Rural Premiums, Issuer Participation, and Enrollment in Health Insurance Marketplaces: An Updated Analysis

Research center:
Lead researcher:
Research staff:
Project funded:
September 2022
Project completed:
March 2024

The Patient Protection and Affordable Care Act (ACA) of 2010 established Health Insurance Marketplace plans (HIMs) as a mechanism to improve the functioning of existing individual insurance markets. Since their implementation in 2014, HIMs have operated in a political environment that has challenged their structure and viability over time, a fact which has been documented and discussed widely but with limited attention to its impact in rural areas. Such areas often experience a unique set of additional challenges mostly related to lack of scale, i.e. fewer potential covered lives over whom to spread risk, and challenges with the formation of networks due to limited provider availability. Such factors may further inhibit competition, diminish coverage options, and increase costs. Yet it is possible that certain policy choices may mitigate some of these challenges. This project built upon existing work to:

  • Describe trends in premiums in rural and urban places over the past five years, stratified by Census region, by Medicaid expansion status, rating area design, and population density.
  • Describe any differences in plan design (copays, coinsurance, deductibles, etc.) between rural and urban places.
  • Estimate current net-of-subsidy premiums paid in rural and urban places and projected actuarial value purchased (corresponding to the metal levels).
  • Predict current county-level average premiums as a function of variables such as provider availability, population density, Medicare specific population, economic conditions (household income, poverty level), Census region, and policy indicators (e.g. Medicaid expansion, Federally Facilitated Marketplace vs. State-based Marketplace, rating area design).
  • Describe the association between county-level enrollment and average premiums in rural and urban places.
  • Describe the relationship between average premiums and average number of issuers in rural and urban places.

The results of the project inform future adjustments to federal and state policies governing HIMs that can enhance opportunities to offer affordable marketplace plans in rural areas.