Private health insurance enrollment remains highly concentrated, according to a report released this month by the Government Accountability Office (GAO), the legislative branch government agency that provides auditing, evaluation, and investigative services for the United States Congress.
The GAO’s new report, entitled “Private Health Insurance: Enrollment Remains Concentrated among Few Insurers, Including in Exchanges,” reviews the status of health insurer competition in healthcare markets across the U.S., including in the large group market, the small group market, and the individual market.
As the report notes, “A highly concentrated health insurance market may indicate less competition and could affect consumers’ choice of issuers and the premiums they pay. In 2014, PPACA required the establishment of health insurance exchanges—a new type of marketplace where individuals and small groups can compare and select among insurance plans sold by participating issuers—and the introduction of other reforms that could affect market concentration and competition among issuers. GAO previously reported that enrollment through these newly established exchanges was also generally concentrated. PPACA [the Patient Protection and Affordable Care Act of 2010, better known as the Affordable Care Act, or ACA] included a provision for GAO to study market concentration. This report,” the report’s authors note, “describes changes in the concentration of enrollment among issuers in (1) overall individual, small group, and large group markets, and (2) individual and small group exchanges. GAO determined market share in the overall markets using enrollment data from 2015 and 2016 that issuers are required to report annually to the Centers for Medicare & Medicaid Services (CMS) and compared that data to 2011 through 2014 enrollment data GAO analyzed in previous reports. GAO determined market share in the exchanges from 2015 through 2017 using other sources of enrollment data from CMS and states. For all data sets, GAO used the most recent data available.”
Significantly, the report states, “Enrollment in private health insurance plans continued to be concentrated among a small number of issuers in 2015 and 2016. In the overall large group market (coverage offered by large employers), small group market (coverage offered by small employers), and individual market (coverage sold directly to individuals), the three largest issuers held 80 percent of the market or more in at least 37 of 51 states. This is similar to what GAO previously reported for 2011 through 2014.”
The impact of overall market concentration on the ACA market exchanges has been detrimental, the report notes. “States’ overall individual health insurance markets were generally concentrated in 2015 and 2016, similar to what we reported for previous years. Individual market exchanges—representing 57 percent of the overall individual market nationally in 2016—were also concentrated in most states and in many cases became more concentrated in recent years.” What’s more, the report notes, “States’ overall individual health insurance markets were generally concentrated among a small number of issuers in 2015 and 2016. On average, there were 16 issuers participating in each state in 2016. However, that same year, the 3 largest issuers cumulatively held 80 percent or more of the market—an indicator of high concentration—in 37 of 51 states, generally consistent with what we previously reported for years 2011 through 2014 (see fig. 2).25 The remaining issuers in each state often had significantly smaller market shares—on average, 12 of the 16 issuers in each state held less than 5 percent market share.”
The report also noted some extreme examples of market concentration. “In more than 30 states in 2015 and 2016,” it stated, “market share was not only concentrated among a small number of issuers, but a single issuer held at least 50 percent of the overall large group market, as in prior years. A single issuer held at least 50 percent market share in 33 states in 2016, with significantly higher levels of concentration by the largest issuer in some states. For example, in 2016, a single issuer held at least 90 percent of the market in Alabama and at least 80 percent of the market in 5 other states (Alaska, Mississippi, Montana, South Carolina, and Vermont). Further, this largest issuer position was held by the same company in 2015 and 2016 in 49 states; and, in 47 of those states, the largest issuer position has been held by the same company since 2011.”
