North Carolina experienced a 5.3 percent decline in enrollment in the 2017 federal health insurance exchange, according to a report released Wednesday.
There were 519,803 enrollees for 2017, down from 549,158 in 2016, according to The National Academy for State Health Policy.
Blue Cross and Blue Shield of N.C. covered 502,000 marketplace participants in 2017. It was the only provider in 95 of the state's 100 counties for 2018.
The national enrollment was 11.8 million, down 3.7 percent from 2017.
Even with the decline, North Carolina again had the fourth highest overall enrollment, as well as third highest among the 34 states on the federal-based marketplace.
Only five states with the federal-based marketplace had an enrollment increase, while 11 of the 16 states with state-based marketplaces had an increase.
The North Carolina percentage decline matched the overall decrease for the 34 federal-based marketplaces.
Uncertainty over the Affordable Care Act plans cast a shadow on the 2017 enrollment period amid a push by President Donald Trump to allow the purchase of skimpier insurance plans than the ACA requires. Federal money for marketing the exchange was sharply reduced during the sign-up period. That period also was shortened from 90 days to 45 days.
"For the first time, we now have the full national picture of how the individual marketplaces did this year, and it is a picture of remarkable stability," said Trish Riley, executive director of the state health policy group.
"Despite all the uncertainty and challenges we have seen, particularly for consumers living in states supported by state-based marketplaces, we see millions of Americans continuing to benefit from the coverage they get in the individual market."
'Structure remains solid'
Mark Hall, a professor of law and public health at Wake Forest University, said the report "shows that, despite the Trump administration's effort to undermine the Affordable Care Act, its basic structure remains solid."
"This is a testament to its fundamental soundness. In North Carolina, enrollment dipped, but not as much as some people feared."
North Carolina experienced another drop in the number of individuals without health insurance to a record low of 10.4 percent in 2016, according to data released in September by the U.S. Census Bureau.
However, the rate could be significantly lower if the Republican-controlled General Assembly approved expanding Medicaid coverage to more than 500,000 of the 1.04 million North Carolinians who still lack health insurance.
North Carolina is one of 10 states that can move forward with a Medicaid work requirement, if the legislature approves it, since they have a waiver request in to the Centers for Medicare and Medicaid Services.
In October, Blue Cross received state Insurance Department approval for a 14.1 percent premium increase for 2018 for marketplace exchange plans. The 14.1 percent rate increase was an average across all ACA plans; consumers in some counties could pay more than the average, the insurer said.
Brian Tajlili, director of actuarial and pricing services for the insurer, said in August that "the individual market in North Carolina has become less volatile."
"We have gotten a better handle on the anticipated medical costs of people covered in this group (during June and July), which has made it easier for us to estimate the necessary price of our ACA health plans," Tajlili wrote.
"We think this (14.1 percent) increase will allow our ACA plans to be financially viable, while being more affordable for our customers."
Overall 2018 enrollment - whether renewals or new participants - was bolstered by:
larger tax subsidies that lowered costs for millions of Americans;better targeted outreach to key populations;heightened news coverage;and improved enrollment operations.
Subsidies cut costs
Across the nation, for people who receive subsidies, many paid less for their plan in 2018 than in 2017. Subsidized consumers are insulated from premium increases because as the cost of their coverage rises, so does the amount of assistance they receive.
In 2018 the increase in financial assistance was often greater than the change in their plan's premiums.
The left-leaning N.C. Justice Center said in October that 356,560 North Carolinians - 65 percent of those who enrolled in a plan in 2016 - qualified for a federal payment subsidy.
The state health policy group cautioned that state marketplaces and state insurance departments should expect to brace for new challenges in 2019.
That's when the repeal of the federal individual tax penalty takes effect, along with projections of higher health care costs.
There's also expectations that some states, most notably Idaho currently, will pursue the ability to offer limited association health plans and short-term insurance plans as lower-cost, lower-coverage options to millennials.
Mitch Kokai, a policy analyst with Libertarian think tank John Locke Foundation, said congressional health-care policymakers "should devote more attention to ideas that are likely to play a role in helping to reduce costs."
"This means bringing market forces into the process," he said. "It means having patients and doctors playing a larger role in health care decisions, not just government bureaucrats and insurance companies."
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