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North Dakota health insurance

Uninsured is at 7.85 percent

A variety of factors play a role in each state’s overall health outcomes. How the state’s leadership approaches healthcare reform, the prevalence of numerous health factors, and access to health insurance and realistic healthcare are all important. Here’s a summary of health and healthcare reform in North Dakota:

2016 ND health insurance carriers

In North Dakota’s individual market, there are three health insurance carriers, all of which sell policies both on and off the exchange:

  • Blue Cross Blue Shield of North Dakota
  • Medica
  • Sanford

BCBS has the lion’s share of the market, with roughly 29,000 enrollees in the ACA-compliant individual market. Medica has almost 5,000 enrollees. Sanford’s on-exchange enrollment stood at 1,894 members as of September 2015, although that does not include their off-exchange market share.

North Dakota health ratings

In 2014, the Commonwealth Fund’s Scorecard on State Health System Performance rated North Dakota 26th out of the 50 states and District of Columbia – a dramatic slide from 14th in 2014. North Dakota’s Scorecard includes details about the state’s health factors and outcomes to show how the rankings are calculated.

But America’s Health Rankings for 2014 placed North Dakota 9th, a position it has held for several years. The state earned high marks for having the nation’s lowest number of drug deaths and for having a high rate of immunization among adolescents, a low rate of poor mental health days, and low levels of air pollution. High rates of binge drinking, obesity and occupational fatalities negatively impacted North Dakota’s ranking the most.

Trust for America’s Health has summarized additional information on the state’s specific disease incidence and health factors for adults and children. The details are in the 2015 listing of Key Health Data About North Dakota.

You can also view North Dakota health data on a county level with this interactive map showing the counties in North Dakota based on their public health outcomes and health factors. High- and low-ranking counties are well dispersed in the state, with no single region clearly outperforming the others.

North Dakota and the Affordable Care Act

In 2010, both of North Dakota’s U.S. Senators, Democrats Kent Conrad and Byron Dorgan, were supportive of the health reform law. In the House, the Earl Pomeroy, a Democrat, and the lone representative from North Dakota, also voted yes.

The entire congressional delegation from North Dakota has changed since 2010, however, and now includes one Democratic senator and one Republican, as well as a Republican representative. Sen. Heidi Heitkamp is supportive of the law, but would like to see some improvements added to it.

Sen. John Hoeven, a Republican and the former governor, is opposed to the ACA but was one of the 23 Republicans who joined with Democrats in voting to end the debate in 2013 on a resolution that would have defunded Obamacare.

Rep. Kevin Cramer, a Republican, is opposed to the ACA and would prefer to see it repealed and replaced with a market-driven solution. He won re-election in November 2014. One of his challengers in the campaign, Libertarian Jack Seaman, also believed the ACA should be repealed. But the third candidate, Democrat George Sinner, was supportive of the law.

At the state level, Republicans hold the majority in both the House and Senate. Gov. Jack Dalrymple, a Republican, has stated that he is opposed to the ACA, but he has not been obstructionist about the law the way many other Republican governors have. In 2013, Dalrymple said, “It’s not going to help to throw a bunch of roadblocks in front of this thing [the ACA] and have it fail. That’s not the responsible thing to do.”

In the spring of 2013, Dalrymple signed a bill to expand Medicaid in the state, allowing all legal residents with incomes up to 138 percent of poverty to be eligible for Medicaid benefits starting in 2014. The state opted for a federally facilitated marketplace however, and HHS is running the exchange in North Dakota.

How did the ACA help North Dakota?

At the end of 2013, there were about 70,000 uninsured residents in North Dakota. Thanks in large part to the ACA and the state’s acceptance of Medicaid expansion, 39 percent of them are now eligible for Medicaid. Another 31 percent are eligible for subsidies in the exchange.

In 2013, about 15 percent of non-elderly North Dakota residents were uninsured. According to Gallup data, by mid-2015, that rate had dropped to just 6.9 percent. That number is lower than even the 8.9 percent average among states that expanded Medicaid AND established their own exchanges — North Dakota expanded Medicaid, but did not establish its own exchange.

North Dakota enrollment in qualified health plans

As of June 2015, there were 16,651 people enrolled in qualified health plans (QHPs) through North Dakota’s health insurance exchange, and 85.5 percent are receiving premium subsidies. Initially, 18,171 had enrolled during the 2015 open enrollment period, but not all enrollees pay their initial premiums, and some people cancel their coverage mid-way through the year. The ND Insurance Department reported that in-force enrollments stood at 16,666 by mid-September 2015.

In late 2013, shortly after open enrollment began, the Kaiser Family Foundation estimated the potential market for the exchange in North Dakota to be 77,000 residents. They also predicted that about 44,000 of them would qualify for premium subsidies.

North Dakota Medicaid/CHIP enrollment

Accepting federal funds to expand Medicaid in North Dakota has been a key aspect of the law’s success there. All legal residents with incomes up to 138 percent of poverty are now eligible for Medicaid. With North Dakota Medicaid expansion underway in 2014, there were 35,000 people estimated to be newly eligible for coverage.

As of mid-April, 6,843 people had enrolled in Medicaid through the North Dakota exchange – about a quarter of the Medicaid-eligible uninsured population in the state. The state’s total monthly enrollment grew 27 percent from 2013 to August 2015, reaching 88,602.

Enrollment in Medicaid is year-round though, so enrollment numbers may continue to grow, further reducing the uninsured rate in North Dakota.

Does North Dakota have a high-risk pool?

Before the ACA brought guaranteed issue health insurance to the individual market, medical history was used to determine eligibility to purchase coverage in North Dakota, as it was in nearly every state. Pre-existing conditions could prevent an applicant from getting a policy at all, or could result in significant initial rate increases or policy exclusions.

The Comprehensive Health Association of North Dakota (CHAND) was created in 1981 to provide an alternative for residents who were unable to purchase individual private health insurance because of their medical history. The plan is administered by Blue Cross Blue Shield of North Dakota.

Now that Obamacare is in effect and all health insurance plans are guaranteed issue, risk pools are not needed the way they were prior to 2014. But CHAND is one of a few state-run pools that is still operational and still accepts new members if they meet the eligibility guidelines. In April 2015, Gov. Dalrymple signed SB 2231 into law. If HHS determines that CHAND coverage does not meet minimum essential coverage requirements under the ACA, SB 2231 gives the CHAND board the ability to modify the benefits in order to make the plan qualify as minimum essential coverage.

North Dakota Medicare enrollment

In 2015, Medicare enrollment reached 118,311 in North Dakota – that’s nearly 16 percent of the Peace Garden State’s population. Historically, 86 percent of North Dakota Medicare recipients have qualified for coverage based on age alone, while 14 percent are on Medicare as the result of a disability.

Medicare pays about $7,957 per North Dakota enrollee each year. In terms of overall annual Medicare spending, the state ranks 48th with $859 million.

North Dakotans can select a Medicare Advantage plan instead of original Medicare if they wish to gain some additional benefits beyond what traditional coverage offers. About 17 percent of North Dakota Medicare recipients are enrolled in a Medicare Advantage plan, and 32 percent of all Medicare beneficiaries nationwide have made that selection.

Medicare Part D plans are also an option for those who want to stand-alone prescription drug coverage. North Dakota far exceeds the national average (43 percent) when it comes to Medicare Part D enrollment; 66 percent of North Dakota Medicare recipients have Part D plans.

State-based health reform legislation

Here’s a summary of recent North Dakota bills related to public health and healthcare reform: