United States Government Accountability Office GAO Report to Congressional Committees November 2022 PRIVATE HEALTH INSURANCE Markets Remained Concentrated through 2020, with Increases in the Individual and Small Group Markets GAO-23-105672 GAO Highlights Highlights of GAO-23-105672, a report to congressional committees Why GAO Did This Study Individuals have various options for obtaining private health insurance, including through the individual, small group, and large group markets. A concentrated health insurance market may indicate less issuer competition and could affect consumers' choice of issuers and the premiums they pay for coverage. PPACA included a provision for GAO to periodically study health insurance market concentration. This report describes changes in the concentration of enrollment among issuers in the overall individual, small group, and large group health insurance markets and in the individual market exchanges. GAO determined market share in each of the three overall markets using enrollment data from 2019 and 2020 that issuers are required to report to the Centers for Medicare & Medicaid Services (CMS). GAO determined market share in the individual market exchanges in 2018, 2019, and 2020 using enrollment data from CMS. For all analyses, GAO used the most recent data available at the time of its review. View GAO-23-105672. For more information, contact John Dicken at (202) 512-7114 or dickenj@gao.gov. PRIVATE HEALTH INSURANCE Markets Remained Concentrated through 2020, with Increases in the Individual and Small Group Markets What GAO Found In November 2020, GAO reported that, from 2010 through 2018, enrollment in private health insurance plans was concentrated, meaning a small number of issuers of those plans enrolled most of the people in a given market. Specifically, GAO considered a market concentrated in a state if three or fewer issuers held at least 80 percent of that market. GAO examined the individual (coverage sold directly to individuals), small group (coverage offered by small employers), and large group (coverage offered by large employers) markets and found that this pattern continued in 2019 and 2020. Specifically: e Each of the three markets in 2020 was concentrated in at least 42 states (including the District of Columbia). e = The individual and small group markets generally became more concentrated in recent years. The median market share of the top three issuers in each market increased by 12 and 10 percentage points, respectively, from 2011 through 2020. With these increases, their median market share was at least 97 percent in both markets in 2020. Number of States, including the District of Columbia, Where the Three Largest Issuers Had at Least 80 Percent of Enrollment, by Market, 2011-2020 Individual market Number of states Small group market Number of states Large group market Number of states 50 50 50 45 45 45 40 40 40 35 35 35 30 30 30 25 25 25 20 20 20 15 15 15 10 10 10 5 5 5 0 0 0 111213 14 15 16 17 1819 20 111213 1415 1617 1819 20 11 1213 1415 16 17 18 19 20 Year Year Year Source: GAO analysis of data from the Centers for Medicare & Medicaid Services (CMS). | GAO-23-105672 GAO found similar patterns of high concentration across individual market exchanges. Exchanges, which are marketplaces where consumers can compare and select among insurance plans offered by participating issuers, were established by the Patient Protection and Affordable Care Act (PPACA). From 2015 through 2020, most states' exchanges were concentrated and became more concentrated over time. This was often because the number of issuers decreased or the existing issuers increased their market share within a state. In 2020, the exchanges were concentrated in all states. GAO received technical comments on a draft of this report from the Department of Health and Human Services and incorporated them as appropriate. United States Government Accountability Office Contents Letter Background 5 Concentration in the Individual Health Insurance Market, Including the Exchanges, Was Higher in Recent Years than in 2011 6 Concentration in Small Group Health Insurance Markets Generally Increased from 2011 through 2020 14 Large Group Health Insurance Markets Remained Concentrated from 2011 through 2020 17 Appendix | Number and Market Share of Largest Issuers Participating in Each State's Individual Market 22 Appendix II States' Individual Market Exchange Enrollment as a Proportion of Overall Individual Market Enrollment, 2020 29 Appendix III Number and Market Share of Issuers in Individual Market Exchanges, 2015-2020 31 Appendix IV Number of Issuers and Market Share of Largest Issuers Participating in Small Group Health Insurance Market 40 Appendix V Number of Issuers and Market Share of Largest Issuers Participating in Large Group Health Insurance Market 46 Appendix VI GAO Contact and Staff Acknowledgments 52 Tables Table 1: Trends in Issuer Participation and Concentration in the Individual Health Insurance Market across States, 2011 through 2020 8 Page i GAO-23-105672 Health Insurance Market Concentration Table 2: Trends in Issuer Participation and Concentration in the Small Group Health Insurance Market across States, 2011 through 2020 15 Table 3: Trends in Issuer Participation and Concentration in the Large Group Health Insurance Market across States, 2011 through 2020 18 Table 4: Number of Issuers in Each State's Individual Health Insurance Market, 2011 through 2020 22 Table 5: Market Share of the Largest and Three Largest Issuers in Each State's Individual Health Insurance Market, 2017 through 2020 23 Table 6: Percentage Change in Market Share for the Three Largest Issuers' in Each State's Individual Health Insurance Market, 2011 to 2020 and 2019 to 2020 27 Table 7: Covered Life-Years in Each State's Individual Market Health Insurance Exchange as a Proportion of Total Covered Life-Years in the Overall Individual Market, 2020 29 Table 8: Weighted Average Number of Individual Market Exchange Issuers Participating in Each State's Rating Areas, 2015 through 2020 31 Table 9: Market Share of the Largest and Three Largest Issuers in Each State's Individual Market Health Insurance Exchange, 2017 through 2020 33 Table 10: Weighted Average Market Share of the Largest Issuer across Each State's Rating Areas, Individual Market Exchange, 2015 through 2020 35 Table 11: Percentage Change of Largest Issuer's Market Share across a State's Rating Areas in Each Individual Health Insurance Market Exchange, 2015 to 2020 and 2019 to 2020 37 Table 12: Number of Issuers in Each State's Small Group Health Insurance Market, 2011 through 2020 40 Table 13: Market Share of the Largest and Three Largest Issuers in Each State's Small Group Health Insurance Market, 2017 through 2020 41 Table 14: Percentage Change of the Three Largest Issuers' Market Share in Each State's Small Group Health Insurance Market, 2011 to 2020 and 2019 to 2020 44 Table 15: Number of Issuers in Each State's Large Group Health Insurance Market, 2011 through 2020 46 Page ii GAO-23-105672 Health Insurance Market Concentration Table 16: Market Share of the Largest and Three Largest Issuers in Each State's Large Group Health Insurance Market, 2017 through 2020 47 Table 17: Percentage Change of the Three Largest Issuers' Market Share in Each State's Large Group Health Insurance Market, 2011 to 2020 and 2019 to 2020 50 Figures Figure 1: Covered Life-Years Reported by Issuers to CMS in the Individual, Small Group, and Large Group Health Insurance Markets, 2011 through 2020 5 Figure 2: Number of States Where the Market Share of the Largest Issuer and Three Largest Issuers Was at Least 80 Percent, Individual Health Insurance Market, 2011 through 2020 7 Figure 3: Percentage Point Change in Market Share Held by the Three Largest Issuers in the Individual Market from 2011 through 2020, by State 10 Figure 4: Extent to Which the Three Largest Individual Market Exchange Issuers Were Concentrated, on Average, in 51 States' Rating Areas, 2015 through 2020 11 Figure 5: Percent Point Change in Average Market Share of the Largest Individual Market Exchange Issuer across Rating Areas from 2015 through 2020, by State 13 Figure 6: Number of States Where the Market Share of the Largest Issuer and Three Largest Issuers Was at Least 80 Percent, Small Group Health Insurance Market, 2011 through 2020 14 Figure 7: Percentage Point Change in Market Share Held by the Three Largest Issuers in the Small Group Market from 2011 through 2020, by State 16 Figure 8: Number of States Where the Market Share of the Largest Issuer and Three Largest Issuers Were at Least 80 Percent, Large Group Health Insurance Market, 2011 through 2020 17 Figure 9: Percentage Point Change in Market Share Held by the Three Largest Issuers in the Large Group Market from 2011 through 2020, by State 19 Page iii GAO-23-105672 Health Insurance Market Concentration Abbreviations CMS Centers for Medicare & Medicaid Services HHS Department of Health and Human Services PPACA Patient Protection and Affordable Care Act This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Page iv GAO-23-105672 Health Insurance Market Concentration i U.S. GOVERNMENT ACCOUNTABILITY OFFICE 441 G St. N.W. Washington, DC 20548 November 7, 2022 Congressional Committees Historically, the market for private health insurance in the United States has been highly concentrated, meaning a small number of issuers enrolled most of the people in a given market.' In November 2020, we reported that, from 2010 to 2018, three types of insurance markets-the large group market (coverage offered by large employers), the small group market (coverage offered by small employers), and the individual market (consisting mainly of coverage sold directly to individual consumers who lack access to group coverage)-were highly concentrated.2 We found that the three largest issuers in each of these markets held at least 80 percent of the market in most states from 2010 through 2018.3 Within the individual market, we reported similar concentration patterns for those issuers participating in the individual insurance exchanges-marketplaces operated by either the state or federal government (known as federally facilitated exchanges) that were required to be established in each state by the Patient Protection and Affordable Care Act (PPACA)-starting in 2015.4 Highly concentrated insurance markets may indicate less competition and could affect consumers' choices of issuers and the premiums they pay. 1We use the term "issuer" when referring to the entities that are licensed by a state to engage in the business of health insurance in that specific state. 2Federal law defines a small employer as having an average of 1 to 50 employees during the preceding calendar year; however, states may apply this definition based on an average of 1 to 100 employees. See 42 U.S.C. §§ 300gg-91(e)(4), 18024(b)(3). 3See GAO, Private Health Insurance: Markets Remained Concentrated through 2018, with Increases in the Individual and Small Group Markets, GAOQ-21-34 (Washington D.C.: Nov. 13, 2020) 4Pub. L. No. 111-148, § 1321, 124 Stat. 119, 186 (2010) ("PPACA'). Health insurance exchanges are markets that operate within each state's overall individual and small group market where eligible individuals and small employers can compare and select among qualified insurance plans offered by participating issuers. In this report, the term "state" includes the District of Columbia. States may choose to operate their own exchanges, or this responsibility can be carried out by the federal government. Page 1 GAO-23-105672 Health Insurance Market Concentration PPACA included a provision for us to conduct a study on competition and concentration in health insurance markets. This report describes changes in the concentration of enrollment among issuers in each state's 1. individual health insurance market, including the individual market exchange; 2. small group health insurance market; and 3. large group health insurance market. To describe changes in concentration in the three health insurance markets in each state, we analyzed Medical Loss Ratio data that PPACA requires issuers to report annually to the Department of Health and Human Services' (HHS) Centers for Medicare & Medicaid Services (CMS) for years 2019 and 2020. These were the most recent data available at the time of our analyses.® We previously used this same data source to analyze concentration from 2011 through 2018. Where applicable, we present this information alongside our updated analyses in 5PPACA, § 1322(i), 124 Stat. at 192. PPACA includes a provision for us to report to Congress biennially beginning in 2014. In addition to GAO-21-34, our prior work in response to this mandate includes GAO, Private Health Insurance: Concentration of Enrollees among Individual, Smail Group, and Large Group Insurers from 2010 through 2073, GAO-15-101R (Washington, D.C.: Dec. 1, 2014); Private Health Insurance: In Most States and New Exchanges Enrollees Continued to be Concentrated among Few Issuers in 2014, GAO-16-724 (Washington, D.C.: Sept. 6, 2016); Private Health Insurance: Enrollment Remains Concentrated among Few Issuers, including in Exchanges, GAO-19-306 (Washington, D.C.: Mar. 21, 2019). SPPACA required that all issuers report Medical Loss Ratio data to CMS, which include the percent of premiums the issuers spent on their enrollees' medical claims and quality initiatives, known as their medical loss ratio. These data also include enrollment data that can be used to calculate the market share for fully insured health plans. We did not examine self-funded health plans, where small and large employers set aside funds to pay for employee health care rather than pay premiums to an issuer to do so. These data include state-level enrollment data and are publicly available on the CMS website. The federal government declared the COVID-19 pandemic a public health emergency in January 2020. It had far-reaching effects on the U.S. economy, including lower levels of employment relative to the pre-pandemic period. While we did not examine the effects of the pandemic in this report, it may have led to disruptions in the health insurance market. These include employees obtaining coverage through a health insurance exchange upon losing access to employer-sponsored health insurance. For more information on trends in the health insurance market during the COVID-19 pandemic, see GAO, COVID-19: Current and Future Federal Preparedness Requires Fixes to Improve Health Data and Address Improper Payments, GAO-22-105397 (Washington, D.C.: April 27, 2022). Page 2 GAO-23-105672 Health Insurance Market Concentration this report." Within the individual, small group, and large group markets in each of the 51 states, we determined the state-level market share for each issuer by calculating the ratio of the total number of covered life- years for each issuer in a state to the total number of covered life-years in that state.® To analyze changes in concentration in the individual market exchanges, we obtained data from CMS for 2018, 2019, and 2020, the most recent data available at the time of our analyses. For states that used a federally facilitated exchange, CMS provided us with summary-level enrollment data from its data warehouse, the Multidimensional Insurance Data Analytics System, for 2019 and 2020.'° For states that operated their own exchange, CMS provided us with summary-level enrollment data from its PPACA Risk Adjustment Program for 2018, 2019, and 2020. CMS told us its PPACA Risk Adjustment Program collects enrollee-level data submitted by issuers annually, which CMS can access at the insurance plan summary level. Where applicable, we present previously reported information on the exchanges alongside our updated analyses in this report. 11 For each state's overall markets and exchange, we counted issuers as participating in a market if they had enrollment in that market. We did not count issuers as participating if they offered coverage in a market but did not have any enrollment. Because there can be multiple issuers within a 7GAO-16-724, GAO-19-306, and GAO-21-34, 8We measured beneficiary enrollment by calculating covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. Rather than a point-in-time measurement, this measure accounts for changes in enrollment that occur throughout the year. 8We did not include an analysis of small group exchanges in this report because officials from CMS told us that they discontinued collection of enrollment data for the small group exchanges in 2019. Additionally, we have previously reported that enrollment in the small group exchanges was low-typically less than 1 percent of the overall small group market. For more information about concentration in small group exchanges, see GAO-19-306. 10States that operate their own exchanges can use a federally facilitated exchange for certain functions, such as enrollment. For this report, states that use federal infrastructure (i.e., Healthcare.gov) to operate their exchanges, even if the states retain plan management functions, are classified as "federally facilitated exchanges." 11We did not report on state-based exchange data in our most recent report in response to this mandate, GAO-21-34. In the report prior to that, GAO-19-306, we reported data on state-based exchanges that we received from the individual states. Page 3 GAO-23-105672 Health Insurance Market Concentration market that share a single parent company, we aggregated such issuers to the parent company level. If there was no parent company, we analyzed the data by the individual issuers.12 We did this to more fully account for the portion of the market held by each parent company. We calculated the three-firm concentration ratio-the combined shares of covered life-years for the three largest issuers in that market-and the market share of the single largest issuer in that market. We considered states' overall markets or exchanges to be highly concentrated if three or fewer issuers held at least 80 percent of the market share. Finally, while states may have multiple local markets with differing concentrations of enrollees among health issuers, the data we used to measure concentration were generally limited to enrollment at the state level, with the exception of our individual exchange enrollment data-thus precluding our ability to measure concentration within local markets except for the individual market exchanges. '3 For all other markets, we present state-wide issuer market share, although all issuers may not have participated across the entire state. We analyzed enrollment data from all of our sources as they were reported by issuers to CMS. We did not otherwise independently verify the accuracy or completeness of the information with the issuers. We assessed the reliability of the data in several ways, including reviewing relevant data manuals and other documentation and performing electronic tests of the data to identify any outliers or anomalies. We determined that the data were sufficiently reliable for the purposes of our reporting objectives. We conducted this performance audit from January 2022 through November 2022 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the 12Specifically, we considered issuers to have the same parent company if in their Medical Loss Ratio data they reported having the same National Association of Insurance Commissioners holding group identifier, the same National Association of Insurance Commissioners company identifier, or the same Health Insurance Oversight System company identifier. 134 recent analysis of health issuance concentration found that, in 33 states, the largest issuer in the state overall was also the largest issuer in at least three-quarters of the local markets studied in that state. That analysis used 2020 data on enrollment in fully and self- insured plans by metropolitan statistical areas, which include a county or counties associated with a city or urbanized area that has a population of at least 50,000. See American Medical Association, Competition in Health Insurance: A Comprehensive Study of U.S. Markets, 2021 Update (Chicago, Ill.: 2021). Page 4 GAO-23-105672 Health Insurance Market Concentration Background audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Private health insurance is the most common source of health coverage in the United States-covering approximately two-thirds of the U.S. population in 2020, according to the U.S. Census Bureau. Small and large employers may offer fully insured group plans (by purchasing coverage from an issuer) or self-funded group plans (by setting aside funds to pay for employee health care). 14 While the majority of private health insurance is provided through group plans, either small group (for small employers) or large group (for large employers), people may also choose to purchase coverage directly from an issuer through the individual market. Figure 1 shows the total covered life-years reported by issuers to CMS in the individual and fully insured small and large group markets. Figure 1: Covered Life-Years Reported by Issuers to CMS in the Individual, Small Group, and Large Group Health Insurance Markets, 2011 through 2020 Individual market Small group market Large group market Enrollment in millions Enrollment in millions Enrollment in millions 50 50 50 45 45 45 40 40 40 35 35 35 30 30 30 25 25 25 20 20 20 15 15 15 10 10 10 5 5 5 0 0 0 11 12 13 141516 17 18 19 20 11 12 13 1415 16 17 18 19 20 111213 141516171819 20 Year Year Year Source: GAO analysis of data from the Centers for Medicare & Medicaid Services (CMS). | GAO-23-105672 Notes: We calculated the size of each market from 2011 through 2020 using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. This is one of several ways to measure health insurance enrollment, so it may differ from other measures of market size. Small and large employers may offer fully insured group plans (by purchasing coverage 14Most small employers purchase fully insured plans, while most large employers self-fund at least some of their employee health benefits. Approximately 67 percent of covered workers were in a self-funded plan in 2020, with 84 percent and 23 percent of covered workers in large employers and small employers, respectively, enrolled in self-funded plans; see Kaiser Family Foundation, Employer Health Benefits 2020 Annual Survey (San Francisco, Calif.: October, 2020). Page 5 GAO-23-105672 Health Insurance Market Concentration Concentration in the Individual Health Insurance Market, Including the Exchanges, Was Higher in Recent Years than in 2011 from an issuer) or self-funded group plans (by setting aside funds to pay for employee health care). Most small employers purchase fully insured plans, while most large employers self-fund at least some of their employee health benefits. For the small group and large group markets, enrollment data is from fully insured plans only. Several factors can affect concentration in health insurance markets. 15 High concentration levels have often been the result of consolidation- mergers and acquisitions-among existing issuers. However, concentration can also increase if existing issuers leave the market, thereby reducing the number of issuers from which enrollees can purchase coverage. In addition, concentration can persist because it can be difficult for new issuers to enter the market. For example, issuers that do not have large numbers of enrollees may have greater challenges negotiating discounts with health care providers, which may encourage issuers to consolidate in order to attain enough enrollees to gain bargaining power.'6 States' individual health insurance markets were generally concentrated from 2011 through 2020, and concentration has increased since 2011. The individual market exchanges, which represented three-fourths of the overall individual market in 2020, have generally been concentrated since 2015, and all exchanges were concentrated in 2020. 151n 2009, we conducted a structured literature review that examined the factors that can influence concentration of private health insurance markets. See GAO, Private Health Insurance: Research on Competition in the Insurance Industry, GAO-09-864R (Washington, D.C.: July 31, 2009). 16PPACA contains provisions that may affect market concentration and competition among health issuers, both in the overall market and in the health insurance exchanges initially established in 2014 within each state's individual and small group markets. For example, PPACA required that issuers offer coverage to all individuals regardless of health status, and it limited the ability of issuers to deny coverage or charge higher premiums to individuals and small groups based on health risks or certain other factors. For additional discussion about industry consolidation, see Leemore S. Dafny, "Evaluating the Impact of Health Insurance Industry Consolidation: Learning from Experience," Commonwealth Fund Issue Brief (New York, N.Y.: Commonwealth Fund, 2015). Page 6 GAO-23-105672 Health Insurance Market Concentration The Individual Health Insurance Market Generally Has Become More Concentrated since 2011, and Most States Markets Remained Concentrated in 2019 and 2020 Our analysis of CMS data shows that enrollment in states' individual health insurance markets was generally concentrated from 2011 through 2020, and concentration has increased since 2011. The number of states with three or fewer issuers that held at least 80 percent of the market increased from 33 states in 2011 to 44 states in 2020, despite brief declines in 2015, 2016, and 2020 (see fig. 2).1" Across all states, the median market share of the three largest issuers increased from 85 percent in 2011 to 97 percent in 2020 In addition, the number of states in which 80 percent of enrollment was concentrated in a single issuer increased from four in 2011 to 11 in 2020. Despite this increase, the median market share of all states' largest issuer remained relatively consistent during this time period, and some states' largest issuer lost market share. For instance, lowa's largest issuer held 83 percent of the market in 2011 and 50 percent of the market in 2020. Figure 2: Number of States Where the Market Share of the Largest Issuer and Three Largest Issuers Was at Least 80 Percent, Individual Health Insurance Market, 2011 through 2020 Number of states 50 45 40 35 30 25 20 15 10 5 0 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Year iS Largest issuer held at least 80% market share [| Three largest issuers held at least 80% market share Source: GAO analysis of data from the Centers for Medicare & Medicaid Services (CMS). | GAO-23-105672 Notes: This figure includes the 50 states and the District of Columbia. All states had at least three issuers in their individual markets during this time period. Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. We calculated market share using covered life-years, which measure the average number of lives insured, including dependenis, during the reporting year. 17See appendix | for additional data on the individual market from 2011 through 2020. Page 7 GAO-23-105672 Health Insurance Market Concentration As concentration increased, the number of issuers participating in the individual market decreased from 2011 through 2020. From 2011 through 2020, the median number of issuers per state decreased from 30 to 10. In 2020, New York had the most issuers (23, down from 38 in 2011). Three states-Alaska, Hawaii, and Vermont-had the fewest issuers (four; all these states had at least 10 in 2011). Despite these decreases, all states had multiple issuers participating in the market, including those that had a single issuer with at least 80 percent market share. For example, although South Carolina had 11 issuers participating in the individual market in 2020, Blue Cross Blue Shield of South Carolina held around 92 percent of market. (See table 1 for trends in issuer participation as concentration increased.) Table 1: Trends in Issuer Participation and Concentration in the Individual Health Insurance Market across States, 2011 through 2020 Median Median Median number of market share of three market share of the Year issuers per state largestissuers (percent) largest issuer (percent) 2011 30 85 56 2012 26 87 54 2013 25 88 55 2014 21 88 56 2015 19 90 56 2016 15 90 54 2017 14 96 56 2018 12 98 59 2019 10 98 58 2020 10 97 57 Source: GAO analysis of data from the Centers for Medicare & Medicaid Services (CMS). | GAO-23-105672 Notes: This table includes the 50 states and the District of Columbia. All states had at least three issuers in their individual markets during this time period. Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. We calculated market share using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. From 2011 through 2020, 42 states experienced increases in concentration among the three largest issuers, and nine states experienced decreases (see fig. 3). e Of the 42 states with increased concentration, 25 states had an increase of 10 or more percentage points, with a median increase of 11 percentage points. For example, in Wyoming, which had the Page 8 GAO-23-105672 Health Insurance Market Concentration largest percentage point increase (29 percent), 20 issuers exited the individual market, which may have contributed to more concentration among remaining issuers. e Of the nine states with decreased concentration, two states had a decrease of 10 or more percentage points, with a median decrease of 6 percentage points. For example, Wisconsin, the state with fourth largest percentage point decrease (8 percent), had no issuer with more than a 25 percent share of the market, making it the least concentrated state in 2020. Page 9 GAO-23-105672 Health Insurance Market Concentration Figure 3: Percentage Point Change in Market Share Held by the Three Largest Issuers in the Individual Market from 2011 through 2020, by State a = OR Percentage point change in concentration 0 10 20 Source: GAO analysis of data from the Centers for Medicare & Medicaid Services (CMS). | GAO-23-105672 Notes: All states had at least three issuers in their individual markets in 2011. Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. We calculated market share using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. Page 10 GAO-23-105672 Health Insurance Market Concentration Most Individual Market Our analysis of CMS data also showed that enrollment in the individual Exchanges Were market exchange was concentrated in at least 47 states from 2015 : through 2020, with all states' exchanges concentrated in 2020 (see fig. concemwared d ia 4) Year 4).18 From 2015 through 2020, states in which the top three issuers since , an ere already had at least 80 percent market share became more concentrated. Concentrated in 2020 This was often because the number of issuers decreased or the existing issuers increased their market share within a state-such that the state Exchange Enrollment Increased as a had three or fewer issuers with 100 percent of the market share. The Proportion of the Overall Individual Market hiymber of states in which three or fewer issuers held 100 percent of the from 2019 through 2020 ket share i d from 16 states in 2015 to 31 states in 2020, with Enrollment through the health insurance market share increase rom s ales In 0 States In : » Wi exchanges-marketplaces where consumers a peak of 38 states in 2019. In addition, the median number of issuers can compare and select among insurance participating in each state's exchange decreased from four in 2015 to plans sold by participating issuers-became a . larger proportion of overall individual market three in 2020. enrollment in states, increasing from 52 percent in 2015 to 75 percent in 2020. Figure 4: Extent to Which the Three Largest Individual Market Exchange Issuers Were Concentrated, on Average, in 51 States' Rating Areas, 2015 through 2020 2015 Number of states 51 2016 2017 a 2018 47 2019 0 2015 2016 2017 2018 2019 2020 2020 Year 0 20 40 60 80 100 On average, states had three or fewer issuers participating and Percent 100% market share Source: GAO analysis of data from the Centers for Medicare | On average, three largest issuers held at least 80% market share, & Medicaid Services (CMS). | GAO-23-105672 excluding states with three or fewer issuers Fy On average, three largest issuers held less than 80% market share Source: GAO analysis of data from the Centers for Medicare & Medicaid Services (CMS). | GAO-23-105672 Notes: Hawaii and Minnesota are not included in this figure for 2015 because we were unable to obtain data for that year. The remaining 49 states, including the District of Columbia, are included in 2015, and Hawaii and Minnesota are included for later years. Rating areas are geographic areas established by states and used, in part, by issuers to set premium rates. Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. The market share is calculated using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. Market share in 18We present statistics by state in appendix II. Page 11 GAO-23-105672 Health Insurance Market Concentration this figure refers to the average market share of the three largest issuers across a state's rating areas weighted by the number of covered life-years in each rating area. Issuer counts in this figure reflect the number of issuers, on average, across a state's rating areas, weighted by the number of covered life-years in each rating area. From 2015 through 2020, 35 states experienced increases in concentration among their largest issuer and 16 states experienced decreases (see fig. 5). e Of the 35 states with increased concentration, 21 states had increases of 10 or more percentage points, with a median increase of 14 percentage points. For example, Louisiana had the largest percentage point increase (44 percent); the number of issuers participating in the state's exchange decreased from four issuers in 2015 to one issuer in 2020. e Of the 16 states with decreased concentration, 10 states had decreases of 10 or more percentage points, with a median decrease of 10 percentage points. Page 12 GAO-23-105672 Health Insurance Market Concentration Figure 5: Percent Point Change in Average Market Share of the Largest Individual Market Exchange Issuer across Rating Areas from 2015 through 2020, by State Percentage point change in concentration -30 -15 0 15 30 Source: GAO analysis of data from the Centers for Medicare & Medicaid Services (CMS). | GAO-23-105672 Notes: Hawaii and Minnesota's percent point change is from 2016 through 2020 because we were unable to obtain data for 2015 for those states. Rating areas are geographic areas established by states and used, in part, by issuers to set premium rates. Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. We calculated issuers' market share using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. Market share refers to the average market share of the largest issuer across a state's rating areas- geographic areas established by states and used, in part, by issuers to set premium rates-weighted by the number of covered life-years in each rating area. In some cases, the identity of the largest issuer varied across rating areas in a state, and changed over time. Page 13 GAO-23-105672 Health Insurance Market Concentration Concentration in Small Group Health Insurance Markets Generally Increased from 2011 through 2020 Our analysis of CMS data shows that enrollment in states' small group health insurance markets generally became more concentrated from 2011 through 2020. During this time, the number of states with three or fewer issuers that held at least 80 percent of the market share increased from 36 states to 47 states, with a marked increase since 2015 (see fig. 6). Additionally, from 2011 through 2020, the median market share of the top three issuers increased by 10 percentage points-from 87 percent to 97 percent. '9 In addition, the number of states in which 80 percent of enrollment was concentrated in a single issuer increased from three states in 2011 to 13 states in 2020. The median market share of the largest issuer also increased by 7 percentage points-from 50 percent in 2011 to 57 percent in 2020. For example, lowa's largest issuer, the Wellmark Group, increased its market share from 61 percent in 2011 to 79 percent in 2020. Figure 6: Number of States Where the Market Share of the Largest Issuer and Three Largest Issuers Was at Least 80 Percent, Small Group Health Insurance Market, 2011 through 2020 Number of states 50 45 40 35 30 25 20 15 10 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Year iS Largest issuer held at least 80% market share [| Three largest issuers held at least 80% market share Source: GAO analysis of data from the Centers for Medicare & Medicaid Services (CMS). | GAO-23-105672 Notes: This figure includes the 50 states and the District of Columbia. All states, except Vermont and Wyoming, had at least three issuers in their small group markets during this time period. Small and large employers may offer fully insured group plans (by purchasing coverage from an issuer) or self- funded group plans (by setting aside funds to pay for employee health care). Most small employers purchase fully insured plans, while most large employers self-fund at least some of their employee health benefits. For the small group and large group markets, enrollment data are from fully insured plans only. Where multiple issuers in a state shared a parent company, we aggregated the individual 198See appendix IV for additional data on the small group market from 2011 through 2020. Page 14 GAO-23-105672 Health Insurance Market Concentration issuers to the parent company level. We calculated market share using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. As concentration increased, the number of issuers per state decreased. Specifically, the median number of issuers decreased from 13 issuers in 2011 to five issuers in 2020. For example, the number of issuers in Indiana decreased from 27 issuers in 2011 to nine issuers in 2020. (See table 2 for trends in issuer participation as concentration increased.) Table 2: Trends in Issuer Participation and Concentration in the Small Group Health Insurance Market across States, 2011 through 2020 Median market share Median market share Median number of of three largest of the largest Year issuers per state issuers (percent) issuer (percent) 2011 13 87 50 2012 12 88 55 2013 12 88 59 2014 10 88 57 2015 9 89 55 2016 7 92 53 2017 6 92 57 2018 5 94 57 2019 6 96 58 2020 5 97 57 Source: GAO analysis of data from the Centers for Medicare & Medicaid Services (CMS). | GAO-23-105672 Notes: This table includes the 50 states and the District of Columbia. All states, except Vermont and Wyoming, had at least three issuers in their small group markets during this time period. We calculated market share using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. From 2011 through 2020, 45 states experienced increases in concentration among the three largest issuers, and six states experienced decreases (see fig. 7). Of the 45 states with increased concentration, 23 states had an increase of 10 or more percentage points, with a median increase of 10 percentage points. The six states with decreased concentration had a median decrease of 3 percentage points. Page 15 GAO-23-105672 Health Insurance Market Concentration Figure 7: Percentage Point Change in Market Share Held by the Three Largest Issuers in the Small Group Market from 2011 through 2020, by State Pe: aan) :\ . # | Se | & ~ OR , | - I ui Dri NJ DE MD Percentage point change in concentration 0 10 20 Source: GAO analysis of data from the Centers for Medicare & Medicaid Services (CMS). | GAO-23-105672 Notes: All states, except Vermont and Wyoming, had at least three issuers in in their small group markets during this time period. Small and large employers may offer fully insured group plans (by purchasing coverage from an issuer) or self-funded group plans (by setting aside funds to pay for employee health care). Most small employers purchase fully insured plans, while most large employers self-fund at least some of their employee health benefits. For the small group and large group markets, enrollment data are from fully insured plans only. Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. We calculated market share using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. Page 16 GAO-23-105672 Health Insurance Market Concentration Large Group Health Insurance Markets Remained Concentrated from 2011 through 2020 Our review of CMS data shows that concentration in states' large group health insurance markets remained generally steady from 2011 through 2020. The number of states with three or fewer issuers that held at least 80 percent of the market increased from 40 states in 2011 to 42 states in 2020 (see fig. 8).2° During this time period, the median market share of the top three issuers increased by 4 percentage points, from 88 percent to 92 percent. The number of states in which 80 percent of enrollment was concentrated in a single issuer also remained relatively unchanged, although the median market share of states' largest issuers increased. States with a single issuer that held at least of 80 percent market share slightly increased from six in 2011 to eight in 2020, with small fluctuations within the decade. During the same period, the median market share of the largest issuer increased by 9 percentage points, from 55 percent to 64 percent. Figure 8: Number of States Where the Market Share of the Largest Issuer and Three Largest Issuers Were at Least 80 Percent, Large Group Health Insurance Market, 2011 through 2020 Number of states 50 45 40 35 30 25 20 15 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Year i Largest issuer held at least 80% market share [| Three largest issuers held at least 80% market share Source: GAO analysis of data from the Centers for Medicare & Medicaid Services (CMS). | GAO-23-105672 Notes: This figure includes the 50 states and the District of Columbia. All states had at least three issuers in their large group markets during this time period. Small and large employers may offer fully insured group plans (by purchasing coverage from an issuer) or self-funded group plans (by setting aside funds to pay for employee health care). Most small employers purchase fully insured plans, while most large employers self-fund at least some of their employee health benefits. For the small group and large group markets, enrollment data are from fully insured plans only. Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent 20See appendix V for additional data on the large group market for 2011 through 2020. Page 17 GAO-23-105672 Health Insurance Market Concentration company level. We calculated market share using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. In addition, as concentration remained generally steady, the number of issuers in each state generally decreased. Specifically, the median number of issuers per state decreased from 12 issuers in 2011 to eight issuers in 2020 (see table 3). Table 3: Trends in Issuer Participation and Concentration in the Large Group Health Insurance Market across States, 2011 through 2020 Median market share of | Median market share Median number of three largest of the largest Year issuers per state issuers (percent) issuer (percent) 2011 12 88 55 2012 11 89 60 2013 11 89 60 2014 10 90 59 2015 10 90 61 2016 9 90 58 2017 9 91 56 2018 9 92 58 2019 8 92 64 2020 8 92 64 Source: GAO analysis of data from the Centers for Medicare & Medicaid Services (CMS). | GAO-23-105672 Notes: This table includes the 50 states and the District of Columbia. All states had at least three issuers in their large group markets during this time period. We calculated market share using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. From 2011 through 2020, 31 states experienced increases in concentration among the three largest issuers, and 20 states experienced decreases (see fig. 9). Of the 31 states with increased concentration, six states had an increase of 10 or more percentage points, with a median increase of approximately 4 percentage points. Similarly, the 20 states with decreased concentration had a median decrease of 1 percentage point. Page 18 GAO-23-105672 Health Insurance Market Concentration Figure 9: Percentage Point Change in Market Share Held by the Three Largest Issuers in the Large Group Market from 2011 through 2020, by State Percentage point change in concentration Decrease <Q) 0 a > Increase -5 0 5 10 Source: GAO analysis of data from the Centers for Medicare & Medicaid Services (CMS). | GAO-23-105672 Notes: All states had at least three issuers in their large group markets during this time period. Small and large employers may offer fully insured group plans (by purchasing coverage from an issuer) or self-funded group plans (by setting aside funds to pay for employee health care). Most small employers purchase fully insured plans, while most large employers self-fund at least some of their employee health benefits. For the small group and large group markets, enrollment data are from fully insured plans only. Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. We calculated market share using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. In some cases, the identity of the largest three issuers changed over time. Page 19 GAO-23-105672 Health Insurance Market Concentration We provided a draft of this report to HHS for review and comment. The department provided technical comments, which we incorporated as appropriate. We sent copies of this report to the appropriate Congressional committees, the Secretary of Health and Human Services, and other interested parties. In addition, the report is available at no charge on the GAO website at hitp://www.gao.gov. If you or your staff have any questions about this report, please contact John E. Dicken at (202) 512-7114 or dickenj@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff wno made key contributions to this report are listed in appendix VI. ih, € Dike John E. Dicken Director, Health Care Page 20 GAO-23-105672 Health Insurance Market Concentration List of Committees The Honorable Ron Wyden Chairman The Honorable Mike Crapo Ranking Member Committee on Finance United States Senate The Honorable Patty Murray Chair The Honorable Richard Burr Ranking Member Committee on Health, Education, Labor, and Pensions United States Senate The Honorable Bobby Scott Chairman The Honorable Virginia Foxx Republican Leader Committee on Education and Labor House of Representatives The Honorable Frank Pallone, Jr. Chair The Honorable Cathy McMorris Rodgers Republican Leader Committee on Energy and Commerce House of Representatives The Honorable Richard E. Neal Chair The Honorable Kevin Brady Republican Leader Committee on Ways and Means House of Representatives Page 21 GAO-23-105672 Health Insurance Market Concentration Appendix |: Number and Market Share of Largest Issuers Participating in Each State's Individual Market The three tables below present information for each state on a) the number of participating issuers in the individual health insurance market from 2011 through 2020, b) the market share of the largest and three largest issuers from 2017 through 2020, and c) the percentage change in market share of the three largest issuers from 2011 through 2020 and 2019 through 2020. Table 4: Number of Issuers in Each State's Individual Health Insurance Market, 2011 through 2020 Number of issuers State 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Alabama 27 22 23 17 16 11 10 10 7 8 Alaska 13 13 14 12 10 7 5 5 3 4 Arizona 30 26 24 27 23 17 15 11 12 12 Arkansas 32 26 24 21 19 16 14 14 10 11 California 45 34 30 33 31 27 27 23 22 21 Colorado 35 29 25 26 24 19 17 15 14 15 Connecticut 26 20 19 17 15 11 9 8 7 8 Delaware 20 17 16 14 13 10 8 7 6 6 District of Columbia 18 18 18 16 13 10 8 7 6 6 Florida 40 33 31 28 30 22 20 17 16 17 Georgia 38 32 31 29 25 18 17 15 13 16 Hawaii 14 15 12 10 9 7 6 4 4 4 Idaho 23 22 19 18 17 14 11 10 8 8 Illinois 42 37 34 30 25 21 18 16 15 14 Indiana 37 30 28 23 23 19 14 11 8 8 lowa 33 27 25 21 19 14 12 9 8 7 Kansas 35 30 28 24 20 15 15 13 11 11 Kentucky 27 22 23 21 21 17 15 14 11 12 Louisiana 34 26 26 24 22 16 15 14 9 10 Maine 20 18 18 15 12 9 8 6 8 7 Maryland 27 24 23 19 18 15 13 10 8 9 Massachusetts 31 29 28 25 25 20 19 16 15 15 Michigan 41 33 33 31 29 22 18 14 12 12 Minnesota 36 29 26 25 25 18 15 13 13 13 Mississippi 30 25 22 21 18 14 14 12 8 10 Missouri 37 31 31 25 23 18 18 15 14 16 Montana 25 22 21 20 16 13 11 8 7 7 Nebraska 31 28 26 25 19 16 13 11 8 8 Page 22 GAO-23-105672 Health Insurance Market Concentration Appendix |: Number and Market Share of Largest Issuers Participating in Each State's Individual Market Number of issuers State 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Nevada 24 20 21 19 19 15 12 10 10 9 New Hampshire 20 17 15 13 14 9 7 6 6 5 New Jersey 24 24 20 19 19 16 14 12 10 10 New Mexico 28 24 22 18 18 14 13 11 10 10 New York 38 32 28 32 33 27 27 23 23 23 North Carolina 31 26 25 22 18 15 14 12 11 11 North Dakota 21 20 19 13 12 10 7 8 7 6 Ohio 43 36 34 32 29 24 20 19 16 15 Oklahoma 30 26 25 23 21 16 15 12 9 12 Oregon 31 28 25 29 25 21 17 13 11 11 Pennsylvania 38 34 36 33 31 24 22 22 21 21 Rhode Island 14 12 13 11 9 7 7 6 5 5 South Carolina 31 24 22 20 17 15 13 10 9 11 South Dakota 30 26 25 17 14 11 9 9 8 8 Tennessee 33 29 26 23 20 15 14 13 13 14 Texas 50 40 36 38 37 32 30 25 19 20 Utah 24 19 19 19 17 14 13 11 9 9 Vermont 16 14 12 10 6 5 5 5 4 4 Virginia 32 29 29 29 26 21 21 16 16 17 Washington 30 27 25 24 23 19 16 14 12 14 West Virginia 27 25 24 19 18 15 12 11 9 9 Wisconsin 42 38 35 35 31 24 23 18 19 19 Wyoming 25 23 21 16 14 11 9 7 5 5 Total 1529 1311 1235 1131 1031 816 725 621 545 563 Source: GAO analysis of data from the Centers for Medicare & Medicaid Services. | GAO-23-105672 Note: Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. Table 5: Market Share of the Largest and Three Largest Issuers in Each State's Individual Health Insurance Market, 2017 through 2020 Market share of the Market share of the three largest issuer (percent) largest issuers (percent) State Largest issuer name 2017 2018 2019 2020 2017 2018 2019 2020 Alabama BCBS OF AL GRP 97.6 97.3 96.7 96.5 99.9 99.7 99.8 99.7 Alaska PREMERA BLUE CROSS 99.3 99.3 99.5 91.1 99.9 100.0 100.0 100.0 GROUP Arizona CENTENE CORP GRP 43.8 49.5 40.6 37.1 95.8 99.0 88.9 85.5 Page 23 GAO-23-105672 Health Insurance Market Concentration Appendix |: Number and Market Share of Largest Issuers Participating in Each State's Individual Market Market share of the largest issuer (percent) Market share of the three largest issuers (percent) State Largest issuer name 2017 2018 2019 2020 2017 2018 2019 2020 Arkansas ARKANSAS BCBS 63.6 63.3 63.9 57.4 93.5 93.5 92.9 89.3 GRP California BLUE SHIELD OF 30.0 36.9 36.2 - 81.5 80.1 80.0 79.1 CALIFORNIA GROUP KAISER - - - 34.7 FOUNDATION GRP Colorado KAISER 41.1 41.0 37.0 _- 87.8 83.2 81.6 78.5 FOUNDATION GRP WELLPOINT INC GRP _- _- _- 34.1 Connecticut HIP INS GRP 61.4 67.7 72.9 73.4 98.4 99.3 99.7 99.9 Delaware HIGHMARK GRP 62.2 99.1 99.0 99.2 99.5 99.9 99.8 99.9 District of CAREFIRST INC GRP 84.6 81.7 83.7 83.8 99.5 99.4 99.9 99.9 Columbia Florida BLUE CROSS AND 60.1 68.5 64.4 60.2 88.8 93.0 93.3 92.3 BLUE SHIELD OF FLORIDA, INC. Georgia CENTENE CORP GRP - 47.4 55.8 64.1 91.3 88.6 92.8 89.0 WELLPOINT INC GRP 55.5 - - - Hawaii HAWAII MEDICAL 58.7 58.8 56.6 64.6 99.9 99.9 99.9 99.9 SERVICE ASSOCIATION Idaho BLUE CROSS OF 34.7 50.5 44.2 _ 78.6 91.8 93.2 92.7 IDAHO HEALTH SERVICE, INC. IHC INC GRP - - - 41.1 Illinois HCSC GRP 73.0 76.8 79.5 76.1 89.7 91.1 93.1 94.0 Indiana CENTENE CORP GRP _ _ 57.5 51.3 72.5 96.1 96.6 97.3 CARESOURCE - 46.3 - - MANAGEMENT GROUP WELLPOINT INC GRP 28.2 - - - lowa WELLMARK GROUP 63.5 58.7 59.9 50.4 95.6 99.7 99.8 99.8 Kansas BCBS OF KS GRP 61.2 67.2 69.5 60.2 97.0 92.9 94.6 90.8 Kentucky WELLPOINT INC GRP 77.9 55.7 69.6 58.6 99.3 99.8 100.0 100.0 Louisiana LOUISIANA HLTH 76.1 91.8 98.6 98.7 98.4 99.6 100.0 100.0 SERV GRP Maine MAINE COMMUNITY 40.1 58.6 42.7 - 98.6 99.8 99.8 99.8 HEALTH OPTIONS WELLPOINT INC GRP - _ _ 42.8 Maryland CAREFIRST INC GRP 76.5 66.1 65.2 70.4 99.2 99.4 99.6 99.6 Page 24 GAO-23-105672 Health Insurance Market Concentration Appendix |: Number and Market Share of Largest Issuers Participating in Each State's Individual Market Market share of the Market share of the three largest issuer (percent) largest issuers (percent) State Largest issuer name 2017 2018 2019 2020 2017 2018 2019 2020 Massachusetts TUFTS HEALTH PLAN 41.4 44.3 49.7 52.8 78.1 83.2 86.2 86.7 Michigan BCBS OF MI GRP 49.3 58.5 56.1 52.2 81.4 82.9 86.3 85.3 Minnesota HEALTHPARTNERS 38.4 39.2 36.5 31.2 82.9 82.9 78.6 78.5 GRP Mississippi CENTENE CORP GRP 45.2 55.7 61.6 65.4 94.6 99.4 99.7 97.5 Missouri CENTENE CORP GRP - - 37.2 42.9 82.4 86.2 87.4 85.4 CIGNA HLTH GRP - 36.7 - - WELLPOINT INC GRP 44.7 _ _ _ Montana HCSC GRP 50.6 - 38.8 39.4 99.7 99.8 99.9 99.9 MONTANA HEALTH _- 42.9 _- _- COOPERATIVE Nebraska MEDICA GRP _- 74.5 79.1 86.1 93.7 99.7 99.8 99.8 AETNA GRP 35.6 - - - New Hampshire WELLPOINT INC GRP 45.7 61.1 68.4 61.3 99.7 99.8 99.6 99.7 New Jersey BCBS OF NJ GRP 71.6 61.3 55.6 55.9 98.8 97.8 98.3 98.4 New Mexico MOLINA 40.4 40.6 42.1 45.5 88.8 89.9 91.7 80.5 HEALTHCARE INC GRP New York NEW YORK STATE 17.4 25.1 26.6 29.4 45.5 52.5 52.5 54.2 CATHOLIC HEALTH PLAN, INC. Nevada UNITEDHEALTH GRP 58.4 65.1 60.8 68.5 94.0 94.1 96.9 92.4 North Carolina) BLUE CROSS AND 95.6 96.2 97.4 91.8 99.5 99.7 99.4 99.0 BLUE SHIELD OF NORTH CAROLINA North Dakota BLUE CROSS BLUE - - 80.7 65.7 99.7 99.6 99.7 99.9 SHIELD OF NORTH DAKOTA NORIDIAN MUTUAL 82.3 85.7 - - INSURANCE COMPANY Ohio MEDICAL MUTUAL 31.4 35.6 38.7 30.8 77.6 70.5 70.0 68.7 OF OHIO Oklahoma HCSC GRP 93.8 95.5 94.8 87.5 99.7 99.8 99.0 97.4 Oregon PROVIDENCE 46.0 45.3 37.7 34.1 76.7 90.1 82.3 80.5 HEALTH PLAN Pennsylvania INDEPENDENCE 37.9 40.0 39.2 36.7 78.1 81.3 80.8 81.5 BLUE CROSS GRP Rhode Island NEIGHBORHOOD HEALTH - 52.3 58.1 60.6 99.7 99.7 99.9 99.9 PLAN OF RHODE ISLAND Page 25 GAO-23-105672 Health Insurance Market Concentration Appendix |: Number and Market Share of Largest Issuers Participating in Each State's Individual Market Market share of the Market share of the three largest issuer (percent) largest issuers (percent) State Largest issuer name 2017 2018 2019 2020 2017 2018 2019 2020 BLUE CROSS & BLUE 61.5 - - - SHIELD OF RHODE ISLAND South Carolina BCBS OF SC GRP 95.7 96.5 97.1 91.5 99.7 99.8 99.8 96.6 South Dakota AVERA HEALTH 41.2 - 35.7 38.1 98.2 98.4 98.6 98.7 PLANS, INC. WELLMARK GROUP _ 36.4 _ _ Tennessee BCBS OF TN INC 26.8 45.0 44.1 41.6 74.5 88.5 82.8 83.7 Texas HCSC GRP 39.7 37.1 38.3 36.3 73.4 73.4 80.2 78.9 Utah IHC INC GRP 60.0 85.2 86.9 85.1 97.2 99.8 99.7 95.3 Vermont BCBS OF VT GRP 80.1 66.8 57.0 52.3 100.0 100.0 100.0 100.0 Virginia WELLPOINT INC GRP 49.9 - 42.6 48.7 75.6 72.4 84.8 81.8 CIGNA HLTH GRP _ 24.9 _ _ Washington KAISER 29.7 47.6 45.8 38.4 70.9 88.1 88.4 79.6 FOUNDATION GRP West Virginia HIGHMARK GRP 78.2 67.6 67.7 68.2 98.3 98.4 98.3 98.6 Wisconsin COMMON GROUND - 23.3 28.3 24.3 50.4 53.5 57.5 51.0 HEALTHCARE COOPERATIVE MOLINA 23.8 - - - HEALTHCARE INC GRP Wyoming BLUE CROSS BLUE 96.1 96.8 97.7 98.4 99.7 99.7 99.9 99.9 SHIELD OF WYOMING Legend: - This symbol indicates that this issuer was not the largest in that year. Source: GAO analysis of data from the Centers for Medicare & Medicaid Services. | GAO-23-105672 Notes: Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. We calculated issuers' market share using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. We reprinted issuer names as they were reported in the data from the Centers for Medicare & Medicaid Services. Page 26 GAO-23-105672 Health Insurance Market Concentration Appendix |: Number and Market Share of Largest Issuers Participating in Each State's Individual Market Table 6: Percentage Change in Market Share for the Three Largest Issuers in Each State's Individual Health Insurance Market, 2011 to 2020 and 2019 to 2020 Percentage change in market Percentage change in market share for the three largest share for the three largest State issuers from 2011 to 2020 issuers from 2019 to 2020 Alabama 2.7 -0.1 Alaska 23.6 0.0 Arizona 8.4 -3.5 Arkansas -2.2 -3.6 California 1.0 -0.9 Colorado 25.1 -3.2 Connecticut 15.5 0.2 Delaware 15.3 0.1 District of Columbia 12.0 0.0 Florida 19.8 -1.0 Georgia 21.3 -3.8 Hawaii 0.8 0.0 Idaho 0.1 -0.6 Illinois 14.8 0.9 Indiana 15.4 0.7 lowa 8.1 0.0 Kansas 14.4 -3.8 Kentucky 3.9 0.0 Louisiana 14.9 0.0 Maine 7.6 0.0 Maryland 11.1 0.0 Massachusetts -1.7 0.5 Michigan 8.5 -1.0 Minnesota -6.3 -0.1 Mississippi 14.4 -2.2 Missouri 16.4 -2.0 Montana 14.6 0.0 Nebraska 11.8 0.0 Nevada 9.1 45 New Hampshire 6.6 0.0 New Jersey 8.7 0.1 New Mexico -9.3 -11.2 New York -1.5 1.7 Page 27 GAO-23-105672 Health Insurance Market Concentration Appendix |: Number and Market Share of Largest Issuers Participating in Each State's Individual Market Percentage change in market share for the three largest Percentage change in market share for the three largest State issuers from 2011 to 2020 issuers from 2019 to 2020 North Carolina 8.9 -0.4 North Dakota 9.6 0.2 Ohio -11.6 -1.3 Oklahoma 18.1 -1.6 Oregon 15.9 -1.8 Pennsylvania 9.8 0.7 Rhode Island 0.3 0.0 South Carolina 16.8 -3.2 South Dakota 9.9 0.2 Tennessee 3.8 0.8 Texas 47 -1.3 Utah 9.7 4.4 Vermont 1.2 0.0 Virginia -4.7 -3.0 Washington -16.2 -8.8 West Virginia 20.9 0.3 Wisconsin -7.6 -6.5 Wyoming 28.8 0.0 Source: GAO analysis of data from the Centers for Medicare & Medicaid Services. | GAO-23-105672 Notes: This table includes the 50 states and the District of Columbia. All states had at least three issuers in their individual markets from 2011 through 2020. Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. We issuers' calculated market share using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. Page 28 GAO-23-105672 Health Insurance Market Concentration Appendix II: States' Individual Market Exchange Enrollment as a Proportion of Overall Individual Market Enrollment, 2020 Table 7 presents a) covered life-years in each state's individual health insurance market exchange, b) covered life-years in each state's overall individual market, and c) covered life-years in each state's individual market exchange as a proportion of covered life-years in the overall individual market. Table 7: Covered Life-Years in Each State's Individual Market Health Insurance Exchange as a Proportion of Total Covered Life-Years in the Overall Individual Market, 2020 Individual market exchange covered Covered Covered life-years as a life-years, individual _life-years, overall proportion of overall State market exchange _ individual market market (percent) Alabama 142,035 183,729 77.3 Alaska 15,373 18,255 84.2 Arizona 134,007 184,662 72.6 Arkansas 55,548 339,550 16.4 California 1,508,779 2,248,756 67.1 Colorado 153,679 227,455 67.6 Connecticut 99,874 115,588 86.4 Delaware 22,124 26,396 83.8 District of 15,171 17,755 85.4 Columbia Florida 1,744,519 2,056,020 84.8 Georgia 409,976 436,326 94.0 Hawaii 18,400 32,813 56.1 Idaho 68,239 93,390 73.1 Illinois 257,165 373,377 68.9 Indiana 124,149 135,645 91.5 lowa 51,057 99,690 51.2 Kansas 75,969 103,273 73.6 Kentucky 70,626 96,531 73.2 Louisiana 74,801 114,865 65.1 Maine 55,084 62,585 88.0 Maryland 148,438 229,018 64.8 Massachusetts 293,236 363,620 80.6 Michigan 232,966 340,932 68.3 Minnesota 102,984 159,150 64.7 Mississippi 86,086 127,738 67.4 Page 29 GAO-23-105672 Health Insurance Market Concentration Appendix Il: States' Individual Market Exchange Enrollment as a Proportion of Overall Individual Market Enrollment, 2020 Individual market exchange covered Covered Covered life-years as a life-years, individual __life-years, overall proportion of overall State market exchange _ individual market market (percent) Missouri 181,558 225,011 80.7 Montana 39,800 49,830 79.9 Nebraska 81,881 90,884 90.1 Nevada 66,282 95,524 69.4 New Hampshire 40,321 51,164 78.8 New Jersey 214,640 315,252 68.1 New Mexico 36,795 44,441 82.8 New York 239,849 359,103 66.8 North Carolina 449,264 537,400 83.6 North Dakota 19,770 42,246 46.8 Ohio 173,251 245,663 70.5 Oklahoma 142,226 162,980 87.3 Oregon 126,256 174,046 72.5 Pennsylvania 288,081 404,484 71.2 Rhode Island 33,003 43,743 75.4 South Carolina 187,372 238,573 78.5 South Dakota 27,351 51,567 53.0 Tennessee 176,649 226,049 78.1 Texas 1,001,733 1,186,029 84.5 Utah 183,835 223,102 82.4 Vermont 26,567 32,427 81.9 Virginia 230,765 277,650 83.1 Washington 189,849 231,703 81.9 West Virginia 17,384 20,859 83.3 Wisconsin 175,219 210,649 83.2 Wyoming 22,517 27,282 82.5 Total 10,332,503 13,754,780 75.1 Source: GAO analysis of data from the Centers for Medicare & Medicaid Services. | GAO-23-105672 Note: We calculated the size of each market using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. This is one of several ways to measure health insurance enrollment, so it may differ from other measures of market size. Page 30 GAO-23-105672 Health Insurance Market Concentration Appendix III: Number and Market Share of Issuers in Individual Market Exchanges, 2015-2020 The four tables below present information on the number of participating issuers and the market share of the largest issuers in each state's individual market health insurance exchange, from 2015 through 2020. Specifically: table 8 presents the average number of exchange issuers across each state's rating areas; table 9 presents the names and market shares of the largest exchange issuer and the market share of the three largest issuers for each state, from 2017 through 2020; table 10 presents the average market share of the largest issuer across each state's rating area; and table 11 presents percentage change in market share of the largest and three largest issuers in each state's individual market exchange. Table 8: Weighted Average Number of Individual Market Exchange Issuers Participating in Each State's Rating Areas, 2015 through 2020 Weighted average number of issuers participating in state's rating areas State 2015 2016 2017 2018 2019 2020 Alabama 2.3 2.4 1.0 1.2 1.2 1.2 Alaska 2.0 2.0 1.0 1.0 1.0 1.9 Arizona 11.0 6.3 1.2 1.2 3.1 3.8 Arkansas 3.7 5.0 3.9 3.9 3.9 4.0 California 4.8 5.3 5.3 5.2 4.4 4.9 Colorado 8.2 6.7 5.0 5.0 4.9 5.5 Connecticut 4.0 4.0 2.0 2.0 2.0 2.0 Delaware 2.0 2.0 2.0 1.0 1.0 1.0 District of Columbia 3.0 2.0 2.0 2.0 2.0 2.0 Florida 6.1 4.4 2.9 2.5 2.6 3.8 Georgia 7.8 6.9 3.9 2.4 2.6 4.1 Hawaii n/a? 2.0 2.0 2.0 2.0 2.0 Idaho 5.0 5.0 5.0 4.0 4.0 4.0 Illinois 5.7 5.2 2.6 2.4 24 2.5 Indiana 6.9 6.7 3.9 1.9 2.0 2.0 lowa 2.6 3.4 3.4 1.0 2.0 2.0 Kansas 2.4 2.4 2.4 2.3 2.3 3.7 Kentucky 4.8 6.4 2.3 1.6 1.8 1.8 Louisiana 4.1 3.5 2.5 2.0 1.0 1.2 Maine 3.0 3.0 3.0 2.0 3.0 3.0 Maryland 5.0 5.0 3.0 2.0 2.0 2.0 Massachusetts 9.9 10.0 9.0 6.3 6.6 6.6 Michigan 7.6 6.2 6.2 5.1 5.6 5.7 Page 31 GAO-23-105672 Health Insurance Market Concentration Appendix Ill: Number and Market Share of Issuers in Individual Market Exchanges, 2015- 2020 Weighted average number of issuers participating in state's rating areas State 2015 2016 2017 2018 2019 2020 Minnesota n/a? 4.0 4.0 3.3 3.4 3.4 Mississippi 2.9 3.0 1.9 1.0 1.0 2.0 Missouri 3.3 3.7 2.0 1.9 1.8 2.8 Montana 4.0 3.0 3.0 3.0 3.0 3.0 Nebraska 3.9 4.0 2.0 1.0 1.0 2.0 Nevada 4.1 2.9 2.9 1.9 1.9 2.9 New Hampshire 5.0 5.0 4.0 3.0 3.0 3.0 New Jersey 5.0 5.0 2.0 3.0 3.0 3.0 New Mexico 5.0 4.0 4.0 4.0 4.0 4.0 New York 10.0 8.8 8.9 7.5 6.8 6.8 North Carolina 2.7 2.7 1.3 1.2 1.4 1.8 North Dakota 3.0 3.0 3.0 1.9 3.0 3.0 Ohio 10.0 9.8 4.9 4.2 4.7 5.2 Oklahoma 3.6 2.0 1.0 1.0 2.0 2.3 Oregon 8.2 TT 46 4.0 4.1 44 Pennsylvania 4.9 4.0 2.0 0.0 2.6 3.0 Rhode Island 3.0 3.0 2.0 2.0 2.0 2.0 South Carolina 3.6 1.7 1.0 1.0 1.1 1.9 South Dakota 3.0 2.0 2.0 2.0 2.0 2.0 Tennessee 4.1 3.1 1.5 1.3 2.5 3.6 Texas 7.7 7.3 3.5 3.6 3.6 44 Utah 5.3 3.1 2.8 2.0 2.9 4.3 Vermont 2.0 2.0 2.0 2.0 2.0 2.0 Virginia 4.4 5.6 5.4 3.3 3.6 3.6 Washington 7.3 7.7 6.6 3.9 3.6 49 West Virginia 1.0 1.3 1.8 1.8 1.8 1.9 Wisconsin 6.3 6.9 5.1 3.7 4.0 4.8 Wyoming 2.0 1.0 1.0 1.0 1.0 1.0 Legend: n/a = not applicable. Source: GAO analysis of data from the Centers for Medicare & Medicaid Services (CMS). | GAO-23-105672 Notes: Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. Rating areas are established by states and used, in part, by issuers to set premium rates. Issuer participation and enrollment can vary across rating areas in a state. The issuer counts in this table reflect the average number of participating issuers across a state's rating areas, weighted by the number of covered life-years in each rating area. *Data were not available from Hawaii and Minnesota in 2015. Page 32 GAO-23-105672 Health Insurance Market Concentration Appendix Ill: Number and Market Share of Issuers in Individual Market Exchanges, 2015- 2020 Table 9: Market Share of the Largest and Three Largest Issuers in Each State's Individual Market Health Insurance Exchange, 2017 through 2020 Market share of the largest issuer Market share of the three largest (percent) issuers (percent) State Largest issuer name 2017 2018 2019 2020 2017 2018 2019 2020 Alabama BCBS OF AL GRP 100.0 99.3 98.0 97.6 100.0 100.0 100.0 100.0 Alaska PREMERA BLUE CROSS 100.0 100.0 100.0 90.1 100.0 100.0 100.0 100.0 GROUP Arizona CENTENE CORP GRP 72.6 74.1 58.1 50.9 100.0 100.0 95.9 92.4 Arkansas ARKANSAS BCBS GRP 68.7 60.7 65.4 62.0 99.9 99.5 99.6 99.7 California KAISER FOUNDATION GRP 28.3 33.1 34.3 36.3 72.4 79.8 79.5 78.1 Colorado KAISER FOUNDATION GRP 42.4 42.7 37.8 _- 89.9 85.2 83.6 76.1 WELLPOINT INC GRP - - - 31.9 Connecticut HIP INS GRP 63.4 74.0 776 76.8 100.0 100.0 100.0 100.0 Delaware HIGHMARK GRP 54.7 100.0 100.0 100.0 100.0 100.0 100.0 100.0 District of Columbia CAREFIRST INC GRP 83.0 79.6 81.9 82.9 100.0 100.0 100.0 100.0 Florida BLUE CROSS AND BLUE 58.9 68.1 62.4 57.3 97.4 100.0 97.3 95.0 SHIELD OF FLORIDA, INC. Georgia WELLPOINT INC GRP 48.1 - - _- 93.1 100.0 93.7 90.7 CENTENE CORP GRP _ 52.3 59.8 68.2 Hawaii HAWAII MEDICAL SERVICE 52.8 50.7 59.8 62.7 100.0 100.0 100.0 100.0 ASSOCIATION Idaho BLUE CROSS OF IDAHO - 48.0 - - 85.8 99.7 99.6 99.5 HEALTH SERVICE, INC. IHC INC GRP 36.1 _ 46.8 49.2 Illinois HCSC GRP 66.0 72.8 76.4 71.5 90.7 100.0 94.0 95.0 Indiana CENTENE CORP GRP 35.6 _ 63.8 56.0 80.3 100.0 100.0 100.0 CARE SOURCE - 52.3 - - MANAGEMENT GROUP lowa AETNA GRP 67.0 - - - 99.2 100.0 100.0 100.0 MEDICA GRP - 100.0 84.4 91.1 Kansas BCBS OF KS GRP 61.3 63.0 65.5 54.2 100.0 100.0 100.0 95.3 Kentucky WELLPOINT INC GRP 59.8 _- 56.4 _- 100.0 100.0 100.0 100.0 CARESOURCE - 65.5 - 56.3 MANAGEMENT GROUP Louisiana LOUISIANA HLTH SERV GRP 68.2 90.2 100.0 97.7 100.0 100.0 100.0 100.0 Maine MAINE COMMUNITY HEALTH 42.4 60.3 43.1 - 100.0 100.0 100.0 100.0 OPTIONS WELLPOINT INC GRP - - - 42.0 Maryland CAREFIRST INC GRP 65.4 54.1 54.5 63.3 100.0 100.0 100.0 100.0 Page 33 GAO-23-105672 Health Insurance Market Concentration Appendix Ill: Number and Market Share of Issuers in Individual Market Exchanges, 2015- 2020 Market share of the largest issuer Market share of the three largest (percent) issuers (percent) State Largest issuer name 2017 2018 2019 2020 2017 2018 2019 2020 Massachusetts TUFTS HEALTH PLAN 47.1 49.3 55.0 58.3 90.5 92.1 92.6 92.2 Michigan BCBS OF MI GRP 49.5 61.9 59.1 53.3 86.0 94.1 90.7 86.8 Minnesota UCARE MINNESOTA _ 30.8 32.6 40.5 76.8 86.4 81.1 81.3 HEALTHPARTNERS GRP 26.0 - - - Mississippi CENTENE CORP GRP 90.4 100.0 100.0 96.9 100.0 100.0 100.0 100.0 Missouri WELLPOINT INC GRP 44.7 - - - 91.9 100.0 98.1 94.5 CIGNA HLTH GRP - 48.0 - - CENTENE CORP GRP - - 47.6 53.2 Montana HCSC GRP 43.5 - - - 100.0 100.0 100.0 100.0 MONTANA HEALTH - 50.3 44.9 42.1 COOPERATIVE Nebraska AETNA GRP 56.0 _ _ _ 100.0 100.0 100.0 100.0 MEDICA GRP - 100.0 100.0 89.3 Nevada UNITEDHEALTH GRP 56.6 63.7 54.7 66.1 100.0 100.0 100.0 100.0 New Hampshire WELLPOINT INC GRP - 80.6 64.0 55.7 99.8 100.0 100.0 100.0 MINUTEMAN HEALTH, INC 43.5 - - - New Jersey BCBS OF NJ GRP 68.3 54.6 - - 100.0 100.0 100.0 100.0 INDEPENDENCE BLUE _ _ 48.3 48.1 CROSS GRP New Mexico MOLINA HEALTHCARE INC 62.0 58.0 58.3 54.6 97.0 98.1 97.2 93.8 GRP New York NEW YORK STATE 32.9 42.9 40.1 42.8 55.3 62.2 62.1 65.3 CATHOLIC HEALTH PLAN, INC. North Carolina BLUE CROSS AND BLUE 95.6 96.3 97.6 90.9 100.0 100.0 100.0 99.5 SHIELD OF NORTH CAROLINA North Dakota BLUE CROSS BLUE SHIELD 71.1 80.0 70.1 - 100.0 100.0 100.0 100.0 OF NORTH DAKOTA SANFORD HEALTH - - - 53.5 PLAN/SANFORD HEALTH PLAN OF MINNESOTA Ohio CARESOURCE 31.7 40.7 - 30.7 74.3 89.9 78.7 75.3 MANAGEMENT GROUP MEDICAL MUTUAL OF OHIO - - 30.9 - Oklahoma HCSC GRP 100.0 100.0 97.8 88.7 100.0 100.0 100.0 100.0 Oregon PROVIDENCE HEALTH PLAN 50.4 47.8 38.9 34.1 82.0 98.3 84.9 83.2 Pennsylvania INDEPENDENCE BLUE 39.4 40.6 38.5 34.5 77.3 98.2 81.6 80.9 CROSS GRP Page 34 GAO-23-105672 Health Insurance Market Concentration Appendix Ill: Number and Market Share of Issuers in Individual Market Exchanges, 2015- 2020 Market share of the largest issuer Market share of the three largest (percent) issuers (percent) State Largest issuer name 2017 2018 2019 2020 2017 2018 2019 2020 Rhode Island NEIGHBORHOOD HEALTH 54.5 72.4 78.2 80.7 100.0 100.0 100.0 100.0 PLAN OF RHODE ISLAND South Carolina BCBS OF SC GRP 100.0 100.0 99.9 92.1 100.0 100.0 100.0 98.7 South Dakota AVERA HEALTH PLANS, INC. 75.5 50.6 56.9 57.7 100.0 100.0 100.0 100.0 Tennessee BCBS OF TN INC 35.2 55.0 52.6 47.8 100.0 100.0 90.8 90.0 Texas HCSC GRP 27.8 27.0 - - 73.6 95.4 80.6 78.8 CENTENE CORP GRP - - 35.4 37.0 Utah IHC INC GRP 55.2 88.5 89.5 86.9 100.0 100.0 100.0 97.9 Vermont BCBS OF VT GRP 80.7 60.6 50.2 55.6 100.0 100.0 100.0 100.0 Virginia WELLPOINT INC GRP 43.6 - 38.8 45.9 74.3 98.9 86.8 84.5 CIGNA HLTH GRP - 29.3 - - Washington KAISER FOUNDATION GRP _ 39.2 38.2 30.5 68.2 87.8 88.4 78.4 MOLINA HEALTHCARE INC 23.4 - - - GRP West Virginia HIGHMARK GRP 79.4 67.5 68.0 68.1 100.0 100.0 100.0 100.0 Wisconsin COMMON GROUND - 27.7 32.9 27.4 58.7 95.8 62.9 53.5 HEALTHCARE COOPERATIVE MOLINA HEALTHCARE INC 31.0 - - - GRP Wyoming BLUE CROSS BLUE SHIELD 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 OF WYOMING Legend: - This symbol indicates that this issuer was not the largest in that year. Source: GAO analysis of data from the Centers for Medicare & Medicaid Services (CMS). | GAO-23-105672 Notes: Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. We measured issuers' market share using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. Market share in this table represents an issuer's total state-level market share, which does not take into account variations in market share across a state's exchange rating areas. We reprinted issuer names as they were reported in the data from the Centers for Medicare & Medicaid Services. Table 10: Weighted Average Market Share of the Largest Issuer across Each State's Rating Areas, Individual Market Exchange, 2015 through 2020 Weighted average market share of the largest issuer across each state's rating areas (percent) State 2015 2016 2017 2018 2019 2020 Alabama 80.9 68.0 100.0 99.3 98.0 97.6 Alaska 71.3 69.8 100.0 100.0 100.0 90.1 Arizona 38.8 42.3 98.3 98.8 82.7 70.2 Arkansas 94.2 91.9 68.7 60.7 65.4 62.0 Page 35 GAO-23-105672 Health Insurance Market Concentration Appendix Ill: Number and Market Share of Issuers in Individual Market Exchanges, 2015- 2020 Weighted average market share of the largest issuer across each state's rating areas (percent) State 2015 2016 2017 2018 2019 2020 California 43.4 42.9 42.0 47.3 47.8 49.1 Colorado 48.5 54.3 55.1 55.8 53.4 46.5 Connecticut 54.8 62.8 72.7 78.8 79.3 78.5 Delaware 91.9 90.5 54.7 100.0 100.0 100.0 District of Columbia 80.8 85.6 83.0 79.6 81.9 82.9 Florida 58.6 62.0 70.5 69.9 72.1 67.8 Georgia 60.7 38.1 58.5 75.7 73.3 75.0 Hawaii n/a? 58.5 52.8 50.7 59.8 62.7 Idaho 60.5 48.8 55.8 51.6 64.2 67.3 Illinois 78.4 61.1 70.9 75.2 77.5 73.1 Indiana 47.8 32.5 46.4 68.5 72.1 67.2 lowa 97.4 75.5 72.6 100.0 84.4 91.1 Kansas 66.1 82.7 90.7 84.1 86.8 75.4 Kentucky 65.3 63.4 67.4 89.8 71.8 79.7 Louisiana 53.3 49.9 69.7 90.2 100.0 97.7 Maine 81.0 67.5 42.4 61.5 43.3 42.9 Maryland 77.4 64.6 65.4 65.0 66.3 66.9 Massachusetts 42.0 47.0 47.1 49.6 55.0 58.3 Michigan 67.7 57.9 56.0 62.2 61.7 57.5 Minnesota n/a? 44.1 51.0 54.8 50.3 56.9 Mississippi 56.9 54.2 90.4 100.0 100.0 96.9 Missouri 66.3 51.9 73.6 77.5 74.3 69.2 Montana 46.8 61.5 51.7 50.3 49.3 47.7 Nebraska 60.4 47.8 73.7 100.0 100.0 89.3 Nevada 47.9 63.4 67.2 72.4 63.0 71.0 New Hampshire 60.2 46.0 43.5 80.5 64.0 55.7 New Jersey 54.0 60.1 68.3 54.6 48.3 48.3 New Mexico 42.6 43.6 68.8 58.0 58.3 56.9 New York 24.8 28.3 35.4 44.3 42.2 45.4 North Carolina 69.6 60.4 95.6 96.3 97.6 90.9 North Dakota 72.2 60.3 71.1 88.8 78.3 61.8 Ohio 41.1 39.2 45.1 48.6 44.9 41.9 Oklahoma 97.5 94.9 100.0 100.0 97.8 88.7 Oregon 41.8 55.6 55.0 53.6 49.7 49.0 Pennsylvania 73.3 64.4 79.6 82.3 82.7 75.0 Rhode Island 50.1 48.5 54.5 72.4 78.2 80.7 Page 36 GAO-23-105672 Health Insurance Market Concentration Appendix Ill: Number and Market Share of Issuers in Individual Market Exchanges, 2015- 2020 Weighted average market share of the largest issuer across each state's rating areas (percent) State 2015 2016 2017 2018 2019 2020 South Carolina 59.2 95.5 100.0 100.0 99.9 92.1 South Dakota 60.7 73.2 75.5 65.6 66.2 66.8 Tennessee 77.6 65.6 83.7 87.1 77.6 66.0 Texas 69.4 43.5 §3.3 51.6 49.4 49.4 Utah 54.5 61.9 61.6 88.5 89.5 86.9 Vermont 91.7 88.0 80.7 60.6 50.2 55.6 Virginia 51.2 50.7 56.6 78.8 71.9 62.3 Washington 48.5 40.4 32.2 41.7 44.8 36.9 West Virginia 100.0 95.9 81.1 73.7 76.5 74.3 Wisconsin 51.8 54.1 57.5 60.1 63.4 53.7 Wyoming 61.3 100.0 100.0 100.0 100.0 100.0 Legend: n/a = not applicable. Source: GAO analysis of data from the Centers for Medicare & Medicaid Services (CMS). | GAQ-23-105672 Notes: Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. We calculated issuers' market share using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. Rating areas are established by states and used, in part, by issuers to set premium rates. Issuer participation and enrollment can vary across rating areas in a state. The market shares in this table reflect the average market share of the largest issuer across a state's rating areas, weighted by the share of covered life-years in each rating area. In some cases, the identity of the largest issuer varied across rating areas in a state and changed over time. *Data were not available from Hawaii and Minnesota in 2015. Table 11: Percentage Change of Largest Issuer's Market Share across a State's Rating Areas in Each Individual Health Insurance Market Exchange, 2015 to 2020 and 2019 to 2020 Percentage change in market share of the largest Percentage change in market share of the largest State issuer from 2015 to 2020 issuers from 2019 to 2020 Alabama 16.7 -0.4 Alaska 18.8 -9.9 Arizona 31.5 -12.4 Arkansas -32.1 -3.3 California 5.7 1.3 Colorado -2.0 -6.9 Connecticut 23.8 -0.8 Delaware 8.1 0.0 District of Columbia 2.2 1.0 Florida 9.1 4.3 Georgia 14.4 1.8 Page 37 GAO-23-105672 Health Insurance Market Concentration Appendix Ill: Number and Market Share of Issuers in Individual Market Exchanges, 2015- 2020 Percentage change in market share of the largest Percentage change in market share of the largest State issuer from 2015 to 2020 issuers from 2019 to 2020 Hawaii 4.1 2.9 Idaho 6.8 3.1 Illinois -5.3 4.4 Indiana 19.4 4.9 lowa -6.3 6.7 Kansas 9.4 -11.4 Kentucky 14.4 7.9 Louisiana 44.4 -2.3 Maine -38.1 -0.5 Maryland -10.6 0.6 Massachusetts 16.3 3.3 Michigan -10.1 4.2 Minnesota 12.84 6.6 Mississippi 40.0 -3.1 Missouri 2.9 -5.1 Montana 0.9 -1.6 Nebraska 28.9 -10.7 Nevada 23.1 8.0 New Hampshire -4.5 -8.3 New Jersey -5.7 0.0 New Mexico 14.3 -1.5 New York 20.6 3.2 North Carolina 21.3 -6.7 North Dakota -10.4 -16.5 Ohio 0.8 -3.0 Oklahoma -8.8 -9.1 Oregon 7.2 -0.6 Pennsylvania 1.7 -7.6 Rhode Island 30.6 2.4 South Carolina 32.9 -7.7 South Dakota 6.1 0.6 Tennessee -11.6 -11.6 Texas -19.9 0.0 Utah 32.4 -2.6 Vermont -36.1 5.4 Virginia 11.0 -9.6 Page 38 GAO-23-105672 Health Insurance Market Concentration Appendix Ill: Number and Market Share of Issuers in Individual Market Exchanges, 2015- 2020 Percentage change in Percentage change in market share of the largest market share of the largest State issuer from 2015 to 2020 issuers from 2019 to 2020 Washington -11.7 -7.9 West Virginia -25.7 -2.2 Wisconsin 1.9 -9.7 Wyoming 38.7 0.0 Source: GAO analysis of data from the Centers for Medicare & Medicaid Services (CMS). | GAO-23-105672 Notes: Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. We calculated issuers' market share using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. Rating areas are established by states and used, in part, by issuers to set premium rates. Issuer participation and enrollment can vary across rating areas in a state. The market shares in this table reflect the average market share of the largest issuer across a state's rating areas, weighted by the share of covered life-years in each rating area. In some cases, the identity of the largest issuer varied across rating areas in a state and changed over time. *Hawaii and Minnesota's percent point change is from 2016 through 2020 because we were unable to obtain data for 2015 for those states. Page 39 GAO-23-105672 Health Insurance Market Concentration Appendix IV: Number of Issuers and Market Share of Largest Issuers Participating in Small Group Health Insurance Market The three tables below present information on a) the number of participating issuers in each state's small group health insurance market from 2011 through 2020, b) the market share of the largest and three largest issuers from 2017 through 2020, and c) the percentage change from 2011 through 2020 and 2019 through 2020. Table 12: Number of Issuers in Each State's Small Group Health Insurance Market, 2011 through 2020 Number of issuers State 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Alabama 11 9 8 7 6 5 4 3 3 3 Alaska 7 6 6 6 5 4 4 4 4 4 Arizona 14 12 12 13 12 8 7 7 7 6 Arkansas 13 12 11 11 9 6 6 4 4 4 California 27 27 22 22 18 15 13 14 15 16 Colorado 11 11 9 9 10 8 6 6 6 7 Connecticut 11 8 7 9 9 7 6 6 6 5 Delaware 9 8 8 6 4 3 3 3 3 3 District of Columbia 9 7 6 6 7 5 5 5 5 5 Florida 16 13 14 13 12 9 8 9 7 7 Georgia 23 22 20 16 14 9 9 7 7 8 Hawaii 6 6 6 6 5 5 5 5 5 5 Idaho 11 10 11 10 11 10 9 9 9 8 Illinois 26 27 21 18 14 13 12 9 9 9 Indiana 27 26 24 20 18 16 11 9 9 9 lowa 17 15 15 15 14 11 11 9 8 8 Kansas 17 14 13 10 8 6 6 5 5 5 Kentucky 10 8 9 8 8 5 5 5 4 4 Louisiana 12 10 11 10 8 6 5 5 4 4 Maine 8 6 5 5 6 5 5 5 5 5 Maryland 8 8 8 7 6 5 5 4 4 4 Massachusetts 13 14 13 13 11 12 11 9 9 9 Michigan 25 24 24 22 21 16 15 13 13 12 Minnesota 10 9 9 9 8 8 7 6 8 7 Mississippi 10 9 8 8 7 5 4 3 3 3 Missouri 19 19 17 13 11 8 8 7 7 7 Montana 10 9 8 9 8 6 5 5 5 5 Nebraska 17 15 12 12 8 7 4 3 3 3 Nevada 17 16 14 14 12 8 8 8 7 7 Page 40 GAO-23-105672 Health Insurance Market Concentration Appendix IV: Number of Issuers and Market Share of Largest Issuers Participating in Small Group Health Insurance Market Number of issuers State 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 New Hampshire 9 7 6 7 6 6 5 4 4 3 New Jersey 7 7 6 7 7 7 6 7 6 5 New Mexico 11 8 7 7 4 4 4 5 4 4 New York 16 14 14 16 15 16 17 16 15 13 North Carolina 16 14 13 10 10 5 5 4 4 3 North Dakota 6 6 6 6 5 5 4 4 5 4 Ohio 30 29 25 24 22 17 13 10 10 9 Oklahoma 18 16 15 11 9 8 6 5 5 4 Oregon 9 8 8 13 14 14 13 8 8 9 Pennsylvania 21 19 19 16 14 11 10 10 10 11 Rhode Island 4 4 3 5 4 4 4 4 4 4 South Carolina 15 13 12 10 8 5 4 3 3 3 South Dakota 12 11 11 11 8 7 6 5 6 6 Tennessee 15 14 14 13 11 6 5 4 5 6 Texas 27 25 23 21 18 16 14 11 11 11 Utah 12 13 12 11 10 8 8 8 7 6 Vermont 4 3 3 3 3 3 2 2 2 3 Virginia 20 15 17 15 12 11 11 10 9 9 Washington 13 12 13 12 9 8 6 7 7 8 West Virginia 14 13 12 9 6 5 5 4 4 4 Wisconsin 27 26 24 24 23 21 21 18 18 18 Wyoming 9 7 7 7 6 4 3 2 2 3 Total 729 664 621 585 514 422 379 338 333 328 Source: GAO analysis of data from the Centers for Medicare & Medicaid Services. | GAO-23-105672 Note: Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. Table 13: Market Share of the Largest and Three Largest Issuers in Each State's Small Group Health Insurance Market, 2017 through 2020 Market share of the largest Issuer Market Share of the three largest (percent) issuers (percent) State Largest issuer name 2017 2018 2019 2020 2017 2018 2019 2020 Alabama BCBS OF AL GRP 96.1 96.4 97.3 97.7 100.0 100.0 100.0 2020 Alaska PREMERA BLUE CROSS 70.6 85.3 94.7 93.4 95.4 97.6 98.8 100.0 GROUP Arizona BLUE CROSS AND BLUE - - - - 82.7 86.9 91.6 92.7 SHIELD OF ARIZONA, INC. Page 41 GAO-23-105672 Health Insurance Market Concentration Appendix IV: Number of Issuers and Market Share of Largest Issuers Participating in Small Group Health Insurance Market Market share of the largest Issuer Market Share of the three largest (percent) issuers (percent) State Largest issuer name 2017 2018 2019 2020 2017 2018 2019 2020 UNITEDHEALTH GRP 42.0 47.6 51.2 49.9 Arkansas ARKANSAS BCBS GRP 63.9 62.3 57.8 60.2 98.1 97.3 94.1 95.2 California KAISER FOUNDATION GRP 37.5 38.9 38.9 38.9 76.0 79.3 80.8 80.6 Colorado WELLPOINT INC GRP - - - - 92.0 93.8 95.8 96.7 UNITEDHEALTH GRP 40.0 46.1 49.5 49.8 Connecticut HIP INS GRP - - - - 77.7 84.7 87.2 90.4 WELLPOINT INC GRP 40.3 42.6 - - UNITEDHEALTH GRP - - 36.2 45.9 Delaware HIGHMARK GRP 74.4 85.5 88.1 88.6 100.0 100.0 100.0 100.0 District of Columbia + =CAREFIRST INC GRP 80.4 78.6 77.6 77.3 96.8 97.5 98.4 98.3 Florida BLUE CROSS AND BLUE 42.3 39.8 - 47.0 81.7 85.1 93.4 94.6 SHIELD OF FLORIDA, INC. UNITEDHEALTH GRP - - 46.9 - Georgia WELLPOINT INC GRP _ _ _ _ 80.2 87.1 91.3 89.6 HUMANA GRP 37.7 39.5 40.6 40.3 Hawaii HAWAII MEDICAL SERVICE 48.4 49.1 51.0 50.4 88.1 89.7 90.2 90.1 ASSOCIATION Idaho BLUE CROSS OF IDAHO 42.0 48.9 50.3 48.7 95.9 94.2 90.9 90.6 HEALTH SERVICE, INC. Illinois HCSC GRP 72.9 73.4 78.1 80.5 93.6 95.4 97.7 97.8 Indiana WELLPOINT INC GRP 52.0 53.3 51.7 53.4 87.2 92.0 91.7 91.0 lowa WELLMARK GROUP 84.2 81.9 80.4 79.3 97.3 98.1 99.2 99.4 Kansas BCBS OF KS GRP 61.3 56.8 65.1 75.1 87.5 87.8 91.1 92.7 Kentucky WELLPOINT INC GRP 50.2 51.0 52.6 53.7 96.8 99.6 100.0 100.0 Louisiana LOUISIANA HLTH SERV GRP 81.7 81.5 85.3 89.2 98.9 99.3 99.9 100.0 Maine HARVARD PILGRIM HTH 37.0 53.0 53.2 52.3 86.7 90.0 92.4 93.6 CARE GRP Maryland CAREFIRST INC GRP 67.4 69.5 71.1 73.4 93.4 98.8 99.5 99.7 Massachusetts BCBS OF MA GRP 50.8 53.3 50.7 46.3 80.0 81.6 81.1 79.0 Michigan BCBS OF MI GRP 56.8 63.3 65.4 63.9 84.3 88.5 90.1 91.2 Minnesota HEALTHPARTNERS GRP 43.5 43.8 41.0 37.1 87.9 93.1 93.1 88.9 Mississippi MISSISSIPPI INS GRP 83.8 85.1 87.4 89.2 99.5 100.0 100.0 100.0 Missouri WELLPOINT INC GRP 38.6 36.5 - - 79.1 86.3 93.2 94.9 UNITEDHEALTH GRP - - 44.2 49.1 Montana HCSC GRP 68.0 55.1 55.2 57.0 99.5 99.3 99.3 98.0 Nebraska BLUE CROSS AND BLUE 62.7 56.9 58.1 58.1 96.2 100.0 100.0 100.0 SHIELD OF NEBRASKA Page 42 GAO-23-105672 Health Insurance Market Concentration Appendix IV: Number of Issuers and Market Share of Largest Issuers Participating in Small Group Health Insurance Market Market share of the largest Issuer Market Share of the three largest (percent) issuers (percent) State Largest issuer name 2017 2018 $2019 2020 2017 2018 2019 2020 Nevada UNITEDHEALTH GRP 57.6 64.8 66.8 69.2 81.0 85.0 90.6 93.6 New Hampshire HARVARD PILGRIM HTH 49.7 43.0 - 41.2 97.9 98.9 99.2 CARE GRP 100.0 WELLPOINT INC GRP - - 39.7 - New Jersey BCBS OF NJ GRP 56.0 63.7 66.3 69.6 88.9 95.8 99.4 99.4 New Mexico HCSC GRP - - - - 88.6 85.0 85.6 84.9 PRESBYTERIAN HLTHCARE 34.5 38.8 36.0 34.1 SERV GRP New York UNITEDHEALTH GRP 46.5 51.1 52.4 51.8 70.9 75.5 78.7 79.4 North Carolina BLUE CROSS AND BLUE 46.2 - - - 96.7 98.6 99.6 100.0 SHIELD OF NORTH CAROLINA UNITEDHEALTH GRP - 53.5 54.9 51.3 North Dakota NORIDIAN MUTUAL 85.1 84.5 _ _ 99.8 99.9 99.6 99.4 INSURANCE COMPANY BLUE CROSS BLUE SHIELD - - 83.2 81.8 OF NORTH DAKOTA Ohio WELLPOINT INC GRP 36.6 35.4 - - 80.3 83.6 87.3 87.5 MEDICAL MUTUAL OF OHIO _ _ 38.5 41.6 Oklahoma HCSC GRP 68.1 68.0 76.7 83.6 96.3 97.9 99.8 99.9 Oregon PROVIDENCE HEALTH PLAN 37.6 37.9 31.5 - 72.8 78.2 78.5 81.8 REGENCE GRP - - - 37.8 Pennsylvania INDEPENDENCE BLUE 31.2 31.3 33.7 34.0 73.1 73.9 78.9 79.4 CROSS GRP Rhode Island BLUE CROSS & BLUE 82.8 81.5 80.4 82.0 98.7 98.0 97.4 96.6 SHIELD OF RHODE ISLAND South Carolina BCBS OF SC GRP 86.0 82.4 79.9 83.0 98.9 100.0 100.0 100.0 South Dakota WELLMARK GROUP 77.9 75.0 71.6 70.1 94.8 96.2 95.0 95.9 Tennessee BCBS OF TN INC 63.0 64.6 65.1 63.5 98.5 99.7 99.6 99.6 Texas HCSC GRP 65.0 69.4 78.7 82.5 92.4 94.2 97.5 97.8 Utah IHC INC GRP 67.4 71.7 74.7 73.4 91.7 94.2 98.6 98.9 Vermont BCBS OF VT GRP 86.7 65.7 60.3 50.1 100.0 100.0 100.0 100.0 Virginia WELLPOINT INC GRP 43.2 40.4 39.2 41.1 72.9 79.6 82.3 83.1 Washington PREMERA BLUE CROSS 36.0 36.8 40.8 42.4 89.4 91.4 92.6 93.0 GROUP West Virginia HIGHMARK GRP 83.1 81.1 80.7 83.4 95.1 99.3 99.7 99.7 Wisconsin UNITEDHEALTH GRP 28.9 31.5 32.8 35.2 52.0 57.2 63.5 68.0 Page 43 GAO-23-105672 Health Insurance Market Concentration Appendix IV: Number of Issuers and Market Share of Largest Issuers Participating in Small Group Health Insurance Market Market share of the largest Issuer (percent) Market Share of the three largest issuers (percent) 2018 2019 2020 2017 2018 2019 2020 State Largest issuer name 2017 Wyoming BLUE CROSS BLUE SHIELD 86.0 OF WYOMING 85.9 85.8 87.8 100.0 100.0 100.0 100.0 Legend: - This symbol indicates that this issuer was not the largest in that year. Source: GAO analysis of data from the Centers for Medicare & Medicaid Services. | GAO-23-105672 Notes: Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. We calculated issuers' market share using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. We reprinted issuer names as they were reported in the data from the Centers for Medicare & Medicaid Services. Table 14: Percentage Change of the Three Largest Issuers' Market Share in Each State's Small Group Health Insurance Market, 2011 to 2020 and 2019 to 2020 Percentage change of the Percentage change of the three largest issuers from three largest issuers from 2019 State 2011 to 2020 to 2020 Alabama 0.4 0.0 Alaska 12.4 0.4 Arizona 26.7 1.0 Arkansas -0.1 1.1 California 17.8 -0.2 Colorado 15.3 0.9 Connecticut 7.1 3.2 Delaware 47 0.0 District of Columbia 3.9 -0.1 Florida 15.1 1.2 Georgia 20.3 -1.8 Hawaii 7.2 -0.1 Idaho -5.1 -0.4 Illinois 17.0 0.1 Indiana 15.2 -0.7 lowa 9.4 0.1 Kansas 11.5 1.6 Kentucky 6.6 0.0 Louisiana 5.0 0.1 Maine -45 1.2 Maryland 8.3 0.2 Massachusetts -1.8 -2.0 Michigan 10.3 1.1 Page 44 GAO-23-105672 Health Insurance Market Concentration Appendix IV: Number of Issuers and Market Share of Largest Issuers Participating in Small Group Health Insurance Market Percentage change of the Percentage change of the three largest issuers from three largest issuers from 2019 State 2011 to 2020 to 2020 Minnesota 5.3 4.1 Mississippi 2.5 0.0 Missouri 16.9 1.7 Montana 8.3 -1.3 Nebraska 11.4 0.0 Nevada 20.8 3.0 New Hampshire 1.4 0.8 New Jersey 7.3 -0.1 New Mexico -2.6 -0.7 New York 12.9 0.7 North Carolina 5.4 0.4 North Dakota 0.1 -0.2 Ohio 9.2 0.2 Oklahoma 23.9 0.1 Oregon 21.7 3.3 Pennsylvania 22.3 0.5 Rhode Island -2.6 -0.8 South Carolina 9.6 0.0 South Dakota 5.7 0.8 Tennessee 44 0.0 Texas 18.2 0.3 Utah 21.1 0.3 Vermont 0.0 0.0 Virginia 6.6 0.8 Washington 15.1 0.4 West Virginia 8.1 0.0 Wisconsin 17.1 4.5 Wyoming 12.1 0.0 Source: GAO analysis of data from the Centers for Medicare & Medicaid Services. | GAO-23-105672 Notes: This table includes the 50 states and the District of Columbia. All states, except Vermont and Wyoming, had least three issuers in their small group markets from 2011 through 2020. Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. We calculated market share using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. Page 45 GAO-23-105672 Health Insurance Market Concentration Appendix V: Number of Issuers and Market Share of Largest Issuers Participating in Large Group Health Insurance Market The three tables below present information on a) the number of participating issuers in each state's large group health insurance market from 2011 through 2020, b) the market share of the largest and three largest issuers from 2017 through 2020, and c) the percentage change from 2011 through 2020 and 2019 through 2020. Table 15: Number of Issuers in Each State's Large Group Health Insurance Market, 2011 through 2020 Number of issuers State 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Alabama 7 8 7 7 7 8 6 6 6 6 Alaska 6 4 5 5 5 4 4 4 4 4 Arizona 13 13 12 12 12 11 9 9 9 8 Arkansas 10 10 9 10 10 7 8 8 8 8 California 32 28 24 25 24 23 23 25 24 25 Colorado 13 10 10 10 10 9 9 9 9 9 Connecticut 9 7 5 7 8 8 7 7 7 6 Delaware 6 6 6 5 4 5 4 5 5 5 District of Columbia 9 7 6 6 7 7 6 7 7 7 Florida 14 11 12 11 13 11 10 11 9 9 Georgia 16 16 16 14 15 13 11 10 10 10 Hawaii 7 7 7 7 6 6 7 6 6 6 Idaho 12 9 9 11 12 12 11 11 10 11 Illinois 20 21 18 18 19 18 18 17 18 18 Indiana 23 24 19 17 16 15 15 14 13 13 lowa 14 14 14 12 13 13 14 13 12 13 Kansas 14 13 13 11 10 8 9 8 8 8 Kentucky 11 11 8 9 9 8 9 9 8 8 Louisiana 9 9 10 10 10 9 8 8 7 7 Maine 5 5 5 6 6 6 6 7 7 7 Maryland 9 7 6 6 7 6 6 5 5 5 Massachusetts 13 12 11 12 13 13 12 11 10 12 Michigan 24 25 24 25 25 19 18 17 16 17 Minnesota 14 11 11 9 11 11 11 9 10 10 Mississippi 9 9 8 9 9 7 7 8 8 7 Missouri 18 16 15 14 14 11 10 9 9 9 Montana 8 6 7 8 7 8 7 7 6 7 Nebraska 10 8 9 10 10 7 8 7 7 7 Nevada 14 13 13 13 13 10 12 12 12 11 Page 46 GAO-23-105672 Health Insurance Market Concentration Appendix V: Number of Issuers and Market Share of Largest Issuers Participating in Large Group Health Insurance Market Number of issuers State 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Alabama 7 8 7 7 7 8 6 6 6 6 New Hampshire 6 6 6 6 5 8 7 6 6 5 New Jersey 9 10 8 9 8 8 8 8 7 7 New Mexico 10 8 7 6 6 6 5 6 5 5 New York 16 16 15 16 15 16 16 16 14 14 North Carolina 13 12 11 10 9 8 7 6 7 6 North Dakota 7 8 8 7 7 6 5 7 7 6 Ohio 20 21 18 21 21 20 15 14 13 13 Oklahoma 12 11 12 11 9 10 8 9 9 9 Oregon 12 12 11 11 15 13 13 10 10 10 Pennsylvania 17 17 18 17 16 15 17 17 14 15 Rhode Island 5 5 4 5 5 4 4 4 4 South Carolina 12 10 10 8 8 6 7 7 6 6 South Dakota 11 11 12 10 7 8 8 8 8 8 Tennessee 10 9 9 11 12 9 10 9 9 9 Texas 23 22 22 20 21 21 18 16 16 16 Utah 12 13 14 13 12 12 12 12 11 10 Vermont 4 3 4 4 3 3 3 3 3 3 Virginia 14 13 16 16 14 14 13 12 13 12 Washington 13 13 12 11 10 10 9 9 9 10 West Virginia 11 11 11 8 7 7 5 6 6 6 Wisconsin 28 27 27 26 25 23 21 21 21 21 Wyoming 6 6 7 7 7 6 4 4 4 4 Total 640 604 581 572 567 526 500 489 472 472 Source: GAO analysis of data from the Centers for Medicare & Medicaid Services. | GAO-23-105672 Note: Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. Table 16: Market Share of the Largest and Three Largest Issuers in Each State's Large Group Health Insurance Market, 2017 through 2020 Market share of the Market share of the three largest issuer (percent) largest issuers (percent) State Largest issuer name 2017 2018 2019 2020 2017 2018 2019 2020 Alabama BCBS OF AL GRP 93.2 94.1 94.5 95.1 99.7 99.9 99.8 99.8 Alaska PREMERA BLUE CROSS 87.9 92.7 946 96.1 98.9 99.2 99.4 99.7 GROUP Page 47 GAO-23-105672 Health Insurance Market Concentration Appendix V: Number of Issuers and Market Share of Largest Issuers Participating in Large Group Health Insurance Market Market share of the Market share of the three largest issuer (percent) largest issuers (percent) State Largest issuer name 2017 2018 2019 2020 2017 2018 2019 2020 Arizona BLUE CROSS AND BLUE 39.6 49.6 54.1 57.2 86.5 85.1 88.5 89.5 SHIELD OF ARIZONA, INC. Arkansas ARKANSAS BCBS GRP 77.5 75.5 69.3 62.8 96.4 94.4 91.4 89.3 California KAISER FOUNDATION GRP 49.9 51.3 52.0 53.3 74.5 75.6 77.0 77.1 Colorado KAISER FOUNDATION GRP 48.3 48.2 48.6 49.3 87.1 84.5 84.8 84.1 Connecticut WELLPOINT INC GRP 29.4 - - 29.6 74.6 72.9 75.4 73.3 UNITEDHEALTH GRP - 26.8 27.8 - Delaware HIGHMARK GRP 62.2 68.6 73.6 73.8 94.7 97.4 96.8 96.9 District of Columbia AETNA GRP 44.5 42.0 40.1 37.4 82.7 80.5 79.4 79.0 Florida BLUE CROSS AND BLUE 46.4 46.6 45.9 46.1 87.8 87.7 86.8 85.8 SHIELD OF FLORIDA, INC. Georgia WELLPOINT INC GRP 41.0 36.9 406 428 76.4 75.1 76.0 76.1 Hawaii HAWAII MEDICAL SERVICE 67.2 66.8 66.1 66.2 95.5 95.4 95.3 96.1 ASSOCIATION Idaho BLUE CROSS OF IDAHO 66.5 67.4 70.0 70.1 93.0 93.2 93.3 93.2 HEALTH SERVICE, INC. Illinois HCSC GRP 65.3 68.9 71.4 72.6 88.5 91.0 91.9 92.3 Indiana WELLPOINT INC GRP 61.8 65.6 66.8 68.1 92.2 92.3 92.1 91.5 lowa WELLMARK GROUP 78.0 79.3 78.0 78.8 96.5 95.0 93.3 93.3 Kansas BCBS OF KS GRP 45.7 46.5 48.6 48.7 89.0 90.5 91.6 90.6 Kentucky WELLPOINT INC GRP 65.2 67.0 67.9 67.8 92.5 98.3 98.9 98.0 Louisiana LOUISIANA HLTH SERV GRP 63.9 66.0 69.3 69.9 90.9 92.3 96.5 96.9 Maine WELLPOINT INC GRP 68.5 68.9 69.3 68.0 94.8 94.5 94.2 93.4 Maryland CAREFIRST INC GRP 55.1 55.1 55.1 54.5 91.6 91.3 90.4 90.3 Massachusetts BCBS OF MA GRP 58.2 60.2 61.9 61.0 82.0 83.8 85.1 84.9 Michigan BCBS OF MI GRP 55.2 57.6 65.8 66.7 80.3 83.4 91.1 92.0 Minnesota HEALTHPARTNERS GRP 46.1 48.5 474 444 96.6 97.3 95.4 93.6 Mississippi MISSISSIPPI INS GRP 82.7 84.3 83.3 83.4 98.5 98.5 97.9 98.7 Missouri WELLPOINT INC GRP 36.3 35.9 35.6 - 84.8 84.3 86.4 86.0 BCBS OF KC GRP - - - 333 Montana HCSC GRP 81.1 82.3 84.2 83.7 97.4 97.9 98.5 97.5 Nebraska BLUE CROSS AND BLUE 73.2 73.5 76.8 80.5 98.3 98.8 99.6 99.8 SHIELD OF NEBRASKA Nevada UNITEDHEALTH GRP 65.2 66.4 649 63.7 87.4 89.2 89.2 88.5 New Hampshire WELLPOINT INC GRP 56.0 55.6 56.1 56.5 95.0 94.0 94.0 94.3 New Jersey BCBS OF NJ GRP 54.1 53.6 51.6 52.1 85.9 85.4 82.8 81.6 New Mexico HCSC GRP 54.6 55.2 61.9 69.7 93.2 93.0 92.7 92.2 Page 48 GAO-23-105672 Health Insurance Market Concentration Appendix V: Number of Issuers and Market Share of Largest Issuers Participating in Large Group Health Insurance Market Market share of the Market share of the three largest issuer (percent) largest issuers (percent) State Largest issuer name 2017 2018 2019 2020 2017 2018 2019 2020 New York LIFETIME HLTHCARE GRP - - - - 45.1 46.3 45.4 43.7 UNITEDHEALTH GRP 15.7 16.3 - 15.0 AETNA GRP _ _ 16.1 _ North Carolina BLUE CROSS AND BLUE 63.1 66.4 70.1 73.0 94.6 95.1 95.4 95.5 SHIELD OF NORTH CAROLINA North Dakota NORIDIAN MUTUAL 49.0 51.3 - - 99.9 99.9 99.4 98.0 INSURANCE COMPANY BLUE CROSS BLUE SHIELD OF - - 51.4 47.9 NORTH DAKOTA Ohio WELLPOINT INC GRP 44.0 42.2 45.5 489 82.8 82.9 85.3 85.4 Oklahoma HCSC GRP 50.7 54.2 63.9 69.9 79.9 80.7 87.0 90.5 Oregon KAISER FOUNDATION GRP 42.4 43.6 45.1 46.3 77.4 77.0 77.7 78.3 Pennsylvania HIGHMARK GRP 35.1 39.3 39.3 40.2 64.0 68.3 69.0 70.8 Rhode Island BLUE CROSS & BLUE SHIELD 78.3 77.3 78.7 879.4 98.9 99.6 99.3 99.3 OF RHODE ISLAND South Carolina BCBS OF SC GRP 87.7 91.1 91.2 91.9 98.1 98.6 98.7 99.1 South Dakota WELLMARK GROUP 61.7 64.9 64.9 65.2 90.0 94.4 96.2 96.4 Tennessee BCBS OF TN INC 70.6 71.8 72.0 69.1 92.0 92.8 93.9 92.9 Texas HCSC GRP 41.4 43.0 46.0 50.4 84.2 85.0 86.7 87.8 Utah IHC INC GRP 39.9 41.4 424 440 83.0 82.6 84.5 85.7 Vermont BCBS OF VT GRP 92.1 90.6 91.0 80.2 100.0 100.0 100.0 100.0 Virginia WELLPOINT INC GRP 44.3 41.6 41.8 44.3 70.9 69.3 69.5 70.6 Washington GROUP HLTH COOP GRP - - - - 86.0 82.7 82.7 88.4 KAISER FOUNDATION GRP 34.2 34.1 34.4 38.4 West Virginia HIGHMARK GRP 78.1 80.2 78.2 79.2 97.6 98.4 97.9 97.7 Wisconsin UNITEDHEALTH GRP 18.6 - - - 51.0 50.6 51.6 50.8 UNIVERSITY HEALTH CARE & - 20.6 20.0 20.4 GUNDERSEN LUTHERAN GROUP Wyoming BLUE CROSS BLUE SHIELD OF 71.2 86.0 91.0 91.5 95.8 99.0 98.3 98.2 WYOMING Legend: - This symbol indicates that this issuer was not the largest in that year. Source: GAO analysis of data from the Centers for Medicare & Medicaid Services. | GAO-23-105672 Notes: Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. We calculated issuers' market share using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. We reprinted issuer names as they were reported in the data from the Centers for Medicare & Medicaid Services. Page 49 GAO-23-105672 Health Insurance Market Concentration Appendix V: Number of Issuers and Market Share of Largest Issuers Participating in Large Group Health Insurance Market Table 17: Percentage Change of the Three Largest Issuers' Market Share in Each State's Large Group Health Insurance Market, 2011 to 2020 and 2019 to 2020 Percentage Percentage change of the three largest change of the three largest State issuers from 2011 to 2020 issuers from 2019 to 2020 Alabama -0.1 0.0 Alaska 0.7 0.3 Arizona 9.4 1.1 Arkansas -9.5 -2.1 California 7.7 0.2 Colorado 0.0 -0.7 Connecticut 0.2 -2.2 Delaware 2.9 0.2 District of Columbia 3.7 -0.3 Florida 9.5 -1.0 Georgia -6.8 0.1 Hawaii 3.3 0.8 Idaho -3.4 -0.1 Illinois 6.0 0.3 Indiana 9.3 -0.7 lowa -0.5 0.0 Kansas -0.9 -1.0 Kentucky 9.8 -0.9 Louisiana 8.6 0.3 Maine -1.0 -0.8 Maryland -3.5 -0.1 Massachusetts -0.3 -0.2 Michigan 12.2 0.9 Minnesota 10.8 -1.8 Mississippi 1.5 0.9 Missouri 10.9 -0.4 Montana -1.2 -1.0 Nebraska 0.9 0.2 Nevada 1.1 -0.7 New Hampshire -0.2 0.3 New Jersey -4.6 -1.2 New Mexico -0.8 -0.4 New York -18.3 -1.7 Page 50 GAO-23-105672 Health Insurance Market Concentration Appendix V: Number of Issuers and Market Share of Largest Issuers Participating in Large Group Health Insurance Market Percentage Percentage change of the three largest change of the three largest State issuers from 2011 to 2020 issuers from 2019 to 2020 North Carolina 2.3 0.0 North Dakota -1.4 -1.4 Ohio 6.0 0.1 Oklahoma 10.9 3.6 Oregon 1.0 0.6 Pennsylvania 2.2 1.8 Rhode Island 1.4 0.0 South Carolina 0.9 0.4 South Dakota 8.2 0.2 Tennessee 0.0 -1.0 Texas 6.2 1.1 Utah -3.9 1.2 Vermont 0.2 0.0 Virginia -4.6 1.2 Washington -0.4 5.7 West Virginia 1.4 -0.2 Wisconsin 9.9 -0.8 Wyoming 2.7 -0.1 Source: GAO analysis of data from the Centers for Medicare & Medicaid Services. | GAO-23-105672 Notes: This table includes the 50 states and the District of Columbia. All states had at least three issuers in their large group markets from 2011 through 2020. Where multiple issuers in a state shared a parent company, we aggregated the individual issuers to the parent company level. We calculated market share using covered life-years, which measure the average number of lives insured, including dependents, during the reporting year. Page 51 GAO-23-105672 Health Insurance Market Concentration Appendix VI: GAO Contact and Staff Acknowledgments GAO Contact John E. Dicken, (202) 512-7114, dickenj@gao.gov Staff In addition to the contact named above, William D. Hadley, Assistant Director; Colin Ashwood, Analyst-in-Charge; Gail-Lynn Michel; Laurie Acknowledgments Pachter; Moon Parks; Daniel Ries; Ethiene Salgado-Rodriguez; Ravi Sharma; and Jennifer Whitworth made key contributions to this report. 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