Over the first 10 years of the Affordable Care Act marketplaces, enrollment nationwide has almost tripled, from 8 million individuals in 2014 to 21.4 million in 2024, according to an HHS report.

While the ACA initially envisioned the marketplaces to be developed by states, it also provided states with the option to participate in the federally facilitated marketplace, HealthCare.gov. In 2014, 14 states and the District of Columbia chose to operate their own state-based marketplaces (SBMs). In 2024, there are 19 SBMs.

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Federal policy changes have played a key role in the performance of the ACA marketplaces. In 2014, about 5.4 million people enrolled in marketplace health insurance in HealthCare.gov states and 2.6 million enrolled in SBMs. Yet between 2017 and 2020, the reduction in funding for marketing and the elimination of federal cost-sharing payments to health plans led to enrollment decreases.

But since the COVID-19 pandemic, several policies aimed at expanding health care coverage have contributed to membership increases for four consecutive years. By end of the annual open enrollment period in 2024, 21.4 million individuals had selected or were automatically reenrolled in a marketplace plan. More than 5 million people were new consumers, an increase of 41% from 2023.

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In the early years of the ACA, three-quarters of HealthCare.gov enrollees lived in markets with three or more health plan issuers, while 7% were in markets with only one. By 2016, only 2% of enrollees lived in markets with just a single issuer. The trend reversed in 2017, when some major national insurers — such as CVS Health Corp.’s Aetna and UnitedHealth Group — pulled back from the marketplaces, leaving over 1,000 counties in HealthCare.gov states with only one issuer in 2018.

However, the number of issuers participating in the ACA has climbed since 2019, as several insurers chose to rejoin the market and expand their coverage footprints, according to the Robert Wood Johnson Foundation’s ACA Marketplace Participation Tracker.

Centene Corp. — the country’s largest ACA exchange insurer — gained nearly 1.1 million new members from the first quarter of 2019 to 2023, according to AIS’s Directory of Health Plans. Aetna, which rejoined the marketplaces in 2022, reported year-over-year membership growth of nearly 3,122% and ranked as the fourth largest ACA insurer in 2023.

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Since the establishment of the ACA marketplaces, over 85% of HealthCare.gov enrollees have received subsidies to cover their premiums each year. The expansion of subsidy eligibility to enrollees with household incomes above 400% of the federal poverty level further increased the share of enrollees receiving financial assistance. By 2024, 95% of HealthCare.gov enrollees gained subsidies, according to the HHS report.

Average premiums, both before and after subsidies, began to fall in 2019, partially due to increased insurer participation. The average premium after subsidies was 17% of the gross premium in 2023, compared to 36% in 2015.

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This infographic was reprinted from AIS Health’s weekly publication Health Plan Weekly.