As enrollment on the ACA exchanges surges, insurer participation growth is more modest: study

The number of plans offered under the Affordable Care Act (ACA) for 2022 hit 15,638, up 15% from the 2021 plan year, according to a new analysis.

While membership in exchange plans skyrocketed over the course of 2021, thanks to a lengthy special enrollment period under the pandemic and enhanced premium tax credits, insurer participation grew more slowly than in recent years, according to the report, which was penned by Kathy Hempstead, senior policy adviser at the Robert Wood Johnson Foundation.

The report finds a notable shift toward the exchanges, with growth in exchange plans at 20% compared to 6.8% for off-exchange plans.

"In the short-to-medium run, the most likely prospect for enrollment growth will come from the coverage provisions in the Build Back Better Act and redeterminations out of Medicaid as the public health emergency unwinds," Hempstead wrote. "These trends may take longer than anticipated to materialize, due to both headwinds with the legislation and the persistence of the pandemic."

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"Much of this potential growth will take place in the non-expansion states, which is where recent increases in insurer participation have been concentrated," she added.

The report names some notable entrants into the individual market for 2022, including Ascension, which represents the lone new entrant in the provider-sponsored plan market. Ascension is selling marketplace plans in the Wichita and Detroit markets as well as in 30 Indiana counties.

Two Medicaid managed care organizations, AmeriHealth Caritas and The Health Plan, have also entered the marketplaces in North Carolina and West Virginia, respectively. The paper said the potential synergies between Medicaid and the ACA exchanges are luring these companies into the space.

CVS Health's Aetna headlines the list of returning companies to the exchanges for 2022, after exiting the market fully amid significant loses. The insuer is offering plans across eight states and adopting a similar stance to rival UnitedHealth Group in its return with a slimmed down slate of plan options.

"With Aetna’s entry, nearly all of the major national health insurers have returned to the marketplace, with only Humana remaining on the sidelines," Hempstead wrote.

Other plans such as Centene, Oscar Health, Molina Healthcare, Cigna and Bright Health have entered new states or otherwise expanded their footprints for the 2022 plan year, according to the report.

Hempstead writes that long-term growth trends could follow emerging trends in Medicare Advantage, which saw some insurers with lower-than-expected enrollment growth due to increasing competition. For now, many insurers are focusing on areas with high numbers of uninsured residents, but they will likely need to grow by capturing market share from competitors in the near future.

"Whether this becomes a factor in the individual market depends on both participation trends and the potential for market growth," she wrote.