The individual health marketplace program offers income-based, taxpayer-subsidized private health insurance plans for people who aren't covered on the job.

The number of people who signed up for health coverage through Louisiana’s individual exchange fell to its lowest point on record for the second straight year in 2020, amid a double-digit rate hike and a Republican-backed lawsuit seeking to throw out the law.

Enrollment in the Affordable Care Act’s individual market--commonly known as “Obamacare” – fell to 87,748 this year, from 92,948 last year. Nationwide, enrollment was relatively steady, dipping slightly to about 8.3 million in the 38 states that, like Louisiana, use the federal HealthCare.gov website.

“It’s not what we want,” said Insurance Commissioner Jim Donelon. “We want to see it grow. But the decrease is not out of the ordinary.”

Donelon pinned the drop of 5,200 people in Louisiana on several factors. Premiums are rising by an average of 12% in the individual exchange this year, after falling by nearly 7% the year prior. People in the market continue to leave Louisiana, he said. Plus, as the state adds jobs, more people are moving to employer-sponsored insurance.

The individual exchange was established in 2014, and peaked at 214,148 enrollees in Louisiana in 2016. Since then, though, insurers have fled the market and those remaining have raised rates by double digits. The number of people signing up for coverage has dropped continuously. Since that peak, enrollment has fallen by 59%. The vast majority of people in Louisiana’s individual exchange receive subsidies to offset the costs.

In late 2017, Republicans zeroed out the fine on people who don’t carry insurance, a key part of Obamacare called the individual mandate. Donelon said people are increasingly aware that they are no longer required to have health insurance, something that probably accounts for a small part of the decline in enrollment here.

Brian Burton, CEO of the Southwest Louisiana Area Health Education Center, said the state’s navigators, which help consumers get coverage through the exchange, received less money this year – about $200,000, down from $300,000 last year and $1.1 million during the Obama administration.

Louisiana did welcome a new insurer, the hospital-run Christus Health Plan, to the individual market this year. But Burton said the low cost of the plan inadvertently reduced the amount of tax credits people in the market receive from the government. Those credits are based on the second-lowest cost plan offered in a given state.

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Blue Cross and Blue Shield of Louisiana insures the majority of people in the individual exchange in this state, and the federal government gave the insurer approval last year to purchase the other insurer that has offered individual market plans here, Vantage Health Plan of north Louisiana. 

Still, Burton pointed out Louisiana is insuring more people than other states in the South, mainly a factor of the Medicaid expansion component of the ACA.

“The value of the Affordable Health Care Act is not how many people enroll in the federal marketplace, it’s the number of people insured in the state of Louisiana,” Burton said.

Meanwhile, a group of Republican officials, including Louisiana Attorney General Jeff Landry, are trying to overturn the entire ACA through a lawsuit that argues the mandate is unconstitutional because lawmakers eliminated the penalty, and that the rest of the law must also be struck down.

A federal appeals court in New Orleans recently sent the suit back down to a lower court. Nearly half a million people who get free health coverage through Medicaid expansion in Louisiana, along with the nearly 90,000 who are covered through the individual exchange, rely on the ACA for coverage.

Critics of the lawsuit, like Gov. John Bel Edwards, a Democrat, argue it puts at risk hundreds of thousands of additional people in Louisiana who have pre-existing conditions. The ACA had a list of requirements for health insurance, including that people with pre-existing conditions can’t be denied coverage.

Landry and Donelon have teamed up to come up with a potential state-level replacement to the individual market here, passing a framework piece of legislation last year. But the idea remains far from reality, and it does not address the bigger Medicaid expansion component.

Email Sam Karlin at skarlin@theadvocate.com