Piggy banks with calculator and stethoscope

The Affordable Care Act marketplace is struggling to deliver affordable premiums to rural areas, largely due to a lack of insurance competition.

A new analysis by the Urban Institute, a liberal-leaning think tank, finds that more than half (271) of the country's 498 rating regions had only one or two insurers participating in the ACA marketplace. Those regions are disproportionately in sparsely populated areas.

Meanwhile, the 69 regions that had five or more insurers were largely in densely populated urban areas.

The Northeast was home to many of the regions with the most robust competition. Forty percent of the population in the Northeast lives in a region with five or more ACA health plans.

The opposite is true in the South, where only 4 percent of the population lives in a region with five or more health plans. Fifty-two percent of people live in a region with one or two plans.

In both the West and Midwest, roughly a quarter of the population lives in a region with at least five ACA plans. However, a far greater proportion of the population in the Midwest is located in areas with only one or two plans (40 percent vs. 19 percent).

Regions with little competition tend to have much higher premiums. In a region with only one insurer, the median benchmark plan for a 40-year-old nonsmoker is $592 a month. That compares to $376 for the same consumer in a region with at least five plans.

Granted, the premiums do not reflect what the majority of ACA customers are paying, since the majority of them are eligible for premium tax credits that significantly lower what they owe.

“It's encouraging to see signs of stabilization in the individual market,” said Anne F. Weiss, managing director at the Robert Wood Johnson Foundation, which commissioned the analysis. “However, geographic location still plays too great a role in consumers' coverage options and how much they cost. Everyone should have affordable health insurance options, regardless of where they live, given the impact of coverage on health.”

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Limited competition drives up ACA premiums in rural areas

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