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Details Matter: Healthcare Coverage Landscape Varies in Early Primary States

Summary

As the early presidential primaries unfold, healthcare remains a top issue among voters. As recently as the November Democratic primary debate, polls showed that 24% of Democrats or Democratic-leaning independents said healthcare was the number one issue they wanted to hear discussed, ahead of the environment (12%), immigration (6%), jobs and the economy (5%), education (4%), and gun control (4%).

Healthcare Market Statistics in Early Primary States

As voters in Iowa, New Hampshire, Nevada, and South Carolina consider healthcare proposals from the candidates, Avalere looked at the underlying insurance markets in those states. In particular, the remaining uninsured and populations enrolled in Medicaid and exchanges could shape voter sentiment at a state level:

  • Uninsured: Among the early primary states, Iowa has the lowest percentage of uninsured residents (4%) and Nevada has the most at 11%
  • Medicaid Enrollment: 3 (IA, NH, NV) of the 4 early primary states have already expanded Medicaid eligibility under the Affordable Care Act (ACA). As a result, 1 in 5 insured residents of Iowa and Nevada are enrolled in Medicaid, with Medicaid representing 17% and 12% of the insured populations in South Carolina and New Hampshire respectively
  • ACA Exchanges: While the exchange market represents a relatively small source of coverage in early primary states—ranging from 1% in Iowa to 3% in New Hampshire and South Carolina—premium trends have gained significant media attention since the launch of the ACA. For the first time since the implementation of the exchanges, premiums will decrease nationally, on average, for all plan types in 2020. At the state level, however, average exchange plan premium changes from 2019 to 2020 range from -11% in Iowa to 2% in Nevada.
Table 1: Key State-Level Health Insurance Market Detail, 2020 Early Primary Elections
State Percent Uninsured Medicaid Expansion Medicaid Enrollment as a Percent of Total Insured Population On-Exchange Enrollment as Percent of Total Insured Population Change in Average Monthly Exchange Market Premium (PY 2019-2020)
Iowa 4% Expanded 19% 1% -11%
New Hampshire 7% Expanded 12% 3% -1%
Nevada 11% Expanded 19% 2% 2%
South Carolina 10% Not Expanded 17% 3% -4%

Methodology

To conduct the analysis, Avalere utilized the estimated sources of health insurance coverage in the United States in 2020 from the proprietary Avalere All-Payer Enrollment Model. To determine the latest Medicaid enrollment in early presidential primary states, Avalere used CMS’ Preliminary October 2019 Applications, Eligibility, and Enrollment Data (last updated January 10, 2020). Avalere utilized the recently released 2020 Individual Market HHS Landscape Files of exchange plan premiums in 3 Healthcare.gov states and used the 2020 Federal Health Insurance Exchange Enrollment Period Final Weekly Enrollment Snapshot to determine exchange market enrollment in state with federally facilitated exchanges. To determine Nevada’s state-based exchange market enrollment and average premiums, Avalere used Nevada’s State Based Exchange Announces Enrollment Figures for Plan Year 2020 and the Nevada Division of Insurance 2020 Health Insurance rates report. Polling data was pulled from the Kaiser Family Foundation’s (KFF’s) Health Tracking Poll–November 2019: Health Care in the 2020 Election, Medicare-for-All, and the State of the ACA.

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