Understanding MNsure’s evolution in 5 graphics: bigger, a little older and more subsidies

Feb. 16--Minnesota's state-run health insurance exchange has changed a lot since 2014, when its debut featured cheap premiums and disastrous technological issues.

Today its technology works better but the low prices are just a memory. Now its future is uncertain as politics and market forces alike pose massive changes to the health insurance market.

At the end of MNsure's fourth open-enrollment period, it released stats Wednesday showing how it's changed over four years. Here's a look at what those numbers show:

STEADY GROWTH

The total number of enrollees on MNsure has grown steadily, ever since its chaotic launch in 2014. From 2015 to 2017 the health insurance exchange's enrollment doubled. (Its overall enrollment, though increasing, is far lower than a long-since-abandoned 2013 prediction that MNsure would have 377,000 enrollees in 2016.)

This growth isn't the whole picture, though. Minnesotans can buy individual health insurance through MNsure or directly from an insurer. In 2014, MNsure enrolled only about 14 percent of the whole individual market, among the lowest levels in the county. Now it's up to around 60 percent of the market -- but the market as a whole has shrunk.

"It looks like MNsure's getting a bigger piece of a smaller pie," said Jim Schowalter, president of the Minnesota Council of Health Plans.

MORE SUBSIDIES

The low premiums MNsure had in its first year were a double-edged sword. The way the federal Affordable Care Act was written, Americans could get tax subsidies for their health insurance -- but the subsidies were much lower and scarcer if premiums were low. Since 2014, premiums have increased drastically, and the subsidies have gone up to match them. The share of MNsure enrollees getting subsidies has risen by 50 percent since 2014.

That's good for the roughly 60 percent of MNsure enrollees who've seen subsidies defray most of the effect of rising premiums. But it's left the other 40 percent in the lurch, paying for the whole cost themselves. They're the reason the Minnesota Legislature recently set aside $310 million to give 25 percent discounts to Minnesotans who don't qualify for federal subsidies.

LESS-GENEROUS PLANS

One way Minnesotans have coped with rising premiums is to buy less-generous health plans. Under the Affordable Care Act, insurance plans are rated based on the share of medical expenses the insurance covers. A "Platinum" plan covers 90 percent of costs, a "Gold" plan covers 80 percent, a "Silver" plan 70 percent and a "Bronze" plan 60 percent.

When MNsure first launched, many enrollees took advantage of low premiums to buy generous Platinum plans. But rising prices have changed the picture drastically. Now Platinum plans have disappeared altogether, and the share of MNsure customers buying bare-bones Bronze plans has doubled and now covers more than half of the market.

A LITTLE OLDER

MNsure's customer base started old and has gotten slightly older since 2014. More than half of its customers are 45 or older. That's bad news for the individual insurance market, since older people usually have higher medical bills.

One reason for the relatively old MNsure customer base is the state's decision to offer coverage through MinnesotaCare to the state's working poor. Many MinnesotaCare members are younger: Last year around 30 percent of MNsure were under 35 years old, while 45 percent of MinnesotaCare members were.

CARRIER CHAOS

President Barack Obama infamously promised Americans that under the Affordable Care Act, "If you like your health plan, you can keep it." That ended up not being true, as many plans canceled coverage.

Many Minnesotans have experienced this firsthand on the individual market, where carriers have grown and shrunk dramatically over its four years -- when they haven't dropped out altogether.

MNsure's first year saw PreferredOne capture more than half the market with aggressively low premiums -- far too low, as it turned out. PreferredOne suffered huge losses and dropped out. Blue Cross Blue Shield then took up much of that market share -- only to leave the market itself for 2017.

Meanwhile, insurers that were once also-rans -- HealthPartners, Medica and UCare -- have grown to occupy three-fourths of the market between them.

Unlike past years that featured a dominant carrier, in 2017 all four remaining insurers have roughly equal shares of the market.

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