Time to choose: Much of state left with one Obamacare insurer as enrollment period opens

Nov. 01--The Affordable Care Act, also known as Obamacare, has dominated discussions everywhere from the White House to kitchen tables since the Trump administration took over in January.

Obamacare, passed in 2010 and fully implemented by 2014, has been subject to multiple congressional repeal attempts, several White House executive orders and much fanfare from both sides of the aisle.

In North Dakota and across the country, however, Obamacare enrollment will open Wednesday for a six-week period, about half the length of previous years.

What does all of the action, or inaction, in Washington mean for the roughly 20,000 North Dakotans who rely on health insurance provided by Obamacare exchange markets this year and beyond?

CSRs, Premiums and the Marketplace

North Dakota had a relatively strong and competitive Obamacare marketplace in the last few years with three insurers covering the state.

This year, only Blue Cross Blue Shield (BCBSND) is covering the entire state. Sanford Health Plan is offering Obamacare plans in only five counties (Cass, Traill, Burleigh, Morton and Oliver) and Medica decided to pull out of the marketplace entirely.

Medica and Sanford both cited federal cuts to cost sharing reductions (CSR)--payments made by the federal government to insurance carriers to help low-income consumers with out-of-pocket costs, such as copayments and deductibles--as reasons why they are exiting or limiting their role in the individual health insurance marketplace.

In a statement in late September on Medica leaving the marketplace, Insurance Commissioner Jon Godfread said his department rejected requests from Medica to include cuts to CSRs while setting premium rates.

"We had to make the decision to move forward with rates that assumed payments would be made," Godfread said.

Medica predicted correctly, it turned out a few weeks later.

On Oct. 12 the Trump administration announced the $7 billion CSR cut, and several days later Godfread said there would be "no additional rate increases" allowed for health insurance premiums.

Tony Piscione, vice president of Actuarial Services for BCBSND, said his company received about $4 million in CSR funding in 2016, and that it will have to cover that cost, or likely a higher cost, entirely by themselves this year.

"(Leaving the Obamacare market) this year was a consideration," Piscione said. "Ultimately, we decided that we made that commitment to our members in North Dakota and we wanted to stick with that commitment. We'll just need to absorb whatever that financial impact may end up being."

Sanford announced last week that it was withdrawing from the Obamacare marketplace in all but the five North Dakota counties.

"When things like the termination of CSRs is made after insurers have set the rates for the year, it makes it very difficult," said Kirk Zimmer, executive vice president for Sanford Health Plan. "We worked to continue the exchange (in five counties) in a matter that covers the maximum number of North Dakota consumers and minimizes the losses that we were going to incur because of the CSR."

In Stark County, as in 48 of North Dakota's 53 counties, BCBSND will be the only insurance carrier participating in the Obamacare marketplace. Though premiums would be even higher if CSR funding cuts were factored in, BCBSND premiums are expected to rise on average a little more than 20 percent.

"I suspect that some will be priced out of the market this year," said Deb Nelson, executive director of Dickinson's DLN Consulting. "People should really study those plans on what option is going to work the very best for them."

In previous years, Nelson helped southwest North Dakota residents looking to get coverage through Obamacare. Though funding for her program was cut this year, she will still help navigate Obamacare on a pro-bono basis this enrollment period.

She said it might be more challenging this year to find an affordable health care plan on the exchange market, but she urges people to do all they can to get coverage.

"The big thing is we really encourage people to get insured, one way or the other," Nelson said. "It's so important, not only for them and their own health but for everybody else. Insured people end up having to pay the hospital costs (of uninsured patients)."

Alexander-Murray

Godfread argued that Medica's exit of the market "illustrates that North Dakota will not be insulated from the collapse of the ACA," describing it in a "death spiral." Others believe blame for uncertainty in Obamacare exchanges should fall at least in part on the Trump administration.

Andy Slavitt, former acting administrator of the Centers for Medicare and Medicaid Services (CMS), was in charge of administering Obamacare nationally under the Obama White House and argues that the Trump administration is attempting a "synthetic repeal" of the law through executive action.

"An administration who continually tries to undermine the law of the land is not sustainable and I doubt that it's legal," Slavitt said in a phone interview. "If (Trump's) goal is to increase premiums, he's succeeding. If his goal is to reduce the amount of people getting health care coverage, he's succeeding."

In the wake of the CSR cuts, U.S. Sens. Patty Murray, D-Wash., and Lamar Alexander, R-Tenn., announced they had reached a bipartisan deal to fund the CSR subsidies and other Obamacare outreach programs cut by the Trump administration. The bill, which has the strong support of U.S. Sen. Heidi Heitkamp, D-N.D., is still making its way through the Senate.

"Alexander and Murray invited non-committee members to participate in the process and over 30 volunteered to go, which is kind of unheard of around here," Heitkamp said. "Funding the CSR payments is huge for North Dakota and other states. ... This is really what can happen when you use the process that you are supposed to use. I'm very excited about this."

Sen. John Hoeven, R-N.D. said he will need to see the final product before making a final decision on the bill, and is also wary of the chances it has to pass into law.

"(Rep. Kevin Brady, R-Texas) and (Sen. Orrin Hatch, R-Utah) proposed eliminating individual and employer mandates and that would certainly help bring more support to the bill," Hoeven said, "We need to get to a long-term solution that truly gives people choice. North Dakotans need to do what's best for North Dakotans. This one-size-fits-all government-run health care is not working."

In a statement, U.S. Rep. Kevin Cramer, R-N.D., did not come out firmly for or against the Murray-Alexander proposal.

"I support the efforts of the administration and those in Congress who are working to provide relief to Americans suffering under Obamacare," Cramer said. "Any appropriations to maintain funding for cost-sharing reduction payments ... should be tied to meaningful health policy reform that provides more flexibility for states and better care for the American people."

The Murray-Alexander billhas 12 Republican and 12 Democratic cosponsors in the Senate, but may face stiff barriers in House and White House if it passes in the Senate.

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