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 health care are all important. Here’s a summary of health and healthcare reform in North Dakota:
Health insurance carriers
In the individual market in North Dakota, there are three health insurance carriers, all of which sell policies both on and off the exchange:
- Blue Cross Blue Shield of North Dakota
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 14th out of the 50 states and District of Columbia – down a few spots from 9th in 2009. 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 kept North Dakota in 9th place in 2013. North Dakota’s ranking is helped by a high rate of high school graduation, few drug deaths, and a population that reports few days per month of poor mental or physical health. But the state struggles with a high rate occupational fatalities, binge drinking, and obesity, and roughly 120,000 adults in North Dakota are physically inactive.
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 2014 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. Senator Heidi Heitkamp is supportive of the law, but would like to see some improvements added to it.
Senator 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.
Representative 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. Governor 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 elgible 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, 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 their own exchange).
North Dakota enrollment in QHPs
16,651 people had in-force coverage through the ND exchange as of June 2015, and 85.5 percent are receiving premium subsidies (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. 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. Enrollment in Medicaid is year-round though, so that number is still growing, 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.
State-based health reform legislation
Here’s a summary of recent North Dakota bills related to public health and healthcare reform: