Key Findings Include:
- Non-metropolitan counties (counties classified as either micropolitan or noncore using urban influence codes) 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. In 2018, metropolitan, micropolitan, and noncore counties had on average 2.2, 1.8, and 1.7 unique issuers participating in the marketplaces, respectively. In 2022, metropolitan, micropolitan, and noncore counties had on average 4.2, 3.3, and 3.0 unique issuers participating in the marketplaces, respectively.
- 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). This difference is exacerbated when considering county-level population (population weighted percentages: metropolitan: 7.8; micropolitan: 33.3; noncore: 38.4).
- Marketplace participation trends differ by Census region and rural classification. While marketplace participation by issuers initially lagged in the South and Midwest, by 2022 differences in marketplace participation across Census regions by rurality were narrower.
- 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.
This report was authored by Eliot Jost, MBA, MPH; Abigail Barker, PhD; Leah Kemper, MPH; Fred Ullrich; Keith Mueller, PhD; Timothy McBride, PhD