Known as the Palmetto State for the state tree, the sabal palmetto, this east coast state is no stranger to natural beauty. With miles of beaches, a humid subtropical climate that ensures lush landscape in the summer and mild winters, and wooded areas that sport brilliant fall colors, South Carolina boasts scenery that dazzles residents and visitors alike.
It also has a rich history, beginning an estimated 15,000 years ago when the first human inhabitants are thought to have settled there. Several Native American tribes called the region home until European settlers began to arrive and populate the area starting in the early 16th century.
South Carolina gained distinction as the first state to ratify the Articles of Confederation in 1778. It was also the first U.S. state to secede from the Union in 1861, ultimately sparking America’s Civil War.
Although devastated by war, the state eventually rebounded, transitioning away from cotton to more lucrative crops like tobacco and developing a booming textile industry in the early 20th century. The automotive and machine industries also have interests in South Carolina. BMW and Boeing both have production facilities in the state.
South Carolina is a good place to live and work, but how does it fare in terms of health care, and particularly health insurance? How does it compare to other states and what can residents expect from the system in South Carolina moving into the future?
According to the 2014 Scorecard on State Health System Performance, which ranks the fifty states and the District of Columbia according to a variety of health-related criteria, South Carolina currently comes in at a ranking of 36th, putting it in the lower half of the nation. However, the state has improved since 2009, when it was ranked 39th in the nation.
The state didn’t fare any better in America’s Health Rankings, which listed it at 42nd for overall health, with criteria differing somewhat from the Scorecard on State Health Performance. Of particular note is the high rate of diabetes among adults, which comes in at 12.5%. Although the state ranked high for certain prevention and treatment health indicators, on the whole South Carolina has a long way to go to increase health rankings.
The ACA in South Carolina
At the time the Patient Protection and Affordable Care Act (ACA, or Obamacare) was enacted, the majority of political leaders in South Carolina were opposed to it. Both senators from the state and 4 of 6 representatives voted against it.
Further, South Carolina governor Nikki Haley has been vocal about her opposition to the ACA, vowing to continue fighting the law and refusing to support or promote it within the state. As a result, the state health insurance exchange is managed by the federal government and the state has not contributed any funding to Medicaid expansion.
Still, the ACA has provided insurance to many of the state’s formerly uninsured residents. The uninsured rate continues to decline, from 15.8% in 2013, to 13.6% in 2014, to 12.6% in 2015, although it remains higher than the national average of 11.7%. Of the nearly half a million residents thought to be eligible for enrollment in qualified health plans, less than half have thus far enrolled.
As of 2016, only four insurance providers offer plans through South Carolina’s state exchange, including Blue Shield Health Plan, Blue Cross Blue Shield of South Carolina, Coventry (Aetna), and United Healthcare. Until 2015, the exchange also featured a Consumer Oriented and Operated Plan (CO-OP) provided by Consumer’s Choice, but it announced its closure at the end of 2015, becoming one of 12 failed CO-OPs.
The state also has several health insurance providers that offer private plans (i.e. not through the state exchange). These are Celtic, Cigna, Freedom Life, and National Foundation Life. Notably, all of the on-exchange carriers in the state also supply off-exchange policies. This could be due to the largely negative attitude in the state toward the ACA.
The South Carolina Health Insurance Pool (SCHIP) was established in 1989 as a means of providing alternative coverage options for those unable to obtain health insurance due to pre-existing conditions. Although the system is no longer necessary under the ACA, which guarantees that all citizens have access to affordable health insurance regardless of medical history, SCHIP continues to offer enrollment, with no plans to abolish the program.
Enrollees may continue to receive health insurance through SCHIP or seek coverage through the state exchange. This serves to create additional options for state residents to explore.
Unfortunately, South Carolina is one of several states that opted out of Medicaid expansion under the ACA completely, refusing to allow even the additional federal funding offered. Although the state has no plans to accept Medicaid expansion, it will most likely have to do so eventually for economic reasons, especially since enrollment in Medicaid/CHIP increased by 10% from 2013 to 2015.
Currently, about 17% of the population of South Carolina, which amounts to roughly 123,000 residents, is unable to access needed health insurance assistance, regardless of their income eligibility under general ACA guidelines. This group exists in a coverage gap that makes it almost impossible for them to find affordable insurance options.
Non-disabled adults who have no dependent children aren’t considered eligible at all, while those with dependent children only qualify if they earn an income at or below 62% of the poverty level. Until the state elects to move forward with Medicaid expansion, many low-income residents that would otherwise receive assistance are left without realistic access to health insurance coverage.
The state does offer the Healthy Outcomes program, providing treatment to chronically ill patients via free clinics and hospital charity programs, but the program supports less than 10,000 residents, which is only a small fraction of the more than 100,000 who need assistance.
In addition, about 19% of residents enrolled in Medicare in 2015. Of these people, 78% are eligible due to age, while 22% qualify due to disability.
South Carolina could stand to improve in terms of overall health rankings. Perhaps when the state stops fighting healthcare reform and adopts funding to provide assistance to the neediest residents, the relative level of health among the population will begin to improve.
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