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Affordable Care Act exchanges grow as insurer participation rises

In total, 245 individual insurance carriers took part in federal and state exchanges during the 2019-2020 plan year, offering consumers more choice.

Jeff Lagasse, Associate Editor

Even as the ultimate fate of the law remains uncertain, the Affordable Care Act has shown that its insurance marketplace is still going strong. Insurer participation in the ACA rose in 2019 following three straight years of decline, finds a new analysis by McKinsey and Company.

In total, 245 individual insurance carriers took part in federal and state exchanges during the 2019-2020 plan year. In 2018-2019 that number was only 218; and in 2017-2018 it was lower still, at 194.

What this means is that consumers are being offered more choice, as the number of counties with just one insurance carrier dipped from 36% in 2019 to 25% in 2020.


Despite the gains, the ACA marketplace is still shy of the 333 insurance providers it boasted in 2015.

Still, an expanded marketplace has translated into expanded coverage, with just one in 10 people still forced to choose plans offered by one carrier in their county. Two-thirds of ACA consumers have their pick between three or more carriers.

Prices in the exchanges are also better, particularly in states that have reinsurance programs. Premiums declined in all tiers except for Platinum between 2018 and 2019, with most of the impact being felt in regional and local plans.

The largest premium decreases were filed by regional and local CO-OP plans, dipping 8% after a modest 1% decline last year and minor gains/losses in previous years. Overall, the lowest-premium options for more than half of consumers were offered by Medicaid or regional carriers.

Managed care plans including HMO and EPO are continuing to comprise a higher percentage of marketplace offerings. In 2020, 48% of offerings on the exchange were HMOs and 30% were EPOs, up from 47% and 30% respectively in 2019, and 33% and 9% respectively in 2014.


The numbers come as the U.S. Supreme Court is still mulling whether to take up the fate of the ACA, or relist the case for a future conference date, which would effectively delay a decision in whether or not to hear an appeal in either the California v. Texas or House v. Texas cases. The outcome of those cases could determine whether the court upholds the law, with justices weighing the merits of a lower court's ruling that the ACA's individual mandate is unconstitutional.

Republicans, who have long sought to dismantle the ACA and replace it with a different plan, contend that without the individual mandate the constitutionality of the law cannot stand. A preliminary decision on when and whether to hear the case could come from the Supreme Court later today or this week.

The ACA has been a topic of debate during the Democratic presidential race, with former Vice President Joe Biden defending the law and saying he would expand it to include a public option; Mayor Pete Buttigieg's plan is similar, calling on expanding Medicare and making it optional for all Americans.

Senators Bernie Sanders and Elizabeth Warren have taken a firmer stance on expanded Medicare, particularly Sanders, who favors a government-run system in place of private insurance.

Twitter: @JELagasse

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