Did they come to the dance? Insurer participation in exchanges

Objectives: An important feature of the Affordable Care Act is the creation of insurance exchanges, which are organized marketplaces through which individuals could begin to shop for and purchase coverage beginning in 2014. This study analyzes the decisions of new insurers and incumbent insurers already operating in a major market within a state to participate in state and federally facilitated exchanges. Study Design: Utilizing secondary data from the National Association of Insurance Commissioners∗ and government websites, we describe each state's insurance market in 2012, summarizing the number of incumbent insurers by size and operations in the individual market segment. Next, we investigate the organizational, market, and policy-related factors associated with incumbent insurers' participation decisions. Finally, we discuss the entry patterns of new insurers and briefly assess their potential impact on the market. Methods: We use multivariate regression analysis to identify the organizational, market, and policy-related factors related to insurer participation in exchanges. Results: Only 10% of incumbent insurers are participating in exchanges in 2014, although considerable variation exists across states. Participation is more prevalent among larger insurers, local and regional insurers, and those with prior experience in other market segments in the same state. The entry of newly formed organizations, such as cooperatives (co-ops), and of existing insurers into new states is modest. Conclusions: Robust participation of insurers is an important prerequisite to ensure competition in health insurance markets. Exchange administrators will need to better understand the strategic or operational reasons why insurers chose not to participate in the individual market exchanges in 2014.