Stepping into the Breach

A doctor checks a young girl's heart in a hospital.

Insurers and state regulators worked successfully to ensure all counties in the United States had at least one insurer for 2018.

The Issue

Although the Affordable Care Act (ACA) marketplaces were beginning to stabilize in 2017, policy uncertainty stemming from a potential repeal of the law, threats to cost-sharing reduction reimbursements, and questions about enforcement of the individual mandate led many insurers to re-evaluate participation for 2018.

Key Findings

  • Insurers acknowledged three factors influencing participation decisions: 1) Access to a provider network at reasonable cost; 2) The risk pool within the relevant rating area; and 3) The insurer’s ability to price for that risk, and the actions of competing insurers.

  • States used regulatory measures to ensure insurer participation, including: 1) Clarifying means for meeting regulatory standards; 2) Allowing flexibility in plan offerings and reviews of premiums; 3) Sharing data on claims history; and 4) Allowing plans to assume no reimbursement for CSR payments when filing their rates.


By cooperating in areas such as regulations and premium pricing, insurers and states were able to prevent bare counties, though there is a strong consensus among both state regulators and insurers that these were stopgap measures that are unsustainable without long-term federal action.

About the Georgetown's Health Policy Institute-Center on Health Insurance Reforms

The Center on Health Insurance Reforms at Georgetown University’s Health Policy Institute is a nonpartisan, expert team of faculty and staff dedicated to conducting research on the complex and developing relationship between state and federal oversight of the health insurance marketplace.

About the Urban Institute

The nonprofit Urban Institute is dedicated to elevating the debate on social and economic policy. For nearly five decades, Urban scholars have conducted research and offered evidence-based solutions that improve lives and strengthen communities across a rapidly urbanizing world. Their objective research helps expand opportunities for all, reduce hardship among the most vulnerable, and strengthen the effectiveness of the public sector. Visit the Urban Institute’s Health Policy Center for more information specific to its staff and its recent research.