Analysis of premiums of plans offered during 2014 and 2015, the first years of HIM operation, showed very few definitive patterns in terms of rural/urban differences. However, at the time that 2015 premiums were determined, few insurance firms had significant quantities of claims data on which to base premium change decisions, and many new firms entered the marketplace in 2015 for the first time. Thus, to obtain a current picture of the evolution of HIMs it is extremely important to examine premium data on plans offered in 2016 to determine how rural people may be experiencing HIM changes relative to their urban counterparts. This brief assesses the changes in average HIM plan premiums from 2014 to 2016, before accounting for subsidies, with an emphasis on the widening variation across rural and urban places. Since this brief focuses on premiums without accounting for subsidies, this is not intended to be an analysis of the "affordability" of ACA premiums, as that would require assessment of premiums actually paid, cost-sharing adjustments, and other factors. We find clear evidence that total (presubsidy) cost-of-living-adjusted premiums have grown disproportionately in rural places in 2016, and that they grew less in more highly populated places. Urban counties have an average of 4.2 firms offering coverage through the HIMs (an 8.0 percent decrease from 2015), while rural counties have an average of 3.2 firms participating (a 5.6 percent decrease from 2015). This may cause concern for policymakers since, at the county level, we also find that as the number of firms increases, premiums increase at a slower rate.
Abigail Barker, Leah Kemper, Timothy McBride, Keith Mueller