Nonmetropolitan Premiums, Issuer Participation, and Enrollment in Health Insurance Marketplaces in 2022


Since the inception of the Health Insurance Marketplaces (HIMs) in 2014 following the passage of the Affordable Care Act, significant premium variation has been observed in HIMs across the 50 states and the District of Columbia, and between metropolitan and nonmetropolitan places. Using the Robert Wood Johnson Foundation's HIX Compare data and enrollment counts by county, researchers calculated average premiums along several different dimensions.

Key Findings:

  • Average premium costs in 2022 for consumers without subsidies were highest in noncore counties at $720 per month, compared to $686 in micropolitan counties and $643 in metropolitan counties.
  • However, the average net monthly premium actually paid by consumers (across both subsidized and unsubsidized groups) was lowest in nonmetropolitan counties.
  • Premiums were also higher in both metropolitan and nonmetropolitan counties with fewer than three issuers present.
  • Premiums net-of-subsidy also differed by Medicaid expansion status, indicating disparities within rural America.
RUPRI Center for Rural Health Policy Analysis
Abigail Barker, Ayushi Shrivastava, Eliot Jost, Timothy McBride, Keith Mueller