Insurance markets are changing rapidly in rural areas in response to the 2007-2009 recession, the deterioration of the employer-sponsored insurance market, and reforms of private insurance plans (e.g., managed care, payment reforms). In addition, there may be a massive influx of newly-insured individuals to the market with the advent of Health Insurance Exchanges (HIEs), introduced as part of the Patient Protection and Affordable Care Act (ACA) of 2010. While the development of HIEs has been slow (as of March 2012, 14 states have established HIEs, with the rest of the states either studying HIEs or just planning to establish HIEs), several states are developing their own HIEs. This suggests that the phenomenon of health insurance exchanges, and more broadly insurance market change, has "taken root" in the marketplace and the impact of the evolution of these changes on rural people and places needs to be understood.

A multi-methods approach will be used in this project to explore aspects of insurance market changes in rural areas. Using a qualitative research approach, we will analyze state HIE plans and, where possible, activities of exchanges. This analysis will continue Center work that summarizes state activities using the rural considerations matrix described in a January 2012 Center paper through the collection and monitoring of state work on HIEs.

The Center will complement this work with quantitative analysis that describe rural insurance markets, drawing on several national-level datasets in order to determine what policy variables can potentially affect the level of market competition in a geographic area. The analysis will be used to develop a comprehensive picture of the current structure of insurance markets in rural areas using descriptive and multivariate models as well as to develop simulation models that can be used to analyze the policy options currently under consideration (e.g., the ACA and state-level HIEs).

Hypotheses: The qualitative analysis will generate descriptions of state plans, establishing ranges of decisions along continua for each of the rural considerations. For example, the plans for navigators could range from single source contracting to accepting all bids. The implications for rural people will be considered in the context of the characterization of final decisions made in the plans.

The quantitative research will focus on the firm's decisions to enter and offer insurance plans in a particular geographic market, expected to be driven by three conditions:

1. Demand for insurance, which would change with expansions in coverage and enrollment through HIEs,
2. Market characteristics, as evident in the number of insurance plans currently offered, and
3. The availability of providers to form networks, crucial to the continued development of insurance markets.

Publications

• Accountable Care Organizations in Rural America
  RUPRI Center for Rural Health Policy Analysis
  Date: 07/2013
  This policy brief reports that Medicare Accountable Care Organizations currently operate in 16.7% of all U.S. non-metropolitan counties.