Effect of the Affordable Care Act in North Carolina (2009-2017)

Effect of the Affordable Care Act
Overview of the Affordable Care Act
The ACA in other states
Affordable Care Act glossary
Medicaid • Obamacare lawsuits • Republican effort to repeal the ACA
The data on this page was the most current data available as of October 2017.

The impact of the Affordable Care Act of 2010 (ACA), also known as Obamacare, was debated among politicians, policymakers, and other stakeholders. President Barack Obama (D) signed the ACA into law in 2010. The law facilitated the purchase of health insurance through a system of health insurance exchanges, tax credits, and subsidies. Initially, states were required to expand eligibility for Medicaid under the law; a 2012 ruling by the United States Supreme Court made the Medicaid expansion voluntary for states. The law also required insurers to cover healthcare services within a standard set of benefits and prohibited coverage denials based on preexisting conditions. Under the law, all individuals were required to obtain health insurance.

HIGHLIGHTS

Between 2013 and 2016, the number of uninsured individuals in North Carolina declined by 31.2%.

About 451,000 individuals in North Carolina were enrolled in health plans offered through the health insurance exchange in 2017. Enrollment in Medicaid amounted to about 2.1 million in May 2017.

The Kaiser Family Foundation found that between 2016 and 2017, average monthly premiums for benchmark plans on North Carolina's exchange increased by an average of 40% in the Charlotte market, from $409 to $572.

This article presents data that researchers have collected and analyzed, as well as reports they've released based on that data, as they attempt to understand the ACA's impact. See the following sections for more information:

1. Health insurance: This section provides information on insurance coverage overall, enrollment in Medicaid, and enrollment through the health insurance exchanges.
2. Consumer costs: This section provides information on the average premiums and deductibles paid by consumers.
3. Government spending: This section provides information on federal and state spending for Medicaid, tax credits and subsidies, and uncompensated care costs.
4. Market reactions: This section provides information on health insurer participation in the exchanges, narrow networks, and direct primary care.

For more information about the Affordable Care Act, click here.

Health insurance

Insurance coverage overall

Following the passage of the Affordable Care Act (ACA) in 2010, the nation as a whole saw a decline in the number of individuals without health insurance, particularly following the first open enrollment period for the health insurance exchanges in 2013 and the first state Medicaid expansions in 2014. According to the Census Bureau, between 2013 and 2014, the number of uninsured individuals declined by 18.8%, from 45 million to 36.7 million people. The uninsured rate was 16.3% in 2010, 14.5% in 2013, and 11.7% in 2014. By 2016, about 8.6% of the country lacked health insurance. Between 2013 and 2016, the number of uninsured individuals declined in every state, although the actual rate of decline varied from state to state.

Between 2013 and 2016, the number of uninsured individuals in North Carolina declined from 1.5 million to 1 million, a 31.2% decrease. As a percentage of the population, the portion of uninsured individuals in North Carolina fell from 15.6% to 10.4%. The line graph below displays the percentage of North Carolina's population that lacked health insurance for each year between 2004 and 2016—six years before and after the Affordable Care Act—as compared with the United States as a whole. Hover over the lines to view the data points; the solid line represents North Carolina while the dotted line represents the United States. The table below the graph displays figures on the uninsured population for the years 2013 and 2016 in North Carolina and three of its neighboring states.

Population without health insurance coverage, 2013 and 2016
State	2013 uninsured	2016 uninsured	Difference
Number	Percent	Number	Percent	Number	Percent
North Carolina	1,509,000	15.6%	1,038,000	10.4%	-471,000	-31.2%
Georgia	1,846,000	18.8%	1,310,000	12.9%	-537,000	-29.0%
South Carolina	739,000	15.8%	486,000	10.0%	-253,000	-34.2%
South Carolina	739,000	15.8%	486,000	10.0%	-253,000	-34.2%
United States	45,181,000	14.5%	27,304,000	8.6%	-17,876,000	-39.6%
Source: United States Census Bureau, "Health Insurance Coverage in the United States: 2016"

The Affordable Care Act expanded insurance coverage primarily in two ways: by expanding eligibility for state Medicaid programs and by providing tax credits for people to purchase private insurance. The RAND Corporation described the gains in coverage between 2013 and 2015 in the following way:

Click to view a larger version.

“	[F]rom October 2013 to April 2015 ... 22.8 million Americans became newly insured and 5.9 million lost coverage, for a net of 16.9 million newly insured Americans. The total number of uninsured Americans dropped from 42.7 million to 25.8 million. Much of this increase was driven by gains in employer-sponsored coverage. Among those newly insured, 9.6 million people enrolled in employer-sponsored health plans, followed by Medicaid (6.5 million), the individual marketplaces (4.1 million), nonmarketplace individual plans (1.2 million) and other insurance sources (1.5 million).	”
—RAND Corporation

The law also provided for the establishment of small business insurance exchanges, called Small Business Health Options Program Marketplaces, or SHOPs. The launch of the federal online website for SHOPs was delayed by one year, from November 2013 to November 2014. As of July 2015, 85,000 Americans were insured through a SHOP. According to data analyst and blogger Charles Gaba, who ran the website ACASignups.net, the federal government did not include SHOP enrollment in its official ACA enrollment reports.

Medicaid expansion

The Affordable Care Act originally required states to expand eligibility for Medicaid to cover all individuals, including childless adults, whose income is 138% of the federal poverty level (FPL) or below. In 2017, this amounted to $16,643 for individuals and $33,948 for a family of four. In 2012, the U.S. Supreme Court ruled that participation in the expansion must be made voluntary for states.

The provision for expanding Medicaid went into effect nationwide in 2014. As of September 2017, Medicaid expansion had been approved in 31 states. Of these states, six had obtained a waiver from the Centers for Medicare and Medicaid Services (CMS) to expand via an alternative method, such as assisting low-income individuals with paying premiums for private insurance. Nineteen states had not expanded Medicaid at that time.

North Carolina was one of 19 states that had not expanded Medicaid as of September 2017. Even if a state did not expand Medicaid, it could have seen an increase in enrollment in the program due to the ACA's requirement to acquire health insurance. In fiscal year 2015, annual Medicaid enrollment in North Carolina increased by 5.1%, compared to 4.6% in 2014 and 3.2% in 2013.

In North Carolina, monthly Medicaid enrollment amounted to 2.1 million in May 2017. Before the Affordable Care Act, average monthly enrollment in North Carolina amounted to 1.6 million, according to the Kaiser Family Foundation. This represented a difference of 30.8%.

Change in annual Medicaid enrollment, 2013-2015
State	2013	2014	2015
North Carolina	3.2%	4.6%	5.1%
Georgia	3.0%	1.5%	11.0%
South Carolina	8.2%	6.9%	5.4%
Virginia	3.8%	1.3%	5.4%
United States	2.1%	9.5%	14.6%
Source: National Association of State Budget Officers, "Fiscal Survey of the States"

Health insurance exchanges

As of September 2017, North Carolina was one of 28 states with a federally facilitated health insurance exchange. Enrollment in plans offered on the exchange amounted to about 451,000 in 2017. Of individuals enrolled, 93% were eligible for premium tax credits, which averaged $592 per month. In addition, 67% were eligible for reductions in their cost-sharing responsibilities (labled as CSRs in the graph below), meaning their plans covered more of their costs. The table below provides these figures for North Carolina and three of its neighboring states.

Total exchange enrollment and financial assistance, 2017
State	Total exchange enrollment	Number receiving tax credits	Percent of total	Average monthly tax credit received	Number receiving CSRs	Percent of total
North Carolina	450,822	421,275	93%	$592	300,255	67%
Georgia	404,821	362,868	90%	$358	286,076	71%
South Carolina	183,163	166,682	91%	$422	132,649	72%
Virginia	364,614	301,669	83%	$317	218,241	60%
United States	10,330,759	8,707,757	84%	$371	5,895,662	57%
Sources: Kaiser Family Foundation, "Total Marketplace Enrollment and Financial Assistance" Kaiser Family Foundation, "Estimated Total Premium Tax Credits Received by Marketplace Enrollees"

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Consumer costs

Premiums

The studies and analyses below were conducted by various organizations to examine premiums for health insurance plans in the individual market, where most of the ACA's changes took place. Different studies using similar data may find varying results due to variances in the methodologies used by the organizations conducting the studies.

2016 to 2017

The Kaiser Family Foundation (KFF) analyzed the change from 2016 to 2017 in average premiums for benchmark plans offered in major cities in each state, as estimated for a 40-year-old non-smoker earning $30,000 per year. According to KFF, premiums were "expected to increase faster in 2017 than in previous years due to a combination of factors, including substantial losses experienced by many insurers ... and the phasing out of the ACA’s reinsurance program."

In Charlotte, North Carolina, the organization found that average premiums for the individuals described above increased by 40%, from $409 per month to $572 per month. The organization also analyzed the change in the premium tax credit provided to such individuals, finding that the average tax credit increased by 82%, from $201 per month to $364 per month. These figures are provided in the table below and compared with those in three of North Carolina's neighboring states.

Change in monthly premiums and tax credits for a 40-year-old non-smoker making $30,000/year
State	Major city	Benchmark plan premium			Tax credit
		2016	2017	Change	2016	2017	Change
North Carolina	Charlotte	$409	$572	40%	$201	$364	82%
Georgia	Atlanta	$254	$286	13%	$46	$79	72%
South Carolina	Columbia	$314	$404	29%	$106	$197	85%
Virginia	Richmond	$276	$296	7%	$68	$89	31%
Kaiser Family Foundation, "2017 Premium Changes and Insurer Participation in the Affordable Care Act’s Health Insurance Marketplaces"

2015 to 2016

Commonwealth Fund
The Commonwealth Fund examined premiums for all plans offered on the exchanges. The organization found that premiums increased by an average of 6% nationwide from 2015 to 2016. In Kansas, the Commonwealth Fund found that premiums increased by an average of 26%. The table below shows average 2016 premiums by plan metal level in Kansas and surrounding states, as analyzed by the Commonwealth Fund. N/A indicates that plans in that metal level were not offered in a particular state.

Average 2016 premiums by metal level
State	Bronze	Silver	Gold	Platinum
North Carolina	$341	$418	$504	$646
Georgia	$288	$336	$422	N/A
South Carolina	$282	$325	$412	N/A
Virginia	$269	$325	$413	$409
Source: Commonwealth Fund, "Modest Changes in 2016 Health Insurance Marketplace Premiums and Insurer Participation"

Kaiser Family Foundation
For premium changes from 2015 to 2016, an analysis of benchmark plans from the Kaiser Family Foundation found an average increase of 10.1% on the exchanges. For North Carolina, the organization found that benchmark premiums on the state exchange increased by an average of 25.5% in the Charlotte market, from $326 to $409.

PricewaterhouseCoopers
An analysis from PricewaterhouseCoopers of premium changes from 2015 to 2016 found that average premiums for benchmark plans offered on the exchanges rose by 4.2%. In North Carolina, the organization found that average benchmark premiums rose by 25% from 2015 to 2016.

To read more about premium changes in prior years, click 'Show more' below.

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2014 to 2015

• Commonwealth Fund
  

The Commonwealth Fund (CwF) performed a study on premium costs for all plans on the exchanges and found no change nationwide between 2014 premiums and 2015 premiums. For North Carolina, the Commonwealth Fund found average premium increases of 12% from 2014 to 2015.

• Heritage Foundation
  

The Heritage Foundation performed an analysis of the change in premiums from 2014 to 2015 for plans offered on the exchanges and found a nationwide increase of 5.3%. In North Carolina, the organization found an average increase of 15.6% for individuals age 27, from $257 to $298 per month. For individuals age 50, the organization found an increase of 3.2%, from $439 to $453.

• Kaiser Family Foundation
  

The Kaiser Family Foundation (KFF) analyzed the change in premiums for benchmark plans—used to calculate subsidy amounts—from 2014 to 2015 and found a nationwide 2% increase in premiums. In the market for Charlotte, North Carolina, KFF found an average increase of 6.4% in benchmark plan premiums, from $307 to $326 per month.

• PricewaterhouseCoopers
  

PricewaterhouseCoopers also analyzed premiums for benchmark plans offered on the exchanges and found a nationwide decrease of 0.2% from 2014 to 2015. In North Carolina, the organization found that average premiums for benchmark plans increased by 7%.

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2013 to 2014

In the fall of 2014, a working paper from the National Bureau of Economic Research (NBER), published by the Brookings Institution, found that 2014 premiums in the entire non-group (individual) market (on and off the exchanges) had increased by 24.4% more than they would have risen without the Affordable Care Act. Additionally, the increase in insurers' costs was 11% greater than without the ACA. The results indicated that premium markups increased in 41 states. The paper posited that because insurers had to set premiums before open enrollment, they may have set them high to safeguard the possibility of a sicker-than-expected, and thus costlier, pool of new consumers.

In the table below, the label Pre-ACA refers to what premiums and costs would have been without the passage of the ACA. The label Post-ACA refers to the actual average premiums and costs in the individual market during the first half of 2014. In North Carolina, the paper's author found a 29.2% increase in premiums and a 4.4% increase in insurers' costs relative to what they would have been without the ACA.

Individual market monthly premiums with and without the ACA, by NBER
State	Average monthly premium			Average monthly cost for insurers			Markup increase?
	Pre-ACA	Post-ACA	Change	Pre-ACA	Post-ACA	Change
North Carolina	$240	$310	29.2%	$203	$212	4.4%	Yes
South Carolina	$224	$285	27.23%	$169	$180	6.51%	Yes
Tennessee	$203	$244	20.2%	$165	$190	15.15%	Yes
Virginia	$254	$280	10.24%	$198	$203	2.53%	Yes
Source: Kowalski, Amanda E., National Bureau of Economic Research, "The Early Impact of the Affordable Care Act, State by State"

Analysis

2018 premiums

According to the American Academy of Actuaries, the major drivers of premium changes from 2017 to 2018 were the underlying growth in healthcare costs and regulatory uncertainty. The organization issued a report stating that costs for healthcare services and prescription drugs were expected to rise between 5% and 8% in 2018. In addition, the report listed four areas of regulatory uncertainty impacting health insurance premiums in 2018:

• uncertainty related to whether cost-sharing reduction reimbursements would continue to be paid
• uncertainty related to enforcement of the individual mandate
• uncertainty related to how the shorter open enrollment period (November 1, 2017, to December 15, 2017) and stricter rules for special enrollment periods will impact the risk pool
• uncertainty related to potential legislative changes to the ACA

Other drivers of premium changes included state programs to reimburse insurers for high-cost enrollees that could put downward pressure on premiums, changes in the composition of the risk pool, and the reinstatement of the ACA's fee on health insurers.

2017 premiums

According to the American Academy of Actuaries, the major drivers of premium changes from 2016 to 2017 were the underlying growth in healthcare costs, the end of the reinsurance program, and the availability of more complete information on the health status of the risk pool. Although increases in the cost of healthcare services were expected to be lower than in previous years, insurers were uncertain about whether this trend would continue. In addition, the end of the federal reinsurance program, which had reimbursed insurers for high-cost enrollees, put upward pressure on premiums.

Other drivers of premium changes included a suspension of the ACA's fee on health insurers, putting downward pressure on premiums, a change in the legal definition of small employer, and narrower provider networks.

Initial premiums

According to an article by PolitiFact, premium increases in the individual market were expected by healthcare policy analysts. The article suggested that increases could be due to the following reasons:

• A requirement for plans offered on the exchanges to cover a standard set of benefits that weren't covered before.
• Two provisions known as guaranteed issue and community rating that prevent denial of coverage to individuals with pre-existing conditions and also prohibit differing premium rates based on those conditions and other observable characteristics, such as gender. These two provisions were expected to result in rate increases for everyone to cover associated costs.
• Higher-than-expected medical loss ratios, meaning insurers paid more for claims than expected, or in some cases paid more in claims than they received in premium revenue.

According to the Robert Wood Johnson Foundation, prior to 2014's implementation of the requirement to cover a standard set of benefits, less than half of people with individual coverage were in plans that covered those benefits. The organization found that new benefits likely resulted in an increase in the number of claims filed with insurers and thus an increase in costs requiring an increase in premiums.

Premiums for employer-sponsored insurance

The Henry J. Kaiser Family Foundation (KFF) found that 2013 to 2014 increases for employer-sponsored insurance (both small and large group) were smaller than those in the individual market: average single coverage premiums increased nationwide by 2%; KFF stated that this "difference [was] not statistically significant," meaning premiums were essentially unchanged. Meanwhile, average family coverage premiums increased by 3%. From 2014 to 2015, the organization found an increase of 4% for both single and family coverage, "continuing a fairly long period (2005 to 2015) where annual premium growth has averaged about 5%."

According to subsequent KFF reports, employer-based coverage premiums increased by 2.9% for single plans and 3.4% for family plans from 2015 to 2016, and by 4% for single plans and 3% for family plans from 2016 to 2017. State-based data was not available in any of the reports.

Deductibles

2016

According to the Kaiser Family Foundation, in 2016, average deductibles in the 37 states with federally facilitated or partnership exchanges were as follows:

• $5,765 for combined medical and prescription drug deductibles on bronze plans (89% of bronze plans had combined deductibles)
• $3,064 for combined deductibles on silver plans (56% of silver plans had combined deductibles)
• $3,198 for separate medical deductibles on silver plans (44% of silver plans had separate medical and prescription drug deductibles)
• $1,136 for separate medical deductibles on gold plans (57% of gold plans had separate deductibles)
• $409 for separate medical deductibles on platinum plans (73% of platinum plans had separate deductibles)

2015

In 2014, the publication Modern Healthcare estimated that 60% to 80% of health plans on the exchanges would be high deductible health plans in 2015. For 2015, the Internal Revenue Service (IRS) considered plans with deductibles of at least $1,300 for single coverage and $2,600 for family coverage to be high-deductible plans. According to the Kaiser Family Foundation, in 2015, average deductibles in the 37 states with federally facilitated or partnership exchanges were as follows:

• $5,328 for combined medical and prescription drug deductibles on bronze plans (91% of bronze plans had combined deductibles)
• $2,556 for combined deductibles on silver plans (55% of silver plans had combined deductibles)
• $3,453 for separate medical deductibles on silver plans (45% of silver plans had separate medical and prescription drug deductibles)
• $1,431 for separate medical deductibles on gold plans (63% of gold plans had separate deductibles)
• $418 for separate medical deductibles on platinum plans (62% of platinum plans had separate deductibles)

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Government spending

Overall

In 2016, the Congressional Budget Office (CBO) estimated the net cost to the federal government of the subsidies, taxes, and penalties associated with the health insurance coverage provisions of the ACA to be $8.9 trillion between 2017 and 2026. This was $1.4 trillion higher than if the ACA had never been enacted. The report stated that the CBO would no longer estimate the specific impact of the ACA on the federal budget because "generating such estimates is becoming more difficult and less meaningful" as time goes on.

For states, the primary changes in spending associated with the ACA were on Medicaid and uncompensated care. States that ran their own exchanges were also responsible for financing them, which The Washington Post reported in 2015 could have costed these states $28 million to $32 million per year.

Medicaid

See also Medicaid spending in North Carolina

Projected Medicaid spending

Kaiser Family Foundation

In November 2012, the Henry J. Kaiser Family Foundation (KFF) released a report analyzing the difference in Medicaid expenditures if each state were to expand the program. The organization found that nationwide, total Medicaid expenditures would be $1.02 trillion higher (an increase of 16.2%) between 2013 and 2022 if all states implemented Medicaid expansion than if there was no Medicaid expansion. Total state costs would be $76.5 billion higher, while federal costs would be $952.5 billion higher. Even without expanding Medicaid, the requirement that states make it easier to enroll in the program and the individual mandate could encourage some new individuals to sign up, even if they had already been eligible. States could incur additional costs from the program if this happened.

As of September 2017, North Carolina was one of the 19 states that had not expanded Medicaid. KFF found that North Carolina's Medicaid expenses between 2013 and 2022 would be 7.7% higher with expansion, while federal costs for the state would be 35.1% greater. The organization estimated that between 2013 and 2022, overall expenses for Medicaid expansion in North Carolina would amount to $243.1 billion, 25.8% greater than not expanding Medicaid. See the table below for comparisons between North Carolina and its neighboring states.

Total Medicaid expenditures under the ACA with all states expanding Medicaid compared to no ACA, 2013 - 2022
State	Expenditures without ACA (in millions)			Expenditures under ACA - all states expanding (in millions)			Change relative to no ACA
	Federal	State	Total	Federal	State	Total	Federal	State	Total
North Carolina	$127,286	$65,988	$193,273	$171,996	$71,086	$243,082	35.1%	7.7%	25.8%
South Carolina	$53,227	$21,715	$74,942	$70,230	$23,242	$93,472	31.9%	7.0%	24.7%
Tennessee	$95,404	$46,824	$142,228	$120,650	$49,130	$169,780	26.5%	4.9%	19.4%
Virginia	$52,220	$50,066	$102,286	$68,633	$52,682	$121,316	31.4%	5.2%	18.6%
Source: The Henry J. Kaiser Family Foundation, "The Cost and Coverage Implications of the ACA Medicaid Expansion: National and State-by-State Analysis"

Congressional Budget Office

Between 2012 and 2016, the Congressional Budget Office (CBO) released a series of reports that estimated the impact of the Affordable Care Act (ACA) on state Medicaid spending over the following 10 years:

• March 2012: The CBO estimated that between 2012 and 2022, total state spending for Medicaid would be $73 billion higher than it would have been without the ACA.
  • The Center on Budget and Policy Priorities calculated this to represent a 2.8% difference.
• July 2012: The CBO revised its estimates due to the Supreme Court ruling that Medicaid expansion must be made voluntary on the part of the states. That estimate put the impact of the ACA on state Medicaid spending at $41 billion.
• February 2014: The CBO estimated Medicaid spending would be $70 billion higher between 2015 and 2024 than without the ACA.
• April 2014: The CBO reduced its estimate for the impact of the ACA on state Medicaid spending to $46 billion, where it remained in its March 2015 estimate for 2016 through 2025.

In the CBO's March 2016 estimate of the impact of the ACA on the federal budget, the agency stated it would no longer estimate the impact of the ACA on government spending as compared to no ACA because "generating such estimates is becoming more difficult and less meaningful" over time. The March 2016 report did not estimate the effects on state spending.

Total Medicaid spending, 2012-2016

During fiscal year 2016, combined federal and state spending for Medicaid in North Carolina totaled about $12.2 billion. Spending on North Carolina's Medicaid program increased by about 0.8% between fiscal years 2012 and 2016.

Total Medicaid spending, fiscal years 2012 - 2016
State	2012	2013	2014	2015	2016	Percentage change
North Carolina	$12,282,452,337	$11,915,039,901	$12,097,786,918	$13,212,668,475	$12,382,079,896	0.8%
Georgia	$8,525,953,526	$8,960,367,262	$9,485,829,472	$9,664,791,833	$9,837,218,481	15.4%
South Carolina	$4,847,913,428	$4,906,583,617	$5,552,937,136	$5,767,691,574	$6,240,129,313	28.7%
Virginia	$6,906,432,609	$7,291,109,038	$7,611,531,956	$8,032,760,161	$8,564,487,079	24.0%
United States	$415,154,234,831	$438,233,172,298	$475,910,000,000	$523,709,237,879	$553,453,647,756	33.31%
Note: Expenditures include both state and federal expenditures. Expenditures do not include administrative costs. Percentages calculated by Ballotpedia.

Tax credits

The Kaiser Family Foundation estimated the total amount of premium tax credits received during 2017 by residents in each state. The organization calculated this estimate by multiplying the total number of enrollees by the average tax credit received. Federal spending on cost-sharing reductions was not calculated. In North Carolina, residents received an estimated combined total of $3 billion in federal tax credits during 2017. The table below shows the amounts calculated by the Kaiser Family Foundation for North Carolina and three neighboring states.

Estimated total premium tax credits by state, 2017
State	Total tax credits
North Carolina	$2,991,170,000
Georgia	$1,559,142,000
South Carolina	$844,598,000
Virginia	$1,148,490,000
United States	$38,815,001,000
Source: Kaiser Family Foundation, "Estimated Total Premium Tax Credits Received by Marketplace Enrollees"

Uncompensated care

Uncompensated care is the sum of healthcare services provided to patients without reimbursement; this includes both charity care and bad debt. In 2013, total government spending for uncompensated care nationwide amounted to $53.3 billion. The federal government paid $32.8 billion, while state and local governments paid $19.8 billion. Due to the expansion of insurance coverage options (Medicaid in some states and health insurance exchanges in every state), states could see a reduction in their spending for uncompensated healthcare. According to a 2015 report from the U.S. Department of Health and Human Services, in 2014, uncompensated care costs declined by $5 billion in states that expanded Medicaid and by $2.4 billion in states that did not. State-level data was not available.

According to a separate report from the American Hospital Association, uncompensated care costs nationwide amounted to $35.7 billion in 2015. This was a decline of $7.1 billion from 2014, when the organization estimated uncompensated care costs amounted to $42.8 billion.

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Market reactions

Number of insurers on exchange

In July 2017, the Centers for Medicare and Medicaid Services (CMS) issued a press release stating that fewer health insurers had applied to offer plans on the health insurance exchanges for 2018, 141 compared to 227 applying to offer plans for 2017. The press release followed announcements from Humana and Aetna that they would not offer any health plans on any state exchange in 2018. In addition, in 2016, UnitedHealthcare had announced that it would exit all but three exchanges in 2017. The insurers said their decisions to exit the markets were based on financial losses and regulatory uncertainty regarding the cost-sharing reduction reimbursements.

Nationwide, an average of 4.3 insurers per state offered plans on the exchanges, compared to five insurers in 2014 and six in 2015. In North Carolina, two insurers offered plans on the state's health insurance exchange in 2017, compared to three insurers in 2016 and 2015. The table below displays the number of health insurers that offered plans on each state's exchange for each year between 2014 and 2017. This information is provided for North Carolina and three of its neighboring states.

Number of health insurers offering plans on the ACA exchanges
State	2014	2015	2016	2017
North Carolina	2	3	3	2
Georgia	5	9	8	5
South Carolina	3	4	3	1
Virginia	5	6	7	8
United States	5	6	5.6	4.3
Source: Kaiser Family Foundation, "Number of Issuers Participating in the Individual Health Insurance Marketplaces"

Narrow networks

The Affordable Care Act required insurers to design plans that offered a standard set of health benefits, termed by the law as essential health benefits. The law also prohibited them from denying coverage to individuals with pre-existing conditions or from varying a person's premium for any reason other than age, tobacco use, and location. These provisions limited the ways insurers could design plans that featured lower premiums. One way insurers could keep premiums down was to offer plans with limited or narrow networks, meaning they contracted with fewer providers for services in exchange for lower prices. The Robert Wood Johnson Foundation found that in 2014, 41% of silver-level plans, the most common type sold on the state exchanges, offered narrow networks. In a separate study, management consulting firm McKinsey & Company found that in 2014, 39% of plans offered on the exchanges had narrow hospital networks; in 2015, they found that this figure had increased to 45%.

Although they could allow insurers to offer lower premiums, narrow networks restricted consumers' choice of providers by design. According to Kaiser Health News, this could sometimes cause consumers to drive long distances for care, impede their access to providers, or result in high out-of-pocket costs for necessary care because the provider was out of network. Some state regulators enacted legislation requiring insurers to offer wider provider networks, sometimes referred to as network adequacy standards. Just over half of states applied network adequacy standards to plans offered on their exchanges. As of November 2015, Kansas was not one of these states.

Direct primary care

See also: Direct primary care

In 2012, there were 4,400 direct primary care practices in the United States, up from 146 in 2004.

Direct primary care, a type of retainer-based healthcare, is a healthcare model that emerged as an alternative to the system of paying for healthcare with health insurance. In a direct primary care arrangement, patients contract directly with their primary care physicians, paying a flat monthly, quarterly, or annual fee—also called a retainer—that covers all primary care visits and services over the time period. According to the Heritage Foundation, doctors switch to direct primary care practices due to concerns about "doctor shortages, narrow networks, and ... third-party reimbursement." In 2004, the U.S. Government Accountability Office identified 146 retainer-based practices, which included direct primary care as well as other types of retainer-based healthcare, such as concierge medicine. In 2010, the National Opinion Research Center found that this number had increased to 756. In 2012, the American Academy of Private Physicians counted 4,400 direct primary care practices.

In direct primary care, the physician's practice does not accept insurance; instead, a monthly fee of typically $100 or less is charged and covers all services. Alongside the arrangement with their primary care physician, individuals often have a supplementary insurance plan that covers specialist and catastrophic care. Direct primary care practices often see fewer patients than traditional practices, and their physicians tend to spend more time with their patients in appointments.

The Affordable Care Act contained a provision allowing direct primary care plans to be sold on the health exchanges along with a wraparound insurance plan. Under the law, direct primary care on its own does not constitute insurance. However, in 2005 the West Virginia Insurance Commission investigated a concierge medicine practice for potentially violating state insurance laws. As of November 2015, 15 states had either introduced or enacted legislation clarifying that direct primary care is not subject to insurance laws and removing them from liability. As of November 2015, North Carolina was not one of these states.

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Historical data

Medical loss ratio rebates

To view historical data on the rebates insurers provided to residents in North Carolina due to spending too few premium dollars on medical costs, click Show more below to expand the section.

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For the 2011 plan year, health insurers rebated nearly $19.5 million to nearly 292,000 consumers in North Carolina. For the 2012 plan year, these figures fell: about $10.5 million was rebated to about 213,000 consumers, who received about $85 each on average. The number of consumers receiving rebates for 2013 fell to 182,500 while the total amount rebated fell to about $8.5 million. The three charts below provide data on total MLR rebates, the number of consumers affected, and the average rebate per person in North Carolina for 2011 through 2013. The 2011 data on consumers receiving rebates and average rebate per consumer come from a preliminary estimate by the Henry J. Kaiser Family Foundation because state data on actual figures were not available. All other data come from the Centers for Medicare and Medicaid Services. As of December 2015, data for 2014 was not yet available. Click on a chart to view a larger image.

Insurance coverage overall

To view historical data on health insurance coverage in North Carolina, click Show more below to expand the section.

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In North Carolina, between 2013 and 2014, the number of uninsured individuals declined by 15.4%, from 1.5 million individuals to 1.3 million individuals. As a percentage of the population, the figure declined from 15.6% of the population to 13.1% of the population.

Population without health insurance coverage, 2013 and 2014
State	2013 uninsured	2014 uninsured	Difference
Number	Percent	Number	Percent	Number	Percent
North Carolina	1,509,000	15.6%	1,276,000	13.1%	-233,000	-15.4%
South Carolina	739,000	15.8%	642,000	13.6%	-97,000	-13.1%
Tennessee	887,000	13.9%	776,000	12.0%	-110,000	-12.5%
Virginia	991,000	12.3%	884,000	10.9%	-107,000	-10.8%
United States	45,181,000	14.5%	36,670,000	11.7%	-8,510,000	-18.8%
Source: United States Census Bureau, "Health Insurance Coverage in the United States: 2014"

Health insurance exchange enrollment

To view historical data on health insurance exchange enrollment in North Carolina, click Show more below to expand the section.

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Enrollment in plans offered on North Carolina's health insurance exchange in 2015 amounted to about 460,000, which was 42% of the estimated number of individuals who were most likely to enroll, namely uninsured residents ineligible for Medicaid and those who typically purchased individual insurance. Of individuals enrolled, 91.6% were eligible for advanced premium tax credits, which averaged $315 per month. In addition, 64% were eligible for reductions in their cost-sharing responsibilities, meaning their plan covered more of their costs.

Total marketplace enrollment and financial assistance, 2015
State	Total marketplace enrollment	Estimated number of potential 2015 enrollees	Percent of potential population enrolled	Number receiving tax credits	Percent of total	Average monthly tax credit	Number receiving cost-sharing reductions	Percent of total
North Carolina	459,714	1,097,000	42%	421,307	91.6%	$315	294,130	64.0%
South Carolina	165,276	441,000	37%	146,530	88.7%	$280	103,664	62.7%
Tennessee	177,453	579,000	31%	149,920	84.5%	$221	111,844	63.0%
Virginia	327,026	831,000	39%	274,044	83.8%	$257	178,092	54.5%
United States	9,949,079	28,066,000	35%	8,329,966	83.7%	$270	5,572,833	56%
Sources: National Conference of State Legislatures, "State Actions to Address Health Insurance Exchanges" The Henry J. Kaiser Family Foundation, "Marketplace Enrollment as a Share of the Potential Marketplace Population" The Henry J. Kaiser Family Foundation, "Average Monthly Advance Premium Tax Credit (APTC)"

Recent news

The link below is to the most recent stories in a Google news search for the terms Affordable Care Act North Carolina. These results are automatically generated from Google. Ballotpedia does not curate or endorse these articles.

Effect of the Affordable Care Act in North Carolina (2009-2017) - Google News

See also

• 

  Federal policy on healthcare, 2017-2020

• 

  Medicaid spending in North Carolina

• 

  Healthcare policy in North Carolina

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