Health Insurance iPad

Consumers in a large majority of metropolitan areas across the United States have limited options for health insurance coverage, a new market analysis from the American Medical Association found. The share of commercial markets that are highly concentrated has remained steady at around 95% for most of the past decade, with nearly half of markets that were highly concentrated in 2014 becoming more so by 2023.

“For too many Americans living in highly concentrated health insurance markets, choosing medical coverage feels like having no choice at all,” AMA President Bruce A. Scott, M.D., said. “The AMA strongly encourages a dialogue among regulators, policymakers, lawmakers and others to reverse the trend toward health insurance consolidation and create a better, more open and competitive marketplace to benefit patients.”

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The 2024 edition of Competition in Health Insurance: A Comprehensive Study of U.S. Markets examined 382 metropolitan statistical areas (MSAs), all 50 states and the District of Columbia. It tabulated commercial and Medicare Advantage market shares for the two largest health insurance companies in each of those geographic markets and analyzed state- and MSA-level market concentration. Markets that exceed a regulatory threshold set by federal guidelines are considered “highly concentrated” and lack adequate health insurer competition.

Among the other highlights of the study:

  • In 89% of MSAs, at least one insurer held a commercial market share of 30% or greater, and in 47%, one insurer's share was at least 50%.
  • A Blue Cross Blue Shield insurer had the largest state-level market share in 41 states.
  • A BCBS insurer had the largest MSA-level market share in 83% of MSAs.
  • Elevance Health (formerly Anthem) had the largest MSA-level market share in 21% of MSAs.
  • At the national level, UnitedHealth Group was the largest commercial health insurer by market share, and Centene was the largest insurer by market share in the exchanges.
  • The 10 states with the least competitive commercial health insurance markets were Alabama, Kentucky, Michigan, Louisiana, Hawaii, Illinois, Alaska, Delaware, Vermont and South Carolina.
  • Medicare Advantage markets also are highly concentrated and have remained so over time. In 2023, 97% of MSA-level MA markets were highly concentrated, and this proportion has hovered between 97% and 99% since 2017.
“The prospect of future consolidation in the health insurance industry must be viewed in the context of the low levels of competition in most health insurance markets,” the study concluded. “For more than 20 years, the AMA analysis has been a helpful resource to researchers, policymakers and regulators as they work to identify markets where mergers and acquisitions involving health insurers may cause competitive harm to consumers and providers of care.”

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Alan Goforth

Alan Goforth is a freelance writer in suburban Kansas City. In addition to freelancing for several publications, he has written a dozen books about sports and other topics.