Payer Affordable Care Act Marketplace Participation Grew in 2022

An explosion in enrollment on the Affordable Care Act marketplace coincided with higher payer Affordable Care Act marketplace participation, the Robert Wood Johnson Foundation’s (RWJF) interactive Affordable Care Act insurer participation map revealed.

According to Katherine Hempstead, senior policy advisor at the Robert Wood Johnson Foundation, county-level plan offerings jumped 15 percent in 2022, reaching 15,638 plan offerings. The number of plans per enrollee in 2022 was four times the number of plans per enroll in 2019.

The new plan offerings in 2022 were largely concentrated in the exchange marketplace which saw 20 percent growth, as opposed to the off-exchange marketplace which only grew by 6.8 percent. Off-exchange offerings plummeted from 2015 to 2018 and rose steadily from 2019 to 2022. These offerings escalated around 50 percent in 2021.

While on-exchange offerings mirrored that fluctuation, the changes were more moderate.

Based on RWJF’s “County-level ACA plan offerings, 2015-2022” graph, the offerings in the on-exchange marketplace are only a couple of thousand away from returning to 2015 levels. Moreover, in 2022, on-exchange marketplace offerings were roughly double the number of off-exchange offerings, the graph also indicated.

Smaller companies, particularly Oscar Health and Bright Health, drove most of the growth in the off-exchange market.

Hempstead noted that enrollment growth on the Affordable Care Act marketplace was highest in states that did not expand Medicaid. Currently, 12 states have not expanded their Medicaid programs: Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming.

“This makes sense because the population with incomes between 100 percent and 138 percent of the federal poverty level (FPL) can enroll in the marketplace, and take advantage of newly affordable silver plans, thanks to new ARPA subsidy provisions,” Hempstead explained.

But the marketplace options in these states draw a lot of attention from insurers as well as consumers. North Carolina, for example, saw an 83 percent increase in the number of plan offerings. The number of plans available to North Carolinians grew from 278 to 508 as three new insurers entered the state—CVS Health, AmeriHealth Caritas, and Friday.

While North Carolina saw the highest increase, it was not alone in seeing a dramatic spike in the number of plan offerings available for 2022. Mississippi—a state which may have been able to reduce its uninsurance rate during the pandemic by expanding its Medicaid program, experts say—saw a 54 percent rise in offerings from 2021 to 2022 and Georgia saw a 40 percent increase.

Expansion states also made some gains in insurer participation in the 2022 open enrollment season. Nebraska gained two new insurers, doubling its total number of insurers.

Hempstead noted that Medicaid redeterminations and Build Back Better Act provisions may bolster enrollment and may have delayed effects that will occur primarily in the non-expansion states.

The growth in insurer activity accompanied an explosion of enrollment on the Affordable Care Act marketplace in 2022.

In December 2021 with a month left of the 2022 open enrollment season, the Affordable Care Act marketplace already boasted a record-breaking 9.7 million consumers who had selected plans on the federal health insurance marketplace. By the end of the season, 14.2 million consumers had selected Affordable Care Act plans for 2022, with 10 million automatic re-enrollments.

“In the longer run, if there is substantial growth in the individual market, it may well be more geographically dispersed,” Hempstead concluded. 

“While plans may be focusing now on areas where uninsurance rates are high, they may also be positioning themselves for the future, when more significant and widespread enrollment growth may come from the employer market, or when growth must come through capturing market share.”