Section 1311 of the Patient Protection and Affordable Care Act of 2010 (ACA) created Health Insurance Marketplaces (Marketplaces), formerly known as Health Insurance Exchanges, as one of several strategies for expanding insurance coverage to more Americans. Marketplaces are intended to expand and organize the market for health insurance, providing a way for Americans purchasing insurance through the individual or small-group markets to choose among plan offerings that vary in cost and benefit design. Proactive states have significant flexibility in how to structure their Marketplace. Fifteen states and the District of Columbia currently operate their own individual and Small Business Health Options Program (SHOP) Marketplaces. In addition, three states have chosen to operate their own SHOP Marketplace, while operating an individual Marketplace in partnership with the federal government. Six states will operate a Marketplace in partnership with the federal government. Residents of the other 27 states will participate through a Federally-Facilitated Marketplace (FFM). 1 In later years, states operating partnerships or FFMs may choose to transition toward operating their own Marketplace. Each state’s decision is summarized in Table 1 in the Appendix, along with measures of the size of each state’s rural population. Key characteristics of state-based Marketplaces are summarized in Table 2 in the Appendix. Although states operating their own Marketplace are generally more metropolitan than states with an FFM or partnership Marketplace, millions of rural Americans live in states operating a state-based Marketplace.

In two previous papers, 2, 3 the Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis identified several domains in which state choices could affect rural residents’ access to care through the Marketplaces—market function, governance, access, enrollment, certification of qualified health plans (QHPs), and the SHOP. These papers traced the development of Marketplaces through the point at which enabling legislation authorized the creation of a state-based Marketplace in 17 states and the District of Columbia.