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South Carolina health insurance

21k off-exchange enrollees in SC may be missing out on subsidies

South Carolina 2019 enrollment

  • Enrollment in individual market plans for 2019 coverage in South Carolina will run from November 1, 2018, to December 15, 2018.

South Carolina health insurance at a glance

As of early 2018, there were nearly 198,000 people enrolled in individual market health insurance plans through South Carolina’s exchange. As is the case nationwide, the vast majority of the population does not have individual market coverage — most people have employer-sponsored insurance or government-provided coverage (Medicare, Medicaid, CHIP, etc.)

South Carolina’s federally facilitated exchange has only one carrier offering 2018 health insurance coverage (Blue Cross and Blue Shield of South Carolina) and that will continue to be the case in 2019. Off-exchange, there are only two insurers (BCBSSC, along with Blue Choice Health Plan), which is down from six carriers that offered individual market plans off-exchange in 2017.

Of South Carolina’s exchange enrollees, 93 percent received premium subsidies in 2017. HHS estimated in 2016 that there were 21,000 people with off-exchange plans who would be subsidy-eligible if they switched to exchange plans. Off-exchange plans are not eligible for Obamacare subsidies, so they’re really only a suitable alternative for people who wouldn’t otherwise qualify for premium subsidies and/or cost-sharing subsidies (premium subsidies extend up to 400 percent of the poverty level; for a family of four in 2018, that’s $98,400).

Open enrollment for 2019 coverage in the individual major medical market (both on- and off-exchange) will run from November 1, 2018 to December 15, 2018. After December 15, 2018, individual market coverage for 2019 will only be available to people who experience a qualifying event. Native Americans can enroll in individual market plans year-round, however. And Medicaid/CHIP enrollment also continues year-round for people who are eligible. South Carolina has not expanded Medicaid under the Affordable Care Act, which means the state’s pre-ACA eligibility guidelines still apply.

South Carolina health ratings

South Carolina ranked 41st out of the 50 states and District of Columbia by The Commonwealth Fund’s Scorecard on State Health System Performance in 2017, which was unchanged from their ranking in 2015. The state was scored on health indicators related to five measures: Access, Prevention & Treatment, Avoidable Hospital Use & Costs, Healthy Lives, and Equity.

South Carolina performed poorly in the areas of Prevention & Treatment, Healthy Lives, and Equity, ending up in the bottom quartile of the states for all three measures. In particular, the percentage of adults who went without medical or dental care in the past year due to cost was particularly high in South Carolina. If South Carolina improved to the level of the best-performing state (Vermont), then 341,580 more adults would be insured and 333,722 fewer adults would go without needed care because of cost.

Additional details showing how the state was rated are available in the South Carolina scorecard.

The 2017 edition of America’s Health Rankings placed South Carolina squarely in the bottom quartile, at 44th out of the 50 states in terms of overall health.

The state’s rating is helped somewhat by a relatively moderate disparity in health status and a somewhat low number of preventable hospitalizations. But the state’s public health challenges are formidable: A quarter of the population is physically inactive, and South Carolina has one of the nation’s higher uninsured rates. The state ranked in the bottom 20 for public health funding and the number of primary care physicians and doctors.

Trust for America’s Health provides more data on overall public health in South Carolina in their 2017 edition of Key Health Data About South Carolina, which includes information on specific diseases and health factors. The Robert Wood Johnson Foundation has also compiled health data in South Carolina and broken it down to a county level; you can use this interactive map to see how the counties in South Carolina rank against one another.

2019 SC health insurance carriers — unchanged from 2018

Blue Cross and Blue Shield of South Carolina is the only carrier offering exchange plans in South Carolina. For 2019, average premiums in the South Carolina exchange are increasing by 9.3 percent (before premium subsidies are applied). For off-exchange BlueChoice plans, the proposed average rate increase is less than 7 percent.

Rates for BCBS of South Carolina plans sold through the state’s federally facilitated exchange increased an average of 31 percent for 2018, but most of that was due to the Trump Administration’s decision to eliminate federal funding for cost-sharing reductions (CSR). The cost of CSR has been added to silver plan premiums, which makes plans at other metal levels particularly affordable for enrollees who qualify for premium subsidies.

Aetna (Coventry), BlueChoice, and UnitedHealthcare previously offered plans through South Carolina’s exchange but did not return for 2017. Blue Choice continues to offer coverage outside the exchange (as does BCBSSC), but the other individual market insurers have left the state altogether.

How has Obamacare helped SC?

According to US Census data, the uninsured rate in South Carolina dropped from 15.8 percent in 2013 to 10 percent in 2016. The nation’s average dropped from 14.5 percent to 8.6 percent in the same time period.

South Carolina leadership’s opposition to the ACA means the state has thus far refused to expand Medicaid, so a cornerstone of the law’s ability to reduce the uninsured rate is not being utilized. A Kaiser Family Foundation analysis estimates that there are 92,000 people in the coverage gap as a result of South Carolina’s refusal to accept federal funding to expand Medicaid.

South Carolina qualified health plan enrollment

In November 2013, the Kaiser Family Foundation estimated that 491,000 people could potentially buy qualified health plans (QHPs) through South Carolina’s health insurance exchange, and that 336,000 of them would qualify for premium subsidies.

By February 2018, early in the fifth year of exchange operation, a total of 197,699 people had effectuated coverage under private plans through South Carolina’s exchange. Of those individuals, 93 percent were receiving premium subsidies that averaged $582 per month.

South Carolina and the Affordable Care Act

In 2010, both of South Carolina’s U.S. senators, Republicans Jim DeMint and Lindsey Graham, voted no on the ACA. DeMint has since been replaced by Tim Scott, who is also a Republican. Graham is still in office and was instrumental in Senate Republicans’ last-ditch effort to repeal the ACA in September 2017 via the Graham-Cassidy Amendment. But Graham noted after the effort failed that he had essentially no understanding of health policy, saying “Well, I’ve been doing [healthcare reform policy] for about a month. I thought everybody else knew what the hell they were talking about, but apparently not.

In the U.S. House, four Republican representatives from South Carolina voted no, while two Democrats voted yes. Only one of them, Jim Clyburn, is still in office and is the lone Democrat in South Carolina’s current U.S. congressional delegation, which includes two Republican senators and six Republican representatives.

Nikki Haley was Governor when the ACA was enacted and implemented, and has long been fiercely opposed to the ACA, calling it “disastrous” and vowing to “continue to fight ObamaCare every step of the way.” Haley had a state legislature with a strong Republican majority, so her efforts to block ObamaCare in South Carolina were largely successful. The state defaulted to a federally run exchange, and has refused to expand Medicaid.

Haley is currently serving as Ambassador to the United Nations in the Trump Administration, and Henry McMaster is the current Governor of South Carolina. McMaster was Attorney General in South Carolina before becoming lieutenant governor and then governor. During his time as AG, McMaster organized a legal challenge against the ACA.

South Carolina Medicaid/CHIP enrollment

South Carolina is currently one of 19 states that has not yet expanded Medicaid (18 states if you count Maine as having expanded Medicaid; Maine voters approved Medicaid expansion in November 2017, but the state still has to work out the funding and implement the expansion). South Carolina has no pending plans to expand coverage, despite tireless work on the part of consumer advocates. The ACA would have expanded Medicaid to cover all legal residents with incomes up to 138 percent of poverty, but in 2012 the Supreme Court ruled that states could opt out of Medicaid expansion. Governor Haley, Governor McMaster, and the state’s Republican-led legislature have steadfastly refused expansion.

Despite this, total Medicaid/CHIP enrollment in South Carolina has increased by 13 percent from 2013 to September 2017, largely as a result of outreach and education due to the ACA.

The general consensus is that states like South Carolina will eventually expand Medicaid because of the economics involved. The question is really when, rather than if. But in states where political leadership is strongly opposed to Obamacare, South Carolina Medicaid expansion could still be several years away.

Roughly 224,000 additional people would be eligible to enroll in Medicaid if the state were to expand coverage guidelines. But instead, enrollment is still contingent on South Carolina’s strict eligibility guidelines: Non-disabled adults without dependent children are ineligible regardless of income, and parents with dependent children are only eligible if their household income doesn’t exceed 62 percent of poverty (a little over $1000/month for a family of three).

Because the state refused to expand Medicaid, South Carolina has 92,000 people – about 21 percent of its uninsured population – in the coverage gap, with no access to financial assistance with their health insurance. These residents would be eligible for Medicaid if the state were to accept federal funds to expand coverage. But for now, there are no realistic insurance options available for people with incomes below the poverty level who do not qualify for Medicaid under the state’s existing guidelines.

South Carolina officials have said that instead of expanding Medicaid, they are focusing on their Healthy Outcomes program, which helps chronically ill people without health insurance get access to treatment through free clinics and hospital charity programs. Unfortunately, the program can only assist about 8,500 people – a tiny fraction of the people who are in the coverage gap in South Carolina.

South Carolina’s CO-OP

In 2014 and 2015, South Carolina residents could buy health insurance through Consumers Choice, the state’s Consumer Oriented and Operated Plan (CO-OP). The CO-OP was funded under the ACA with a grant from the federal government.

Nationwide, about $2 billion was awarded to CO-OPs in 22 states. In South Carolina, Consumers’ Choice Health Plan (CCHPSC) received about $87.6 million. However, by November 2015, officials had announced its closure. As of September 2018, there were only four remaining CO-OPs offering plans in five states.

Does South Carolina have a high-risk pool?

Prior to 2014, individual health insurance was underwritten in nearly every state, including South Carolina. This meant that pre-existing conditions could prevent an applicant from getting coverage, or could result in significantly higher premiums or policy exclusions.

The South Carolina Health Insurance Pool was created in 1989 to give people an alternative if they were unable to obtain individual health insurance because of their medical history.

Implementation of the ACA and a guaranteed issue individual market has made high-risk pools largely obsolete, but the South Carolina Health Insurance Pool is still operational and does not yet have plans to terminate coverage. HIPAA-eligible and TAA-eligible (Trade Adjustment and Assistance Act) enrollees can still obtain coverage for 2018. While SCHIP is still available for these applicants, they can also get policies in the individual market now, without having to worry about pre-existing conditions.

Medicare enrollment in South Carolina

South Carolina Medicare enrollment reached 941,169, about 19 percent of the state’s population, in 2015. As of 2015, South Carolina Medicare enrollment broke down as follows: 82 percent of beneficiaries were eligible based on age alone, while the other 18 percent qualified as the result of a disability.

As of 2009, South Carolina ranked 23rd in overall annual Medicare spending with $7.2 billion. More recent data shows that Medicare pays about $8,675 per South Carolina enrollee each year.

Those who want additional benefits beyond what original Medicare includes may select a Medicare Advantage plan instead of traditional coverage. In South Carolina, nearly 23 percent of Medicare recipients make this choice compared with 31 percent of all Medicare recipients.

Medicare Part D plans are also an option for South Carolina Medicare beneficiaries who want to stand-alone prescription drug coverage. Roughly 49 percent of South Carolina Medicare enrollees also have a stand-alone Rx plan compared with 45 percent of all Medicare enrollees.

State-based health reform legislation

Here’s a summary of recent South Carolina bills related to healthcare reform:

More South Carolina coverage

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