What's Behind 2018 and 2019 Marketplace Insurer Participation and Pricing Decisions?

A medical professional listens to a girl's heart using a stethoscope.

ACA marketplaces gain stability in 2019 after turbulent 2018.

The Issue


Consumers using Affordable Care Act (ACA) marketplaces to assess 2019 health insurance options had more choices of insurers with generally modest premium increases—and even some decreases. This is a contrast to 2018 when several insurers left the marketplaces and premiums increased dramatically in most markets. Researchers conducted extensive interviews with marketplace insurers in 10 states (California, Florida, Georgia, Indiana, Maryland, Minnesota, Ohio, Virginia, Washington, and West Virginia) to prepare the analysis.

Key Findings

  • Insurer participation declined in the 2018 plan year primarily because of policy changes made in 2017 as well as increased political uncertainty and the associated financial risks. Policy changes included the ending of direct funding of cost sharing subsidies, reduction in the length of the open enrollment period, and reduced funding for outreach and enrollment assistance. Efforts to repeal the ACA also were felt to discourage enrollment and thus insurer participation.

  • For the 2019 plan year insurers were increasingly willing to enter new markets, marking a substantial shift from 2018 when political uncertainty and policy changes drove sharp declines in participation.

  • Shifts between 2018 and 2019 show more plans offering narrow provider networks, an increasingly common strategy insurers use to contain costs and limit networks to high-performing providers. 

  • Many markets were also dominated by health maintenance organization products offered by Blue Cross Blue Shield affiliates and Medicaid insurers.


Researchers found that insurer participation in the marketplaces began to rebound in 2019, following decreases in participation in many areas in 2018. Some insurers expanded their geographic footprint in states in which they already participated, and others expanded to new states. Insurers were generally satisfied with the outcomes of their 2018 decisions.

Following many dramatic marketplace premium increases in 2018, premium growth in 2019 tended to be modest, and even negative in some areas. The 2018 increases were largely attributable to insurers incorporating the costs associated with cost-sharing reductions into their premiums and to the tremendous uncertainty created by other regulatory changes and the political debate surrounding reform. Insurers appear to be readjusting premium growth in 2019 to account for 2018 overestimates.

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. For more information, visit www.urban.org. More information specific to the Urban Institute’s Health Policy Center, its staff, and its recent research can be found at www.healthpolicycenter.org.

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