Health Insurance Marketplaces: Issuer Participation Trends in Non-Metropolitan Places, 2014-22


Since the 2014 implementation of Health Insurance Marketplaces (HIMs), authorized by the Patient Protection and Affordable Care Act of 2010, considerable changes have been observed in the number of insurance companies offering plans across the 50 states and the District of Columbia. This policy brief describes the changes in HIM plan issuers over the 2014-2022 period with an emphasis on the variation across metropolitan and non-metropolitan places.

Key Findings

  • Non-metropolitan counties have had less marketplace participation than metropolitan counties since their implementation in 2014. However, issuer participation in metropolitan and non-metropolitan counties fluctuates in a similar manner over time.
  • Since 2018, metropolitan, micropolitan, and noncore counties have experienced steady growth in the number of competing issuers in the marketplaces.
  • A larger percentage of non-metropolitan counties (micropolitan: 37.9 percent; noncore: 42.3 percent) had fewer than three issuers participating in the marketplaces, compared to metropolitan counties (20.8 percent).
  • Non-metropolitan counties in states that have expanded Medicaid have had greater marketplace participation on average than their counterparts in states that have not expanded Medicaid. However, this difference appears to be closing as of 2022.
Rapid Response to Requests for Rural Data Analysis, RUPRI Center for Rural Health Policy Analysis
Eliot Jost, Abigail Barker, Leah Kemper, Fred Ullrich; Keith Mueller, Timothy McBride