Problem statement: To date, analysis of the performance of HIMs in rural places has failed to account for the differing policy environments at the state level, which may impact the effective choice set that rural health insurance consumers face. In policy environments that strictly enforce network adequacy standards, a tradeoff may be occurring as firms are prompted to offer coverage to rural residents but at the cost of somewhat higher premiums. Conversely, weak network adequacy or service area standards may keep premiums lower at a cost of less real choice for rural residents.

Goals of this project include gathering detailed data and providing analysis and policy recommendations on issues relating to network adequacy and service areas for HIMs, with additional investigation of other state-level policy variables (such as the Medicaid expansion decision) which may have a confounding or moderating effect on the relationship between network adequacy and enrollees' choices and premiums. RUPRI staff will gather data on the ten study states through searches of state insurance commissions' websites, direct telephone calls when necessary, and thorough examination of plan brochures and websites to obtain data on provider availability to consumers at the county level.

Publications

• 2016 Rural Enrollment in Health Insurance Marketplaces, by State
  Policy Brief
  RUPRI Center for Rural Health Policy Analysis
  Date: 01/2017
  Cumulative county-level enrollment rates in Health Insurance Marketplaces (HIMs) in metropolitan and non-metropolitan areas of each state, defined as the percentage of "potential market" participants selecting plans, are presented as of March 2016. States are separated by Medicaid expansion status.
• Health Insurance Marketplaces: Premium Trends in Rural Areas
  Policy Brief
  RUPRI Center for Rural Health Policy Analysis
  Date: 06/2016
  Total Health Insurance Marketplace premiums have grown disproportionately in rural places in 2016. Urban counties have an average of 4.2 firms, while rural counties average 3.2 firms offering coverage through the HIMs. This causes concern since, at the county level, we find that as the number of firms increases, premiums increase at a slower rate.
• Rural Enrollment in Health Insurance Marketplaces, by State
  Policy Brief
  RUPRI Center for Rural Health Policy Analysis
  Date: 10/2015
  This brief compares cumulative enrollment totals in Health Insurance Marketplaces in metropolitan and non-metropolitan areas by state and the percentages of potential market participants enrolled. Non-metropolitan enrollment rates were higher in several states. The analysis shows how well outreach/enrollment efforts targeting rural areas work.