Ohio has a federally-facilitated exchange, which means residents in Ohio use Healthcare.gov to enroll in exchange plans. But Ohio is one of seven states that participates in plan management and the qualified health plan (QHP) certification process.
Ohio expanded Medicaid under the ACA, due in large part to Republican Governor John Kasich’s efforts. Ohio residents can enroll in QHPs or Medicaid via the exchange, with eligibility dependent on income.
238,843 people enrolled in QHPs through the Ohio exchange during the 2017 open enrollment period (November 1, 2016, through January 31, 2017). That’s 2 percent lower than enrollment in 2016, although the drop-off was not as sharp as it was in other HealthCare.gov states, where enrollment declined by an average of almost 5 percent.
Open enrollment for 2017 has ended, but coverage is still available (regardless of pre-existing conditions) if you experience a qualifying event. And subsidies are available through the exchange for those who are eligible based on their income.
The Ohio exchange and the Trump Administration
A week after the start of open enrollment for 2017 coverage, Donald Trump won the presidential election. The future of the ACA suddenly became uncertain, and the Trump Administration scaled back advertising for HealthCare.gov within days of Trump’s inauguration, both of which were likely factors in 2017’s lower enrollment.
Our Repeal and Replace section has more details about what’s happened since the election and current Republican health care proposals. Initially, it seemed that the ACA would be repealed via reconciliation, but that is becoming less likely as time goes by and GOP lawmakers become more divided in terms of where they want to go from here.
But if the ACA were to be repealed, Ohio stands to lose a lot. HHS reported that from 2010 to 2015, the number of Ohio residents with health insurance grew by 664,000 as a result of the ACA — a number that has continued to climb since 2015. ACA Signups estimates that 945,000 people in Ohio could lose their health insurance if the ACA were to be repealed and the replacement isn’t as robust. The vast majority of those (691,000) have coverage under Ohio’s expanded Medicaid.
Ohio Governor, John Kasich, who ran for the GOP presidential nomination in 2016, has pushed back against Congressional Republicans’ proposals to repeal Medicaid expansion. Kasich met with President Trump and HHS Secretary Tom Price in February to address his concerns and discuss health care reform possibilities.
Kasich favors a modified version of Medicaid expansion, covering people with incomes under the poverty level (as opposed to the current eligibility rules, which allow people with income as high as 138 percent of the poverty level to enroll in Medicaid). His proposal calls for transitioning people with incomes above the poverty level (between 100 percent and 138 percent of the poverty level) to private, subsidized plans in the exchange. All of this, however, is contingent on the basic framework of the ACA remaining in place.
Three insurers that offered exchange plans in Ohio in 2016 — InHealth Mutual, Aetna, and All Savers/UnitedHealthcare — are not offering plans in 2017.
And HealthSpan was purchased by Medical Mutual; HealthSpan’s individual market plans ended on December 31, 2016, and were replaced with Medical Mutual coverage — but enrollees had the option to pick a different carrier instead.
The rest of the carriers that offered coverage in the Ohio exchange in 2016 are continuing to offer plans for 2017, with the following average rate changes (all numbers are averages; specific plans can have rate changes that vary considerably from these numbers):
- AultCare: 24.09 percent increase
- Buckeye Community Health Plan: 0.79 percent decrease and 1.14 percent decrease, depending on whether plan includes vision.
- CareSource: 16.91 percent increase (HMO Enhanced) and 17.64 percent increase (HMO Basic). CareSource reported that they enrolled 71,586 people in individual market plans in Ohio during the 2017 open enrollment period; that’s down about 2 percent from their 2016 total.
- Community Insurance Company (Anthem BCBS): 18.2 percent increase (HMO) and 15.5 percent increase (PPO)
- Humana: 45.11 percent increase (Humana has left the individual market in several states for 2017, but is continuing to offer coverage in Ohio)
- Medical Health Insuring Corp. of Ohio (Medical Mutual): 17.13 percent decrease (but they only have 128 members in 2016; this is expected to increase in 2017 with their purchase of HealthSpan’s business)
- Molina: 2.36 percent increase (on the heels of a rate decrease for 2016)
- Paramount: 9.88 percent increase
- Premier Health Plan: 39.82 percent increase
- Summa: 5.33 percent increase
Although Ohio’s exchange is quite robust compared with most states, plan availability varies from one part of the state to another. There are 20 counties (out of 88 counties in the state) where just one carrier is offering plans for 2017 in the exchange. Another 27 counties have only two carriers offering plans. In 2016, every county had plans available in the exchange from at least four carriers.
But there are still a total of ten carriers offering coverage in the exchange in Ohio in 2017. In neighboring West Virginia, there are only two.
Average rates up 17%, but average benchmark rate up just 2%
At ACA Signups, Charles Gaba calculated a weighted average rate increase of 17.33 percent for the individual market in Ohio. For perspective, the average rate increase approved for 2016 in Ohio was 13 percent, but that was before anyone shopped around for coverage during open enrollment. For 2017, 17.33 percent was still lower than the national average, which was about 25 percent. But it’s important to understand that these percentage rate changes assumed that nobody would shop around and pick a different plan during open enrollment, and they were also calculated before any premium subsidies were taken into consideration.
But that said, the average benchmark premium (second-lowest-cost silver plan) in Ohio only increased in price by 2 percent for 2017. Premium subsidies are tied to the benchmark premium, so there were very modest increases in subsidies in Ohio in 2017. That made it more important than ever for people to actively shop around during open enrollment, as their plan might have been increasing in price significantly more than the second-lowest-cost silver plan in their area. In that case, they could find themselves bearing most of the brunt of the rate hike. On the other hand, if they were willing to switch to a different plan, they could find that their rates are similar to — or even lower than — what they had in 2016.
InHealth Mutual CO-OP liquidated
InHealth Mutual (Coordinated Health Mutual Inc.) was one of the 23 CO-OPs that were created by the ACA. By the end of 2015, 12 of those CO-OPs had closed, but InHealth Mutual was among the 11 that continued to provide coverage in 2016.
But in May 2016, the Ohio Department of Insurance announced that InHealth would be liquidated, and that 21,800 Ohio residents – most of whom had individual plans – would need to select new coverage. The DOI announced that there would be a special enrollment period running from May 26 to July 26, during which InHealth Mutual members would be able to select new plans.
For members who did not select new plans, InHealth Mutual coverage technically remained in place until the end of 2016. But the state guaranty association stepped in to pay claims, which meant that the coverage was no longer considered minimum essential coverage, and had a benefit cap of $500,000. So a member who continued to pay premiums for InHealth Mutual throughout the rest of 2016 was not in compliance with the ACA’s individual mandate, and may end up with a penalty as a result. They also lost eligibility for any subsidies through Healthcare.gov.
The Ohio DOI has clarified that people who picked new plans would likely have to start over with new deductibles and out-of-pocket exposure on the new plan. In order to continue receiving a premium subsidy, new plans had to be selected through Healthcare.gov. For people who don’t receive a premium subsidy, new plans could be selected through Healthcare.gov or outside the exchange. The Ohio DOI estimated that there were still about 7,800 people with InHealth Mutual coverage as of early August.
InHealth Mutual’s history
Ironically, InHealth Mutual may have avoided the first round of CO-OP shut-downs because of the fact that they didn’t get their Ohio license in time to offer subsidized plans in the exchange in 2014. As a result, they had to rely on small group enrollments outside the exchange for 2014, and only ended up with 11 percent of their projected enrollment by the end of the year.
But that first wave of 2014 enrollees turned out to be sicker than expected, and nationwide, carriers lost money. Since InHealth Mutual hadn’t been able to offer plans in the exchange, they were spared the high claims that the other CO-OPs experienced, and ended up with a net income of negative $6 million for 2014 (that’s obviously still not good, but only four other CO-OPs did better that year).
By mid-2015, InHealth’s membership had more than tripled, to 22,000 people. But they still had a loss of $9 million during the first half of 2015, and were placed under enhanced regulatory oversight.
For 2016, InHealth had proposed an average rate increase of 7.7 percent, but later revised their request to 15 percent. The final approved average rate increase for their plans was 14.8 percent. However, regulators have noted that in order to stem their losses, InHealth would have needed a rate increase of about 60 percent for 2017 if they had remained operational.
On January 15, InHealth notified the Ohio Department of Insurance that they were planning to drop OhioHealth hospitals and most OhioHealth doctors from their network as of March 1.
But the public outcry over the network restructuring was fierce, and by the end of February, InHealth announced that they would keep OhioHealth in their network until at least the end of 2016. The liquidation order for InHealth Mutual stipulates that in-network providers must continue to honor their network agreements throughout the liquidation process.
243,715 people enrolled in private plans through the Ohio exchange during the 2016 open enrollment period (November 1 to January 31). That was 104 percent of the total number of of people (234,341) who enrolled in plans during the full 2015 open enrollment period, although the 2016 total had already been reduced in real-time to account for uneffectuated enrollments as of February 1.
Open enrollment for 2016 has ended. New 2016 plans – on or off the exchange – are only available in most cases now to people who have a qualifying event (Native Americans can enroll year-round, as can anyone eligible for Medicaid/CHIP). Open enrollment for 2017 coverage begins on November 1, 2016, and runs through January 31, 2017.
According to Kaiser Family Foundation data, there were still 834,000 uninsured residents in Ohio in 2015. 48 percent were eligible for Medicaid, and 20 percent were eligible for premium subsidies in the exchange. In total, more than half a million people in Ohio were uninsured in 2015 and eligible for financial assistance – either Medicaid or premium subsidies.
AG’s Obamacare lawsuit dismissed
In January 2015, Ohio Attorney General Mike DeWine filed a lawsuit against the federal government over an aspect of the ACA that DeWine’s office – and at least one Ohio County as well – believes is illegal.
The crux of the issue is the reinsurance fee assessed under Obamacare to provide rate stabilization in the insurance market for the first three years of ACA implementation. This requires a per-user fee on all health insurance plans, including self-insured plans like the state of Ohio has for its workers. Across all of the state’s employees, the reinsurance fee comes is at $5.3 million for 2014, and DeWine sees it as a case of one government (federal) taxing another (state).
In addition to DeWine, plaintiffs in the suit include the Ohio Department of Administrative Services and four universities. DeWine had previously consulted with AGs in other states, but ultimately all of the plaintiffs are based in Ohio. As of June, the case was still in the early stages of litigation. But in January 2016, US District Judge Algenon L. Marbley dismissed DeWine’s case, and also noted that it appeared that the case was more about DeWine’s efforts to fight against Obamacare rather than the merits of the reinsurance fee itself.
In April 2016, Ohio regulators opted to go along with the latest extension from the federal government regarding transitional (grandmothered) plans. These are the plans that individuals and small businesses purchased after the ACA was signed into law, but before the exchanges opened for business in October 2013. They’re not compliant with the ACA, but Ohio is one of many states where they will be allowed to continue to remain in force until the end of 2017. But the final decision is up to each carrier.
The federal government issued yet another extension for grandmothered plans in February 2017, allowing them to renew again for 2018. It’s up to each state to determine whether to go along with that extension. In states that allow it, the final decision will be left to the insurance company.
2016: highest after-subsidy premiums among Healthcare.gov states
80 percent of the enrollees in the Ohio exchange in 2016 were receiving premium subsidies, which averaged $240/month. The average pre-subsidy premium in Ohio was $405/month in 2016, but for people who are receiving subsidies, the average after-subsidy premium is $164. That’s a considerable reduction from the pre-subsidy price, but it’s the highest average after-subsidy premium among the 38 states that are using Healthcare.gov (the average after-subsidy premium across all 38 states is $106/month).
That’s despite the fact that the percentage of Ohio exchange enrollees who picked low-cost bronze plans is higher than the average across Healthcare.gov states, and the percentage who picked silver plans is lower than the average.
2016 carriers and rate changes
In late October 2015, HHS released an overview of benchmark premium changes in the states that use Healthcare.gov. It was admittedly of limited value, since the benchmark plan isn’t necessarily the same plan from one year to the next. But it does give a good idea of how subsidies are changing in 2016, and a general feel for the overall rate change trend in many states. Of the 37 states included on the list, only four had an average decrease in their benchmark premiums – and Ohio is among them. The average second-lowest-cost Silver plan in Ohio is 0.7 percent less expensive in 2016 than it was in 2015.
And a Kaiser Family Foundation analysis of second-lowest-cost Silver plan premiums in the Cleveland area found an average decrease of 5.3 percent.
But according to the Dayton Daily News, overall rates in the Ohio exchange have increased by an average of about 13 percent for 2016. However, it’s important to look not just at rate changes, but the rates themselves. According to a Kaiser Family Foundation analysis, a 40-year-old in Cleveland can buy the second-lowest-cost Silver plan for $234/month in 2016, before any subsidies are applied. The analysis examined a major metropolitan area in every state plus DC, and Cleveland, Ohio had the 7th lowest average benchmark price among the 51 exchanges.
Here are the approved average rate changes for the 15 carriers offering plans in Ohio’s exchange for 2016 (some are considerably higher than the carriers proposed):
- Aetna: 13.2 percent increase
- AultCare: 5.47 percent increase
- Buckeye Community Health Plan: 5.31 percent and 7.68 percent increases, depending on whether plan includes vision
- CareSource: 1.2 percent increase
- Community Insurance Company (Anthem BCBS): 4.05 percent increase
- Coordinated Health Mutual (InHealth): 14.8 percent increase (InHealth is being liquidated and is no longer offering plans as of May 2016)
- HealthSpan Integrated Care: 18.22 percent increase
- HealthSpan: 31.96 percent increase
- Humana: 19.25 percent increase
- Medical Health Insuring Corp. of Ohio: 14.47 percent increase
- Molina: 5.78 percent decrease
- Paramount: 9.94 percent increase
- Premier Health Plan: 0.68 percent decrease
- Summa: 0.89 percent and 9.64 percent increase, depending on plan type
- UnitedHealthcare: 1.75 percent increase (United is exiting the individual markets in most states at the end of 2016, including Ohio).
According to a Milliman analysis of the 38 states using Healthcare.gov for 2016, only Wisconsin has more carriers participating in the exchange than Ohio. But an HHS analysis indicated that there are actually 17 carriers in the Ohio exchange – one more than Wisconsin, and trailing only Texas, which has 19 carriers according to HHS (14 according to Milliman). Reports of this nature sometimes conflict simply because a carrier operates under two different names within a state.
234,341 people enrolled in private plans through the Ohio exchange during the 2015 open enrollment period (through February 22, including the week-long extension). 47 percent were new to the exchange for 2015, and 84 percent received premium subsidies. HHS had predicted 200,000 enrollees in the Ohio exchange, so the state ended up well above their target.
But enrollments aren’t the same as effectuated enrollments, since some people never pay their initial premiums and others opt to cancel their coverage for one reason or another. And Healthcare.gov stepped up their enforcement of immigration and/or financial data discrepancies in the first half of 2015, which means that there was more real-time adjustment of enrollment totals based on missing enrollment data. By the end of March 2015, effectuated enrollment in private plans through the Ohio exchange stood at 188,867 people. That number dropped slightly during the second quarter, with effectuated enrollments totaling 188,223 by June 30. Outside of open enrollment, attrition can generally be expected to outpace new enrollments, which require a qualifying event. But the drop in effectuated enrollments in Ohio was only about six hundred people during the second quarter of the year – about 0.3 percent of the total.
Ohio expanded Medicaid under the ACA. Medicaid/CHIP enrollment continues year-round, and total Medicaid/CHIP enrollment in Ohio grew by 623,626 people from late 2013 to October 2015. This includes people who were newly-eligible under the expanded guidelines, as well as people who were previously eligible but didn’t enroll prior to 2014. It also includes people who enrolled through Healthcare.gov as well as those who enrolled directly through Ohio Medicaid.
Uninsured rate plummets
The uninsured rate in Ohio was cut in half between 2013 and early 2015, largely as a result of Medicaid expansion (Ohio’s program was expanded as of January 1, 2014) and the subsidies that have made individual insurance affordable for low and middle-income households.
By mid-2015, the drop in uninsured rate was even more pronounced: According to Gallup data, 13.9 percent of Ohio’s population was uninsured in 2013, and that had fallen to 6.1 percent during the first half of 2015 – a 56 percent drop.
2015 rates and carriers
Sixteen carriers sold 2015 individual plans in the Ohio exchange, up from twelve in 2014. All except Time/Assurant returned to the exchange for 2016.
Ohio was tied with Michigan for having the most carriers of any exchange in the country for 2015. After reviewing plans and rates, the Ohio Department of Insurance announced in the fall that the average rate increase for 2015 would be 12 percent in the individual market – a double digit hike that was immediately held up by ACA opponents as evidence of the law’s failure to rein in premiums.
But the Department of Insurance used very basic math in their calculation, and the result was not particularly informative. A weighted average would have been much more helpful, and appears that it would also have indicated a lower overall average rate increase.
If we consider only plans sold within the exchange, a Commonwealth Fund analysis found an average price increase in 2015 of just 4 percent across all plans and all metal levels, for a 40 year-old non-smoker. For the least expensive silver plans, in 42 of Ohio’s 88 counties, prices were either flat or decreasing for 2015.
People who were enrolled in the second-lowest-cost silver plan (the benchmark plan) in 2014 were able to obtain lower premiums in 2015 if they were willing to shop around and make sure that they enrolled in the benchmark plan for 2015. In many cases this meant switching to a new plan, but in most areas of the state, it resulted in a premium decrease or just a small increase. For benchmark plan enrollees who qualified for premium subsidies, the changes were mostly offset by adjustments to the premium subsidies for 2015.
In the Cleveland area, the lowest and second-lowest cost silver plans and the lowest cost bronze plan were all offered by new carriers in 2015. All three switched from the carriers that were offering them in 2014, highlighting the importance of shopping around during open enrollment.
Also in the Cleveland area, the benchmark plan for a 40-year-old non-smoker averaged $247 per month in 2015, down two dollars from $249 in 2014. Media reports of double digit price increases in Ohio were overblown.
Medicaid expansion in the Buckeye state
Ohio Governor John Kasich is not an ACA proponent, but he’s long been a supporter of expanding Medicaid in Ohio, which was approved in late October 2013. Eligible residents were able to begin enrolling in expanded Medicaid on December 9, 2013 and the state received 1,165 applications on the first day of enrollment. By October 2015, net enrollment in Ohio’s Medicaid program had grown by 27 percent since the fall of 2013.
However, opponents of Medicaid expansion brought a lawsuit against the Ohio Department of Medicaid and the state’s Controlling Board because the General Assembly was bypassed in the decision to expand Medicaid. The plaintiffs hoped to block the state from expanding Medicaid, but on December 20th, 2013 the Ohio Supreme Court sided with Governor Kasich and kept Ohio Medicaid expansion on track. The Court’s ruling came less than two weeks before expanded Medicaid took effect.
Although Medicaid expansion is going well in Ohio, Governor Kasich has continued to reiterate his support for repealing Obamacare. In October 2014, he said that he’d like to see a full repeal, but with an accommodation for Medicaid expansion. ACAsignups’ Charles Gaba crunched the numbers and points out that if Ohio were to pay for its own expanded Medicaid (which would have to be the case if they wanted to keep it even in the face of a full repeal of the ACA), it would amount to an $840 million annual tax increase shouldered by the people of Ohio (reminiscent of Mitch McConnell pushing for repeal of the ACA while allowing Kentucky to keep Kynect?).
Kasich is campaigning for the GOP presidential nomination, and he’s worked to distance himself from Obamacare – officially calling for repeal – while supporting many pivotal aspects of the law. But his support for Medicaid expansion remains steadfast, with Kasich noting – correctly – that if the state had not expanded Medicaid, Ohio residents would have been footing the tax bill to provide coverage for residents of other states, while realizing none of their benefits in their own state.
2014 enrollment and prices
By mid-April, 154,668 Ohio residents had completed their Obamacare enrollment, selecting private plans in the exchange.
And by the end of August, 367,395 people in Ohio had enrolled in the newly-expanded Medicaid program in Ohio – surpassing the state’s estimate for this year and next year combined. In addition, by mid-April another 124,195 people had enrolled in Medicaid who qualified based on the old guidelines but had not been previously enrolled. Their enrollment is due in large part to the attention that ACA implementation has brought to the Medicaid program, called the “woodwork” effect.
All told, that’s over 646,000 people in Ohio who obtained new health insurance by the fall of 2014, thanks to Obamacare.
A report released by HHS in June compared after-subsidy premiums paid by exchange enrollees in the 36 states where HHS is running the exchange. In Ohio, the average after-subsidy premium was $121 per month – significantly higher than the $82 per month average across all 36 states.
Ohio’s after-subsidy premiums in 2014 were the fourth highest among the 36 states (only New Jersey, North Dakota and Deleware are higher), but the discrepancy is a factor of the enrollees’ incomes and the plans they selected: The ACA completely levels the field for people with the same incomes who select the second-lowest-cost silver plan in their exchanges. But among enrollees who qualify for subsidy, there are significant differences in income, and enrollees are free to apply their subsidies to any “metal” plan in the exchange.
Although the average after-subsidy premiums are higher in Ohio than in most other states, base rates in the Ohio exchange are just slightly lower than the average of the 36 states where HHS is running the exchange. Averaged across all age groups, the lowest cost 2014 bronze plan in the Ohio exchange was $263/month, and the lowest cost silver plan was $304/month.
Exchange history in Ohio
In November 2012, Governor Kasich formally announced that Ohio would not implement a state-run health insurance exchange. In the same letter, Kasich indicated that Ohio would retain control of plan management activities and determining eligibility for the state’s Medicaid and Children’s Health Insurance Plan (CHIP). Ohio is one of seven states that use the marketplace plan management model.
CMS announced on November 22 that the technology necessary for applicants to enroll in exchange plans directly through insurers was working and being piloted in three states, including Ohio. The program was summarized in a presentation by Families USA in early March.
Ohio residents can compare plans, determine subsidy eligibility and enroll in coverage at Healthcare.gov.
Leadership’s opposition to the ACA
In June 2013, the Ohio Department of Insurance issued a press release announcing that 14 insurers filed plans to offer more than 200 options for individual insurance, and seven insurers would offer 84 options for small businesses (ultimately, two carriers backed out, leaving 12 in the exchange in 2014). Lt. Gov. Mary Taylor, who also directs the state’s insurance department, stated in the press release that “consumers will have fewer choices and pay much higher premiums for their health insurance starting in 2014.”
Both opponents and supporters of the Affordable Care Act jumped on the press release. Opponents claimed Ohio was the latest example of “rate shock.” Supporters dismissed the announcement for making “apples-to-oranges” comparisons and pointed out that both Kasich and Taylor have been outspoken about their opposition to the ACA.
Taylor is still no fan of the ACA, and is still the Director of the Department of Insurance. In a May 2014 press release, Taylor said that “Obamacare is hitting us harder and driving our costs up significantly.”
Laws were enacted in Ohio to make it more difficult for navigators to be certified, which means that the state has fewer people available to assist applicants, and there was a delay in getting them started as navigators after the exchange opened in October 2013.
Ohio health insurance exchange links
State Exchange Profile: Ohio The Henry J. Kaiser Family Foundation overview of Ohio’s progress toward creating a state health insurance exchange.