Despite the fact that much of the political leadership in North Carolina has been opposed to healthcare reform, the state’s federally facilitated health insurance exchange has been one of the nation’s most successful. High enrollment numbers have likely contributed to improved health rankings and access to care.
Let’s take a look at North Carolina’s overall health and access to health insurance as 2017 open enrollment nears.
North Carolina health ratings
In 2014, North Carolina tied with South Carolina for 37th place on The Commonwealth Fund’s Scorecard on State Health System Performance. In 2015, however, the state took 37th place for its very own, with South Carolina falling to 40th. North Carolina’s best-performing categories were Access, Prevention & Treatment, and Avoidable Hospital Use & Costs.
The state ranked second in the nation for the percentage of children ages 19 to 35 months who received all recommended doses of seven key vaccines (81 percent) and ranked ninth for the number of adults ages 50 and older who received recommended screening and preventive care (45 percent). High percentages of uninsured adults and high out-of-pocket medical costs relative to annual household income were among the state’s lowest-performing indicators. To improve to the level of the best-performing state, North Carolina would need to insure another 832,580 adults and 678,251 fewer adults would need to go without needed healthcare because of cost.
The Tar Heel state was 31st overall in the 2015 America’s Health Rankings – in 2014, it was 37th. The core measures used to evaluate the state showed improvements in North Carolina’s uninsured rate and access to primary care physicians. High rates of immunization among adolescents and children again contributed to North Carolina’s ranking.
Trust for America’s Health also analyzed public health data in North Carolina in their 2016 edition of Key Health Data About North Carolina, which provides information on several specific diseases and health factors. This analysis looked at insurance coverage data from 2014 and showed that 13.1 percent of North Carolinians were uninsured.
The Robert Wood Johnson Foundation’s county rating map for North Carolina lets you see how the counties in the state rank against one another based on a variety of health factor and outcome metrics. County uninsured rates varied from 14 to 26 percent, and the state was in the 90th percentile for the ratio of population to primary care physicians (1,410:1).
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 legal residents 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 during 2016 open enrollment it had the third highest enrollment among HealthCare.gov states.
In 2013, the uninsured rate in North Carolina was 20.4 percent; the Tar Heel State was one of 14 states with more than a fifth of their population uninsured prior to Obamacare implementation in January 2014. By September 2015, that number had dropped 6 percentage points to 14.4 percent, according to a Gallup poll.
North Carolina health insurance rates, carriers for 2017
Charles Gaba at ACA Signups calculates a weighed average proposed rate increase of just over 20 percent in North Carolina. Rates are still subject to review and have not yet been finalized.
North Carolina enrollment in qualified health plans
The Kaiser Family Foundation estimated in late 2013 that 1,073,000 North Carolina residents could potentially buy qualified health plans through the exchange and that 684,000 of them would qualify for premium subsidies. By the end of the first open enrollment period, 357,584 people had purchased plans through the North Carolina exchange, with 91 percent of them receiving premium subsidies.
At the end of the third Obamacare open enrollment period, January 31, 2016, a total of 613,487 people had enrolled in private health plans through North Carolina’s exchange. That number includes renewals and new enrollees and made North Carolina #3 in HealthCare.gov enrollment for 2016. As of March 2016, 91.5 percent of enrollees were receiving premium subsidies.
North Carolina’s successful exchange enrollment numbers have been attributed to many factors, including the availability of navigators and advocacy organizations as well as public-private collaboration of various healthcare professionals and community leaders.
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 the U.S. House now includes just three Democrats from North Carolina, and ten Republicans.
Gov. Pat McCrory took office in January 2013, becoming the first Republican governor of North Carolina since 1988. His predecessor, Gov. 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 is 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 Healthcare.gov 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 HealthCare.gov enrollment in the country by the end of 2016 open enrollment period.
NC Medicaid/CHIP enrollment
North Carolina is currently one of 19 states that has not yet expanded Medicaid and has no pending plans to do so. The ACA would have expanded Medicaid to cover all legal residents with incomes up to 138 percent of poverty, but in 2012 the Supreme Court ruled that states could opt out of Medicaid expansion, and Gov. McCrory has thus far refused expansion.
In 2013, McCrory said that it would be unwise for the state to expand Medicaid in light of a recent audit that uncovered fraud and waste in the state’s Medicaid system, but he left the door open for the possibility of Medicaid expansion in the future, as well as a possible switch to a state-run exchange, “if it becomes clear that the current course of action is not the best interest of North Carolina, our health care system and our citizens.”
Most experts agree that states like North Carolina will eventually expand Medicaid simply because of economics – the lure of reducing uncompensated care on a local level via funding that is almost entirely from the federal government will likely make a case that’s too strong to resist. But it could be several years before all of the states get on board.
Because the state refused to expand Medicaid, North Carolina has 244,000 people in the coverage gap, with no access to Medicaid or exchange subsidies. These residents would be eligible for Medicaid if the state were to accept federal funds to expand coverage. But there are no realistic insurance options available for people with incomes below the poverty level who do not qualify for Medicaid under the state’s existing eligibility guidelines: Non-disabled adults without dependent children cannot enroll no matter how low their income is, and parents with dependent children are only eligible if their household income doesn’t exceed 45 percent of poverty (a little over $742/month for a family of three).
Regardless, North Carolina’s total monthly Medicaid and CHIP enrollment has grown 25 percent from before the ACA to June 2016.
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.
Medicare enrollment in the state of North Carolina
North Carolina Medicare enrollment reached 1.7 million individuals in 2015 – 17 percent of the state’s population, which is on par with national enrollment. Of North Carolina’s beneficiaries, 81 percent qualify based on age alone.
Medicare pays about $8,525 annually per capita in North Carolina, lower than the national average of $8,970. As of 2009, the most recent data available, the state ranks 10th in terms of overall Medicare spending with $14.1 billion per year.
North Carolina residents can enroll in Medicare Advantage plans instead of Original Medicare if they want additional benefits. About 29 percent opted to do so in 2015; nationwide, 31 percent selected a Medicare Advantage plan.
Medicare recipients can also select a Medicare Part D for a stand-alone prescription drug plan. About 45 percent of North Carolina Medicare beneficiaries chose Medicare Part D plans, slightly higher than the national enrollment of 43 percent.
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. The state legislature has also had a variety of other health and healthcare reform bills in the 2016 session. Here’s a summary: