Insurer Participation on ACA Marketplaces, 2014-2018
Since the Affordable Care Act health insurance marketplaces opened in 2014, there have been a number of changes in insurance participation as companies entered and exited states and also changed their footprint within states. Our earlier analyses of insurer participation and some notable company exits can be found here. Note that we consider affiliated insurers serving the same areas as one insurer.
In 2014, there were an average of 5.0 insurers participating in each state’s ACA marketplace, ranging from 1 company in New Hampshire and West Virginia to 16 companies in New York. 2015 saw a net increase in insurer participation, with an average of 6.0 insurers per state, ranging from 1 in West Virginia to 16 in New York. In 2016, insurer participation changed in a number of states due to a combination of some new entrants and the failure of a number of CO-OP plans. In 2016, the average number of companies per state was 5.6, ranging from 1 in Wyoming to 16 in Texas and Wisconsin.
In 2017, insurance company losses led to a number of high profile exits from the market. The average number of companies per state in 2017 was 4.3, ranging from 1 company in Alabama, Alaska, Oklahoma, South Carolina and Wyoming to 15 companies in Wisconsin. In 2017, 58% of enrollees (living in about 30% of counties) had a choice of three or more insurers, compared to 85% of enrollees (living in about 63% of counties) in 2016.
Although insurance company profits improved during 2017, a number of insurers exited the market or reduced their service area for 2018. The average number of companies per state in 2018 is 3.5, ranging from 1 company in Alaska, Delaware, Iowa, Mississippi, Nebraska, Oklahoma, South Carolina, and Wyoming to 12 companies in New York. In 2018, 48% of enrollees (living in about 18% of counties) have a choice of three or more insurers, down from 58% of enrollees in 2017. Note that the share of enrollees with three or more insurers in 2018 is based on 2017 plan selections. Despite concerns earlier in the year, there are no counties without at least one insurer in 2018.
Insurer participation varies greatly within states, and rural areas tend to have fewer insurers. On average, metro-area counties have 2 insurers participating in 2018, compared to 1.6 insurers in non-metro counties. In 2017, 87% of enrollees lived in metro counties.
The map below shows how insurance participation has changed from 2014 – 2018 in every county in the U.S. Data for this map are available for download.
There are a number of areas in the country with just one exchange insurer. In 2018, about 26% of enrollees (living in 52% of counties) have access to just one insurer on the marketplace (up from 21% of enrollees living in 33% of counties in 2017). Often, when there is only one insurer participating on the exchange, that company is a Blue Cross Blue Shield or Anthem plan. Before the ACA, many state individual markets were often dominated by Blue Cross Blue Shield plans.
|Table 1: Total Number of Insurers by State, 2014 – 2018|
|Total Number of Issuers in the Marketplace|
|SOURCE: Kaiser Family Foundation analysis of insurer rate filings to state regulators
NOTES: Insurers are grouped by parent company or group affiliation, which we obtained from HHS Medical Loss Ratio public use files and supplemented with additional research.
Data were gathered from healthcare.gov and state-based exchange enrollment websites and insurer rate filings to state regulators. Companies and related subsidiaries were grouped by their parent or group affiliation using Mark Farrah Associates Health Coverage Portal TM and the Health and Human Services (HHS) Medical Loss Ratio data. Enrollment in states using Healthcare.gov is from HHS (with some adjustments made for counties without reported enrollment). In states running their own exchanges, we gathered county-level data where possible, and if unavailable estimated county level enrollment based on the state’s enrollment total. 2018 enrollment is estimated using 2017 plan selections.