Health insurance in Pennsylvania
- Pennsylvania uses the federally facilitated marketplace and enrolls through HealthCare.gov — for now.
- Pennsylvania plans to be running its own exchange in time for the 2021 plan year.
- Pennsylvania is also working to establish a reinsurance program, using federal pass-through funding and the savings generated by switching to a state-run exchange.
- Open enrollment for 2019 coverage in Pennsylvania ended on December 15; enrollment for 2020 will begin November 1, 2019.
- Enrollment is still possible for Pennsylvanians with qualifying events.
- Short-term health plans are available in Pennsylvania with initial plan terms up to 364 days.
- Eight insurers are offering coverage through the Pennsylvania exchange.
- The average PA individual-market premium decreased 2.3 percent for 2019. But subsidies dropped significantly.
- About 389,000 Pennsylvanians enrolled in 2018 coverage through the state exchange.
- In 2015, ACA’s Medicaid expansion took effect in Pennsylvania; 700,000 people are covered as a result.
- More than 2.7 million Pennsylvania residents are enrolled in Medicare.
Pennsylvania’s health marketplace
Pennsylvania initially opted not to establish its own exchange, so the state utilizes the federally run exchange at HealthCare.gov. But that’s expected to change by the fall of 2020, when Pennsylvania plans to be running its own exchange.
The state enacted legislation in 2019 to authorize the transition away from HealthCare.gov. By switching to its own exchange, Pennsylvania expects to save up to $50 million per year, which will be used to cover the state’s portion of the cost of a reinsurance program. The state will also gain numerous other benefits in terms of flexibility and control over the marketplace, described here by Jessica Altman, Pennsylvania’s Insurance Commissioner.
Assuming the state’s reinsurance waiver proposal is approved, the federal government will provide pass-through funding that will cover the majority of the cost of the reinsurance program (because reinsurance will result in lower premiums, premium subsidies will also decline, resulting in savings for the federal government; pass-through funding refers to the process of using a 1332 waiver to allow the state to use the savings).
Pennsylvania estimates that the transition to a state-based exchange and the implementation of a reinsurance program will result in individual market premiums about 5 to 10 percent lower in 2021 than they would otherwise have been.
Open enrollment for 2019 coverage ran from November 1 2018, through December 15, 2018. Open enrollment for 2020 coverage will run from November 1, 2019 through December 15, 2019. Pennsylvania has eight insurers participating in the exchange market for 2019 (although some of them share a parent company; the state’s official tally is six). That includes newcomer Ambetter in the Philadelphia area, and Geisinger Quality Options has rejoined the exchange after exiting at the end of 2016. And while the average rate increase proposed by those insurers was initially 4.9 percent (later modified to 0.7 percent), the average approved premium for participating insurers ended up decreasing by 2.3 percent. But average premium subsidies in Pennsylvania are significantly smaller than they were for 2018, making it particularly important that people actively shopped during open enrollment.
Pennsylvania enrollment in qualified health plans
By the end of ACA’s first open enrollment period, 318,077 people purchased private plans in the Pennsylvania exchange, and 81 percent received premium subsidies. As of March 2015, Pennsylvania’s effectuated exchange enrollment was 412,347. About 78 percent of those enrollees were receiving premium subsidies on average of $248 per month.
Enrollment continued to grow through 2016, but decreased in 2017 and again in 2018. For 2018, just over 389,000 Pennsylvania residents enrolled in coverage through exchange during open enrollment. That was almost 9 percent lower than the 426,059 people who had enrolled during the prior year’s open enrollment period.
During the open enrollment period for 2019 coverage, 365,888 people enrolled in private plans through the Pennsylvania exchange. This year-over-year decline mirrors a national trend of reduced enrollment among states that use the federally run exchange. (Enrollment has tended to increase in states that run their own exchanges.)
Read more about Pennsylvania’s health insurance marketplace.
Medicaid in Pennsylvania
Although Pennsylvania was a year behind many other states, the state accepted ACA’s Medicaid expansion and it took effect on January 1, 2015. Eligible enrollees were able to apply starting December 1, 2014. In the first two days of enrollment, 41,500 Pennsylvania residents applied for Healthy Pennsylvania coverage.
By 2015, 439,000 people had enrolled through the Medicaid expansion program. By 2017, there were 716,000 people in Pennsylvania who were covered by Medicaid as a result of the expansion. But total enrollment in expanded Medicaid had dropped slightly by July 2019, when it stood at 685,759.
Read more about Medicaid expansion in Pennsylvania.
Short-term health insurance in Pennsylvania
Pennsylvania does not have state regulations pertaining to the duration of short-term health insurance plans, so the state defaults to the federal regulations.
That means insurers in Pennsylvania can offer short-term plans with initial terms up to 364 days and the option to renew for a total duration of up to 36 months.
Read more about short-term health insurance in Pennsylvania.
How did Obamacare help PA residents?
In 2013, before the bulk of the ACA’s regulations were implemented, the uninsured rate in Pennsylvania was 9.6 percent — well below the 14.5 percent national average uninsured rate at that point.
Initially, the state did not expand Medicaid, which resulted in a small decline in its uninsured rate during 2014, the year the ACA took effect. About 360,000 people obtained coverage, including Medicaid/CHIP and private plans, through the Pennsylvania exchange during the first open enrollment.
Pennsylvania expanded Medicaid in 2015 (initially with a waiver, but then as straight expansion once Gov Wolf took office), and saw even more residents gain coverage. By 2017, Pennsylvania’s uninsured rate dropped to 5.5 percent. Nationwide, 8.7 percent of individuals were uninsured as of 2017.
In September 2015, Pennsylvania was awarded more than $3.1 million in Navigator grants to help six organizations provide outreach and enrollment assistance for health coverage. In September 2017, total Navigator grants for Pennsylvania’s six Navigator organizations amounted to just under $2 million. Across the country, Navigator grants were sharply lower in 2017, due to funding cuts made by the Trump Administration.
Navigator funding was slashed again in 2018, and just one organization — the Pennsylvania Association of Community Health Centers — received $400,000 in Navigator funding prior to the start of open enrollment for 2019 coverage. But the Pennsylvania Insurance Department has explained that they are conducting “an outreach and marketing campaign to make up for a lack of funding by the federal government for outreach during the 2019 open enrollment season.”
Pennsylvania and the Affordable Care Act
In 2010, both of Pennsylvania’s U.S. Senators, Democrats Robert Casey and Arlen Specter, voted in favor of the ACA. In the U.S. House, eleven Democrat representatives voted yes, while seven Republicans voted no.
Specter has since been replaced in the Senate by Republican Pat Toomey, and the U.S. House now includes just five Pennsylvania Democrats, and 12 Republicans.
At the state level, the overall population in Pennsylvania has a Democratic majority, but the Republicans hold a majority in the state’s House and Senate. Former Gov. Tom Corbett was also a Republican and not an ACA supporter. As such, the state defaulted to a federally facilitated health insurance exchange.
But unlike many Republican governors, Corbett pursued the possibility of Medicaid expansion under the ACA. Corbett submitted his proposal for a modified version of Medicaid expansion – dubbed Healthy Pennsylvania – to HHS in February 2014. It took half a year of negotiations, but on August 28, 2014, Corbett and HHS announced that they had reached an agreement, and Pennsylvania became the 28th state, including DC, to accept federal funding to expand Medicaid and thereby cover residents with incomes up to 138 percent of poverty.
Corbett lost the 2014 gubernatorial election to Tom Wolf, a Democrat. Gov. Wolf was sworn into office on January 20, 2015. Shortly after he assumed office, Wolf began to do away with Healthy PA in favor of traditional Medicaid expansion, which had been a campaign promise. Pennsylvania has had Medicaid expansion as called for in the ACA ever since, as opposed to the modified version of expansion that Corbett had overseen.
And under Wolf’s administration, the state is pursuing a transition to a fully state-run exchange and a reinsurance program, which are expected to work in tandem to reduce individual market health insurance premiums in the state.
Medicare in the Keystone State
As of mid-2019, Pennsylvania Medicare enrollment exceeded 2.7 million people, which was nearly 21 percent of the state’s population. About 18 percent of the U.S. population is enrolled in Medicare. In the Keystone State, 84 percent of Medicare beneficiaries qualify based on age alone and 16 percent qualify due to a disability; this distribution is also on par with the national average.
As of 2016, Medicare spent about $9,714 annually per Original Medicare enrollee in Pennsylvania, which was just above the $9,533 per enrollee spent nationally.
Pennsylvanians that qualify for Medicare can select a Medicare Advantage plan instead of Original Medicare, and about 42 percent do so. About 42 percent of Pennsylvania’s Medicare beneficiaries are enrolled in stand-alone prescription drug benefits through a Medicare Part D plan. Nationally, about 36 percent of Medicare beneficiaries choose a Medicare Advantage plan and 45 percent select an Rx plan.
Scroll to the bottom of this page to see a summary of recent health care reform legislation in Pennsylvania.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.