The outcome of North Dakota’s gubernatorial election on November 8 could hold major significance for its expanded Medicaid program. The decision to do so has surely contributed to North Dakota’s single-digit uninsured rate. However, current governor Jack Dalrymple, a Republican who was in office when the state expanded Medicaid, has decided not to run for re-election. In the race between Democrat Marvin Nelson and Republican Doug Burgum, a vocal critic of the healthcare reform law and Medicaid expansion, Burgum is expected to win.
As 2017 open enrollment gets underway, North Dakotans will not be subject to the double-digit rate hikes common in other markets. Health insurance premiums may be increasing an average of 25 percent nationwide, but rates for 2017 plans sold through North Dakota’s federally facilitated exchange will go up an average of 1.3 percent overall – tied with Rhode Island as the lowest in the country. Better yet, most North Dakotans who buy an exchange plan will see their rates decrease – approved rates for BCBS of ND dropped an average of 1.57 percent, and BCBS of ND insures the majority of North Dakota exchange enrollees.
ND health ratings
In 2015, the Commonwealth Fund’s Scorecard on State Health System Performance rated North Dakota 28th out of the 50 states and District of Columbia. While the state excelled in the category of Avoidable Hospital Use & Costs, it languished in the Access category. In this analysis, North Dakota’s uninsured rates place 39th for adults and 42nd for children – 19 percent and 9 percent, respectively.
North Dakota’s Scorecard includes additional details about the state’s health factors and outcomes to show how the rankings are calculated.
But the 2015 edition of America’s Health Rankings placed North Dakota quite a bit higher, at 12th place. The ranking was bolstered by relatively strong public health funding, low disparity in health status, an 8 percent decrease in lack of health insurance over the past decade and a 27 percent decrease in preventable hospitalizations.
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 2016 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.
How has the ACA helped 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 became eligible for Medicaid. Another 31 percent were eligible for subsidies in the exchange.
The Peace Garden State has seen the 8th largest reduction in its uninsured population between 2013 and 2015, dropping 8.1 percentage points from 15 percent to 6.9 percent. The national uninsured rate fell to 11.7 percent in the same time period. At the end of 2015, only nine states had uninsured rates below 7 percent, and North Dakota was among them.
2017 health insurance rates and carriers
In North Dakota’s individual market, there are three health insurance carriers, all of which sell policies both on and off the exchange. Those carriers and their average rate increases are as follows:
- Blue Cross Blue Shield of North Dakota – 1.57 percent decrease
- Medica – 14.3 percent increase
- Sanford – 7.85 percent increase
Rates approved for all carriers reflected lower increases than requested, and even a decrease in the case of BCBS of ND, which has the lion’s share of the market in North Dakota.
North Dakota enrollment in QHPs
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.
During the 2016 open enrollment period, 21,604 people enrolled in private plans through North Dakota’s exchange – a 19 percent increase over 2015. Of the 20,536 effectuated enrollees on March 31, nearly 86 percent were receiving premium subsidies and the average after-subsidy premium was $142 per month.
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.
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 June 2016, North Dakota’s monthly average Medicaid enrollment had grown 29 percent, reaching 89,914.
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
Historically, 85 percent of North Dakota Medicare recipients have qualified for coverage based on age alone, while 15 percent are on Medicare as the result of a disability.
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 31 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 (45 percent) when it comes to Medicare Part D enrollment; 67 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: