Insurer Participation on ACA Marketplaces, 2014-2020
Since the Affordable Care Act marketplaces opened in 2014, there have been many changes in insurer participation as companies entered and exited states, or changed their footprint within states. A number of insurers are entering the market or expanding their service area for 2020. This year, 18 states are seeing a total of 26 new entrants (see Table 1) and an additional 54 insurers are expanding their service areas within states.1 There will be an average of 4.5 insurers per state in 2020, up from 4.0 in 2019 and 3.5 in 2018, but down from a peak of 6.0 in 2016. The number of insurers per state ranges from one company each in Delaware and Wyoming to more than ten companies in California, New York, and Wisconsin (see Table 2 in the appendix). In 2020, 67% of enrollees (living in 29% of counties) will have a choice of three or more insurers, up from 58% of enrollees in 2019 and 48% in 2018.2
The map and chart below show how insurer participation has changed from 2014 – 2020 in every county in the U.S. Data for this map are available for download.
|Table 1: States with New Entrants for 2020|
|State||Insurer(s) Entering State Marketplace (by Parent Company)|
|Missouri||Cox, SSM Health, Oscar|
|New Mexico||Evolent (True Health NM)|
|South Carolina||Bright, Molina|
|Utah||Cambia Health Solutions, Cigna|
|SOURCE: KFF analysis of data from Healthcare.gov and a review of state rate filings.|
Although there are an average of 4.5 insurance companies per state in 2020, many insurers do not participate statewide. Insurer participation varies greatly within states, and rural areas tend to have fewer insurers. On average, metro-area counties have 2.6 insurers participating in 2020 (up from 2.3 in 2019), compared to 2.0 insurers in non-metro counties (up from 1.8 in 2019). In 2019, 87% of enrollees lived in metro counties.
Going into 2020, 668 counties are gaining at least one insurer, while 18 counties nationwide will lose an insurer (net of any entrances). The map below shows net insurer entrances and exits for 2020 by county.
Despite these expansions and new entrances, there remain a number of areas in the country with just one exchange insurer. In 2020, about 10% of enrollees (living in 25% of counties) have access to just one insurer on the marketplace (down from 17% of enrollees living in 37% of counties in 2019). 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, state individual markets were often dominated by a single Blue Cross Blue Shield plan.
Insurer Participation in Previous Years
In 2014, there were an average of 5.0 insurers participating in each state’s ACA marketplace, ranging from one company in New Hampshire and West Virginia to 16 companies in New York (see Table 2 in the appendix). 2015 saw a net increase in insurer participation, with an average of 6.0 insurers per state, ranging from one 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 one 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 one company in Alabama, Alaska, Oklahoma, South Carolina and Wyoming to 15 companies in Wisconsin.
Although insurance company financial performance improved during 2017, a number of insurers exited the market or reduced their service area going in to 2018, likely driven in part by legislative and regulatory uncertainty. The average number of companies per state in 2018 was 3.5, ranging from one company in eight states (Alaska, Delaware, Iowa, Mississippi, Nebraska, Oklahoma, South Carolina, and Wyoming) to more than 10 insurers in three states (Wisconsin, California, and New York). Despite concerns earlier in the year, all counties had at least one insurer in 2018. Insurance company margins continued to improve during 2019, and a number of insurers entered the market or expanded their service area. The average number of marketplace insurance companies per state in 2019 was 4.0, ranging from one company in five states (Alaska, Delaware, Mississippi, Nebraska, and Wyoming) to more than 10 companies in three states (California, New York and Wisconsin).
Insurer participation on the ACA Marketplaces will increase in 2020, with an average of 4.5 insurers participating per state, up from 4.0 in 2019. The share of Marketplace enrollees with only one insurer option (10%) will be the lowest since 2016 (when 2% of enrollees had only one insurer option). As was the case in 2019, there are more companies entering into markets or expanding their footprints within states than there are withdrawals in 2020. Nonetheless, the market overall continues to have lower insurer participation than in the early years of ACA implementation.
Insurer financial performance in early 2019 suggests that, despite the effective repeal of the individual mandate, insurers generally continue to be profitable in the individual insurance market. This is one of several indications that the repeal of the individual mandate penalty and expansion of short-term insurance plans did not disrupt the individual market as much as expected. Despite these policy changes, 2020 Marketplace premiums are falling by 2-3% on average, individual market enrollment declines were smaller than expected in 2019, the health status of enrollees does not appear to be significantly worse, and, as this analysis shows, insurer participation is improving in 2020.
|Table 2: Total Number of Insurers by State, 2014 – 2020|
|SOURCE: KFF analysis of data from Healthcare.gov and a review of state rate filings.
NOTE: 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, 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 enrollment data where possible and if unavailable estimated county level enrollment based on the state’s enrollment total. 2020 enrollment is estimated using 2019 plan selections. For most states running their own exchange, insurer participation is measured at the rating area level.