Which Types of Insurance are Marketplace Enrollees Choosing?

A patient gets educated on better eating habits by a dietician in a doctor's office.

Analysis shows cost isn’t always the main factor driving consumers’ health plan selection.

The Issue

For some people, having a recognized brand name or broader provider network can be an important consideration when selecting a health plan. These consumer motivators can have important implications for competition in the marketplaces and for federal health spending on marketplace subsidies.

Authors use new data from the Centers for Medicare & Medicaid Services to examine marketplace enrollment by state and insurer type to determine whether certain types of insurers are increasing or decreasing in importance—with particular interest in assessing how lower-priced insurers are faring.

Key Findings

Health plans issued by Blue Cross Blue Shield companies accounted for nearly half (47%) of the Affordable Care Act marketplace enrollment in 2018, but Medicaid health plans are emerging as competition.

  • Blue Cross Blue Shield-affiliated insurers hold all or close to all of the enrollment in 11 states’ marketplaces (Alaska, Alabama, Delaware, Illinois, Louisiana, North Carolina, North Dakota, New Hampshire, Oklahoma, South Carolina, Wyoming).

  • In another nine states (Arkansas, Florida, Hawaii, Kansas, Michigan, New Jersey, Pennsylvania, Tennessee, West Virginia), Blue Cross Blue Shield plans have the majority of enrollment, though they face increasing competition from other insurer types, typically Medicaid insurers.


Marketplace enrollment is expected to increase due to wide-scale unemployment and the loss of employer-sponsored insurance from the COVID-19 crisis and associated economic fallout. Researchers say the data are a baseline for marketplace enrollment prior to entering the period shaped by the COVID-19 pandemic.

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.