Affordable Care Act enrollment in Texas after rating area adjustments.

Objective: To evaluate the association between Texas Affordable Care Act rating area change and health plan enrollment, plan selection, and premiums from 2022 to 2024 for urban and rural counties.

Study design: Texas integrated a rating area consisting of all 177 rural counties into nearby metropolitan rating areas in 2023. We analyzed this policy using enrollment data from the Marketplace Open Enrollment County-Level Public Use Files from 2022-2024.

Methods: We calculated the growth in enrollment across rural and urban counties and estimated linear regression models to understand whether enrollment grew faster in rural counties than in urban counties after the policy change.

Results: Total marketplace plan enrollment increased by 80% (95% CI, 70%-90%) in urban counties and 76% (95% CI, 68%-84%) in rural counties. Urban and rural counties experienced the largest growth among enrollees aged 35 to 44 years (urban: 107%; 95% CI, 94%-119%; rural: 103%; 95% CI, 95%-112%) and enrollees with incomes between 100% and 150% of the federal poverty level (urban: 124%; 95% CI, 106%-142%; rural: 116%; 95% CI, 106%-127%). The share of counties reporting gold plan enrollment increased in urban and rural counties from 70% to 95% and 51% to 93%, respectively. Rating area changes were not associated with differential enrollment changes across rural and urban counties.

Conclusions: We found similar growth rates in enrollment for rural and urban counties. Marketplace enrollees were more likely to choose a gold plan, suggesting that they shifted away from less-expensive bronze plans.