Trends in Small-Group Market Insurance Coverage: 2013–2020

Nurses at a nurses' station in a hospital.

Nearly a decade after the Affordable Care Act was implemented, the small-group marketplace continues to be a reliable source of health coverage for millions.

The Issue

Some policy analysts predicted that the Affordable Care Act (ACA) would cause small employers to stop offering health coverage. However, an analysis shows the rate at which small businesses offered employer-sponsored health insurance (ESI) coverage to employees stabilized from 2013 to 2020.

Key Findings

  • Health insurance enrollment in the small-group marketplace held stable from 2013 to 2019, hovering between 8.9 and 9.6 million enrollees.

    º In 2020, the number of enrollees dipped to 7.9 million—likely a result of decreases in employment due to the COVID-19 pandemic.

  • The rate at which small employers offered health insurance decreased by just 2.6 percentage points from 2013 to 2020—a marked improvement from the 10.6 percentage point decline from 2002 to 2012.

    º The slight decrease in coverage offerings by small employers mirrors what was observed among large firms during the same time period.

  • Year-over-year premium growth in the ESI market was similar across companies of all sizes.


Small-group insurance plans offered through the Affordable Care Act's marketplace continue to be an affordable and in demand coverage option. 

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.