ACAWith support from the Robert Wood Johnson Foundation (RWJF), the Urban Institute is undertaking a comprehensive monitoring and tracking project to examine the implementation and effects of health reform.

In this brief, they examine insurers’ participation and pricing decisions for the 2018 and 2019 plan years through structured interviews with 10 insurance companies participating in the individual market in 28 states and the District of Columbia.


Although congressional efforts to repeal and replace the Affordable Care Act (ACA) did not succeed in 2017, the law continues to face an uncertain future. Absent legislative action to repeal the law, the Trump Administration issued several policies in late 2017 to roll back some of its key provisions, and just before the end of the year, Congress successfully repealed the ACA’s penalty for individuals who fail to maintain insurance coverage (the individual mandate). This repeal, coupled with federal administrative actions, has generated questions about the long-term availability of affordable health plan choices in the individual market.

Approximately 17.6 million people obtain coverage through private health insurance plans offered in the individual market. However, insurers participating in that market (both inside and outside the ACA’s health insurance marketplaces) must decide annually whether to remain, what types of plans they will offer, and at what price they will offer them. These business decisions are highly dependent on federal and state policy decisions that may stabilize or destabilize the market. Although data suggest that insurers are entering 2018 on much sounder financial footing than in the early years of the ACA’s marketplaces, several policies are in place this year that threaten insurers’ long-term participation in the marketplaces and the affordability of ACA coverage. Such policies include the repeal of the individual mandate penalty, the Trump Administration’s decision to cut off insurers’ reimbursements for the ACA’s CSR plans, and the encouragement of alternative coverage options, such as short-term plans and association health plans (AHPs). At the same time, however, the Trump Administration has offered insurers greater flexibility over plan benefit design, which could lower premiums. Going forward, insurers must also consider the possibility of congressional efforts to repeal the ACA or, conversely, to stabilize it by restoring cost-sharing subsidies or instituting a reinsurance program. Through structured interviews with a range of insurers participating in the ACA’s marketplaces, this brief explores how insurers approached the 2018 plan year given considerable federal policy uncertainty as well as their strategies for 2019 and beyond. We find that federal policies have caused insurers to implement significant premium increases and offer fewer plan choices in 2018, and we predict even higher prices and potentially greater retrenchment of participation in 2019.

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