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.
In 2015, total enrollments were aggregated throughout open enrollment, and it wasn’t until the end of March that we saw the effectuated enrollment total start to decline. In Ohio, effectuated enrollments dropped below 189,000 by the end of March, 2015 – the drop-off in 2016 won’t be as pronounced during the first several weeks following open enrollment, making the 243,715 enrollment figure even more substantial.
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).
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.
InHealth Mutual CO-OP still operational…
InHealth Mutual (Coordinated Health Mutual Inc.) is 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 is among the 11 that are continuing to provide coverage in 2016 (Land of Lincoln Health in Illinois is still operational, but has ceased offering new plans; 10 CO-OPs, including InHealth Mutual, are still selling plans for 2016).
Ironically, InHealth Mutual may have been saved by 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. The risk corridor shortfall that was announced in October 2015 stemmed from the fact that very few carriers were profitable in 2014, while a great many had claims that exceeded expectations. 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. They still had a loss of $9 million during the first half of 2015, and have been placed under enhanced regulatory oversight. And although their reserves had fallen from $49.2 million to $27.1 by mid-2015, they still had ten times as much in reserves as they’re required to have.
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, although the actual rate change varies from one plan to another.
InHealth’s average pre-subsidy silver plan premium in 2016 is almost $345/month, which is quite a bit higher than the $309/month average for silver plans from other carriers in the Ohio exchange. In 2015, InHealth’s average silver premium was also higher than the average for other plans, but only by about $11/month – the gap has widened for 2016 as the CO-OP works to stem their losses.
… and keeping OhioHealth in network
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. The insurer described OhioHealth as an “outlier” in terms of how much it charged, and said that negotiations to try to get OhioHealth to agree to lower reimbursement rates had stalled in December. When InHealth Mutual notified regulators of their plan to drop OhioHealth from the network, the Department of Insurance had 15 days to review the documents related to the provider network changes – pushing the whole process out to almost the end of January. InHealth members weren’t notified until January 30 – or in some cases, early February – that OhioHealth would no longer be in the carrier’s network.
Richard Mayhew has a good explanation of InHealth’s likely strategic plan in terms of minimizing their exposure to high-cost enrollees with this network-shrinking move, but he also points out that the timing of the change – with enrollees receiving notification of the network change at most one day before the end of open enrollment – left many people unable to switch to a different plan until 2017, despite the newly-reduced network.
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, and would notify members by the start of open enrollment (November 1, 2016) if OhioHealth was going to be dropped from the network at the end of 2016. Neither InHealth nor OhioHealth clarified what agreement had been reached, or which side agreed to compromise in order to keep the network intact throughout 2016.
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.
Highest after-subsidy premiums among Healthcare.gov states
80 percent of the enrollees in the Ohio exchange in 2016 are receiving premium subsidies, which average $240/month. The average pre-subsidy premium in Ohio is $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
- 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 exchange markets in most states at the end of 2016, but they haven’t confirmed whether they’ll exit the market in Ohio or not).
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 have 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.