More Minnesotans can claim health insurance than ever before. Unlike many of its neighbors, the state has leaned into the Affordable Care Act, and reaped rewards—only 4% of Minnesotans lack insurance for 2018.

MNSure recently announced that the 2017 open enrollment period broke its previous record for insurance coverage—a victory in the face of a nationwide drop in coverage on the individual market. Several other states that operate their own exchanges experienced success similar to Minnesota’s during the recent open enrollment period. States like California, Washington, and Connecticut reported increases in enrollment back in December. Meanwhile, coverage dropped by 400,000 enrollees in the 39 states that use the federal exchange.

The federal individual mandate to buy insurance will end in 2019. If Minnesota’s legislators do not entice healthy people to buy insurance, then thousands of Minnesotans will lose access to affordable insurance next year.

MNSure By the Numbers

In 2018 Minnesota bumped its individual market coverage rate up by 1%, while the states that rely on the federal exchange saw a 4% decrease in enrollees. MNSure funded several navigator programs and ad campaigns that contributed to Minnesota’s high enrollment, while the rest of the country struggled against a 90% cut in outreach funds.

MNSure reported that 116,358 Minnesotan enrolled in private health plans for 2018. An additional 93,102 Minnesotans enrolled in a public insurance program for 2018. In Minnesota, these programs include Medical Assistance, MinnesotaCare, and the Children’s Health Insurance Program (CHIP). The vast majority of Minnesotans either receive insurance through their job or through Medicare.

Around 60% of private plan enrollees on MNSure received tax credits, which average $6,912 per enrollee. Average tax credits rose for people that live in Southeastern and Southwestern Minnesota, and were lowest in the Twin Cities Metro. A brief reminder: tax credits are calculated by income, and serve to cap the portion of income a person or family must pay towards premiums in a given year. Therefore, tax credits increase when the cost of insurance increases. One Minnesotan in St. Cloud and one in Rochester with equal, qualifying incomes might pay the same per month in premiums, but tax credits would favor Rochester, where both health care and insurance cost more.

MNSure also relied on its customer support system to pass this year’s open enrollment period with flying colors. The website ran smoothly with no unexpected shutdowns, and call wait-times averaged only ten seconds—and, before the last week of open enrollment, wait-times were less than a second. Last year’s open enrollment period began with a malicious robocall scheme, which thankfully did not repeat itself this year.

Minnesota Outshines Its Neighbors

Our neighbors in the Midwest felt the impacts of federal efforts to hamstring the ACA far more than Minnesota.

Wisconsin saw a 6% decrease in enrollments for 2018. And though it was the only one of our neighbors to experience a decrease in enrollment, the others experienced plenty of problems during the 2018 open enrollment period. Iowa saw a modest increase in enrollment, but the premiums on individual market plans increased so much that the Iowa Insurance Division expects a mass exodus from the individual market next year. The Dakotas also saw modest increases in enrollment, but overall coverage rates there are lower than Minnesota’s. North Dakota’s health insurance marketplace has shrunk to a lone health insurance company, while South Dakota is down to two companies, which bumped up premium costs for 2018.

Federal-exchange states (all of our neighbors) felt the impacts of fewer outreach funds and a shorter open enrollment period. The federal-exchange states’ outreach budget next year likely will not return to pre-2017 levels, and so coverage levels may have peaked in federally-run marketplaces.

Minnesota benefited tremendously from a state-run exchange and legislative efforts to stabilize the state’s insurance market. MNSure retained the full use of state-based funds for outreach campaigns and partnerships with insurance brokers. MNSure spent over $4 million on outreach grants for navigators in 2017. Those grants funded organizations that could leverage existing relationships with their communities to maximize enrollment and assist in every step of the process. MNSure provides tools that make buying insurance easier: a price comparison tool that includes projected tax credits; annual costs for a good year and a bad year; and, a quality rating for the insurance. And while federally-run exchanges share a single helpline for 39 states, MNSure operates a state-based helpline and call center, which fielded over 148,000 calls from consumers during the open enrollment period.

Within the next two months, MNSure will announce how many enrollees paid their first month’s premium. This metric, known as “effectuated plans,” better indicates how many people genuinely used the exchange to buy insurance, as some number of enrollees each year accidently auto-enroll. The Centers for Medicare and Medicaid Services will also announce effectuated enrollment numbers for federal exchange states in the coming weeks.

2018 Presents Challenges to Keep Enrollment Up

Despite a very successful 2018 open enrollment period, several issues remain unresolved—some federal in nature, others unique to Minnesota.

Federal lawmakers must decide the fate of several public health programs: CHIP; CHCs; 340b drug pricing; and, DSH payments. Although CHIP funding is safe for six more years, safety net clinics in Minnesota rely on all of these programs. Congress will have to address these programs soon to ensure the viability of safety net clinics, which are vital institutions in keeping insurance rates up.

Minnesota must address the individual mandate before 2019, when it expires as a consequence of the recent federal tax bill. Policymakers will need to decide whether to re-establish a mandate at the state level, or to risk the loss of thousands of enrollments and millions of dollars in premiums. Minnesota must also convince health insurance companies to stay in the marketplace, despite a high probability of smaller profits (or even losses). The Minnesota legislature must restore funding to state-level public health programs like MinnesotaCare. Finally, it must also fight off the inevitable attack on MNSure.

Minnesota reaped the rewards of MNSure for 2018, but it must move quickly to ensure that the 2019 open enrollment period approaches this year’s results.