IDEAS home Printed from
   My bibliography  Save this article

The Impact of Market Size and Composition on Health Insurance Premiums: Evidence from the First Year of the Affordable Care Act


  • Michael J. Dickstein
  • Mark Duggan
  • Joe Orsini
  • Pietro Tebaldi


Under the Affordable Care Act, individual states have discretion in how they define coverage regions, within which insurers must charge the same premium to buyers of the same age, family structure, and smoking status. We exploit variation in these definitions to investigate whether the size of the coverage region affects outcomes in the ACA marketplaces. We find large consequences for small and rural markets. When states combine small counties with neighboring urban areas into a single region, the included rural markets see 0.6 to 0.8 more active insurers, on average, and savings in annual premiums of between $200 and $300.

Suggested Citation

  • Michael J. Dickstein & Mark Duggan & Joe Orsini & Pietro Tebaldi, 2015. "The Impact of Market Size and Composition on Health Insurance Premiums: Evidence from the First Year of the Affordable Care Act," American Economic Review, American Economic Association, vol. 105(5), pages 120-125, May.
  • Handle: RePEc:aea:aecrev:v:105:y:2015:i:5:p:120-25
    Note: DOI: 10.1257/aer.p20151083

    Download full text from publisher

    File URL:
    Download Restriction: no

    File URL:
    Download Restriction: no

    File URL:
    Download Restriction: Access to full text is restricted to AEA members and institutional subscribers.

    References listed on IDEAS

    1. Bresnahan, Timothy F & Reiss, Peter C, 1991. "Entry and Competition in Concentrated Markets," Journal of Political Economy, University of Chicago Press, vol. 99(5), pages 977-1009, October.
    Full references (including those not matched with items on IDEAS)


    Citations are extracted by the CitEc Project, subscribe to its RSS feed for this item.

    Cited by:

    1. Mukhopadhyay, Sankar & Wendel, Jeanne & Zou, Miaomiao, 2019. "Impacts of shifting responsibility for high-cost individuals on Health Insurance Exchange plan premiums and cost-sharing provisions," Journal of Health Economics, Elsevier, vol. 66(C), pages 180-194.
    2. Maria Polyakova & Stephen P. Ryan, 2019. "Subsidy Targeting with Market Power," NBER Working Papers 26367, National Bureau of Economic Research, Inc.
    3. Joshua D. Woodard & Jing Yi, 2020. "Estimation of Insurance Deductible Demand Under Endogenous Premium Rates," Journal of Risk & Insurance, The American Risk and Insurance Association, vol. 87(2), pages 477-500, June.
    4. Lieber, Ethan M.J., 2018. "Does health insurance coverage fall when nonprofit insurers become for-profits?," Journal of Health Economics, Elsevier, vol. 57(C), pages 75-88.
    5. Jean Marie Abraham & Coleman Drake & Jeffrey S. McCullough & Kosali Simon, 2017. "What drives insurer participation and premiums in the Federally-Facilitated Marketplace?," International Journal of Health Economics and Management, Springer, vol. 17(4), pages 395-412, December.
    6. Lizhong Peng, 2017. "How Does Medicaid Expansion Affect Premiums in the Health Insurance Marketplaces? New Evidence from Late Adoption in Pennsylvania and Indiana," American Journal of Health Economics, MIT Press, vol. 3(4), pages 550-576, Fall.
    7. Kurt J. Lavetti & Thomas DeLeire & Nicolas R. Ziebarth, 2019. "How Do Low-Income Enrollees in the Affordable Care Act Marketplaces Respond to Cost-Sharing?," NBER Working Papers 26430, National Bureau of Economic Research, Inc.
    8. Brett Lissenden, 2017. "Three's a Crowd? The Effect of Insurer Participation on Premiums and Cost-Sharing Parameters in the Initial Years of the ACA Marketplaces," American Journal of Health Economics, MIT Press, vol. 3(4), pages 477-506, Fall.
    9. Woodard, Joshua, 2016. "Estimation of Insurance Deductible Demand under Endogenous Premium Rates," 2016 Annual Meeting, July 31-August 2, Boston, Massachusetts 236151, Agricultural and Applied Economics Association.

    More about this item

    JEL classification:

    • G22 - Financial Economics - - Financial Institutions and Services - - - Insurance; Insurance Companies; Actuarial Studies
    • H51 - Public Economics - - National Government Expenditures and Related Policies - - - Government Expenditures and Health
    • H75 - Public Economics - - State and Local Government; Intergovernmental Relations - - - State and Local Government: Health, Education, and Welfare
    • I13 - Health, Education, and Welfare - - Health - - - Health Insurance, Public and Private


    Access and download statistics


    All material on this site has been provided by the respective publishers and authors. You can help correct errors and omissions. When requesting a correction, please mention this item's handle: RePEc:aea:aecrev:v:105:y:2015:i:5:p:120-25. See general information about how to correct material in RePEc.

    For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: (Michael P. Albert). General contact details of provider: .

    If you have authored this item and are not yet registered with RePEc, we encourage you to do it here. This allows to link your profile to this item. It also allows you to accept potential citations to this item that we are uncertain about.

    If CitEc recognized a reference but did not link an item in RePEc to it, you can help with this form .

    If you know of missing items citing this one, you can help us creating those links by adding the relevant references in the same way as above, for each refering item. If you are a registered author of this item, you may also want to check the "citations" tab in your RePEc Author Service profile, as there may be some citations waiting for confirmation.

    Please note that corrections may take a couple of weeks to filter through the various RePEc services.

    IDEAS is a RePEc service hosted by the Research Division of the Federal Reserve Bank of St. Louis . RePEc uses bibliographic data supplied by the respective publishers.