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North Carolina health insurance

All three insurers in North Carolina's exchange are decreasing premiums for 2020 and Bright has begun offering plans in some areas

Health insurance in North Carolina

North Carolina’s health insurance marketplace

State legislative efforts to preserve or strengthen provisions of the Affordable Care Act

North Carolina is among the states that have done the least to preserve the Affordable Care Act’s gains.

North Carolina uses the federally run health insurance exchange, which means enrollment is through

Open enrollment for 2020 health plans has ended, although North Carolina residents with qualifying events can still enroll or make changes to their coverage for 2020. The next open enrollment period, for plans effective in 2021, will begin November 1, 2020.

Three insurers – Blue Cross Blue Shield of North Carolina, Cigna and Ambetter – are offering 2019 individual market plans through the North Carolina exchange. (Most of the state has a single carrier – Blue Cross Blue Shield of North Carolina – offering plans in the exchange.)

For 2020, Bright Health will join the North Carolina exchange, offering plans in the Charlotte and Winston-Salem areas.

Average premiums (before any subsidies are applied) for 2019 are a little lower in North Carolina than they were in 2018. The average benchmark plan premium in North Carolina’s dropped by 1.4 percent for 2019. And for 2020, all three insurers reduced their average rates.

501,271 people enrolled in private plans through the North Carolina exchange during the open enrollment period for 2019 coverage. For comparison, 519,803 people enrolled for 2018, 549,158 people enrolled for 2017, and 613,487 people enrolled for 2016. So enrollment for 2019 is down about 18 percent from the high that it reached in 2016.

Read more about North Carolina’s health insurance marketplace.

Medicaid coverage in North Carolina

North Carolina is one of 16 states that still have not accepted federal funding to expand Medicaid under the ACA. An estimated 626,000 in the state would gain coverage if the state were to accept federal funding to expand the program.

Although the state has not yet expanded Medicaid under the ACA, Gov. Roy Cooper – who took office in January 2017 – has been working to expand coverage. State lawmakers have thus far blocked his efforts, but Cooper’s first budget proposal called for the expansion of Medicaid and he continues to push for it, despite legislative roadblocks.

Because the state refused to expand Medicaid, North Carolina has an estimated 215,000 residents in the coverage gap, with no access to Medicaid or exchange subsidies.

Read more about North Carolina and the ACA’s Medicaid expansion.

Short-term health insurance in North Carolina

North Carolina defaults to new federal regulations regarding short-term coverage. That means short-term plans are allowed to have initial terms up to 364 days, and total duration – including renewal – of up to 36 months.

The state does have various laws and regulations that apply to short-term plans.

Read more about short-term health insurance in North Carolina.

The Affordable Care Act in the Tar Heel State

In 2010, North Carolina’s U.S. Senators were divided on healthcare reform. Kay Hagen, a Democrat, voted yes on the ACA, while Richard Burr, a Republican, voted no. In the U.S. House, five Republican representatives from North Carolina voted no, while eight Democrats voted yes.

Burr remains in the Senate, but Hagen has been replaced by Thom Tillis, a Republican who opposes the ACA. Both Burr and Tillis voted in favor of the three Senate versions of ACA repeal in 2017, although none of them were ultimately enacted.

And the U.S. House now includes just three Democrats from North Carolina, and ten Republicans.

Governor Roy Cooper, a Democrat, took office in January 2017. He supports the ACA and wants North Carolina to accept federal funding to expand Medicaid, but the state’s legislature has clashed with him over whether he has the authority to expand coverage unilaterally, and Medicaid expansion also faces an uncertain future under the Trump Administration.

Cooper replaced former Governor Pat McCrory, who had served for four years as the first Republican governor of North Carolina since 1988. McCrory’s predecessor, Governor Bev Perdue, had stated that North Carolina would enter into a partnership exchange with HHS, but shortly after he took office, McCrory announced that the state would default to a federally-facilitated marketplace.

In addition, MrCrory also decided that the state would not move forward with Medicaid expansion, citing a problematic recent audit of the state’s existing Medicaid program, and noting that the program’s issues needed to be fixed before the state considered expanding it.

McCrory was not a fan of the ACA, but early in the 2014 open enrollment period, he softened his stance a bit in a public announcement to the state’s residents. While he still noted that he was opposed to the ACA, he provided information and resources to help direct people to and enrollment assisters.

In general however, the state’s government has taken a largely hands-off role in terms of promoting and implementing the ACA in North Carolina. But a strong network of community-based public health workers, navigators, and volunteers resulted in North Carolina having the third-highest enrollment in the country by the end of 2016 open enrollment period (the state retained that position in 2017 and 2018 as well).

How Obamacare has helped NC residents

North Carolina’s refusal to expand Medicaid has resulted in an uninsured rate that is considerably higher than it would be if the state had accepted federal funds to make Medicaid available to all adults (assuming they’ve been legal U.S. residents for at least five years) with incomes up to 138 percent of the federal poverty level. But the ACA has certainly benefitted North Carolina residents who used the exchange to enroll in Medicaid or private plans. The state was one of six states that enrolled more than half of its potential market through its exchange in 2015, and has consistently had third highest enrollment among states, and the fourth highest among all states.

According to U.S. Census data, 15.6 percent of North Carolina residents were uninsured in 2013. That had fallen to 10.4 percent by 2016, although there’s no doubt that it would be substantially lower if the state had accepted federal funding to expand Medicaid.

Is there still a high-risk pool in North Carolina?

Before the ACA dramatically reformed the individual health insurance market, coverage was underwritten in nearly every state, including North Carolina. This meant that pre-existing conditions could prevent an applicant from getting coverage, or could result in significantly higher premiums or policy exclusions. The North Carolina Health Insurance Risk Pool was created in 2009 to give people an alternative if they were unable to obtain individual health insurance because of their medical history.

When ACA implementation resulted in a guaranteed issue individual market in January 2014, risk pools were no longer necessary. The North Carolina Health Insurance Risk Pool ceased operations at the end of 2013, and members were able to transition to new, ACA-compliant plans issued on or off-exchange.

Some Republican health care reform proposals have called for a return to high-risk pools, which is not in the best interests of people with pre-existing conditions.

Medicare enrollment in the state of North Carolina

North Carolina Medicare enrollment reached 1.96 million individuals by mid-2019. That’s nearly 19 percent of the state’s population, which is on par with national enrollment. Of North Carolina’s beneficiaries, 82 percent qualify based on age alone.

As of 2015, Medicare spent about $8,869 annually per capita in North Carolina, lower than the national average of $9,171.

North Carolina residents can enroll in Medicare Advantage plans instead of Original Medicare if they want additional benefits (although Medicare Advantage plans also has drawbacks, including smaller networks of doctors and hospitals). 633,558 North Carolina Medicare beneficiaries were enrolled in Medicare Advantage plans in 2018, which was just under a third of the state’s Medicare population. That’s roughly similar to the national average; about 34 percent of Medicare beneficiaries nationwide are enrolled in Medicare Advantage plans.

Medicare recipients can also select a Medicare Part D for a stand-alone prescription drug plan. About 41 percent of North Carolina Medicare beneficiaries are enrolled in stand-alone Medicare Part D plans, which is very similar to the national enrollment rate for stand-alone Part D coverage.

State-based health reform legislation

North Carolina passed a law in 2013 prohibiting the state from establishing a state-run or partnership exchange, and also rejecting Medicaid expansion under the ACA and preventing a future governor from unilaterally expanding Medicaid (this was the basis for state lawmakers’ lawsuit in 2017, when it appeared that Governor Cooper might try to take executive action to expand Medicaid). Here’s a summary of recent health care reform legislation in North Carolina: