U.S. Medicare recipients, 45 percent have stand-alone Rx plans.
Nebraska’s state-based health reform legislation
Here’s a summary of state-level Nebraska bills related to health reform: