Four out of five metropolitan areas in the United States lack a competitive commercial health insurance market, according to analysis from the American Medical Association.

“New data presented by the AMA demonstrates the degree of anti-competitive market clout that some health insurers have gained through mergers and acquisitions,” AMA President Peter Carmel said in a news release.

There are several markets where mergers among health insurers may cause “competitive harm to patients, physicians and employers,” Carmel said. The state with the least competitive commercial health insurance market is Alabama, followed by Alaska, Delaware, Michigan and Hawaii.

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