Health Insurance Marketplaces (HIMs) are in their fifth year of operation, currently in a political environment that renders their future uncertain. Data on issuer participation and premiums charged at the county level across the U.S. from 2014 to 2018 are analyzed to describe trends in rural and urban places as well as to assess the differential impact of Medicaid expansion. We find that insurance carriers reduced HIM participation across both rural and urban places, both in states that expanded Medicaid and in non-expansion states.

The average adjusted premium (before premium subsidy) continues to rise across all categories, and the gap has widened between expansion and non-expansion states. Average adjusted premiums in rural counties are higher than average premiums in urban counties in both expansion and non-expansion states (by $43 per month and $27 per month, respectively). Prior trends of lower premium changes at greater population densities are no longer observed in the data, which may be related to the uncertainty in the marketplace, including the defunding of cost-sharing reductions in 2018. These results describe the impact of the uncertain political environment compared to prior trends and as such can inform policies that may improve options for rural consumers in the individual marketplace.