The local concentration of health insurers can have a significant impact on what coverage Americans buy and what they pay for it.
“In the vast majority of metropolitan areas across the country, health insurers hold outsized market share -- leaving patients with fewer choices and higher costs,” said Dr. John M. Whyte, CEO and executive vice president of the American Medical Association. “When one or two companies call the shots, premiums rise, options shrink and patients suffer. Strengthening competition -- not consolidation -- is the path to lower costs and improved access.”
The AMA analyzed commercial and Medicare Advantage market share in 384 metropolitan areas across the nation. Nationally, the 10 largest health insurers by market share are UnitedHealth Group (16%), Elevance Health (12%), CVS (Aetna) (12%), Cigna (9%), Health Care Service Corp. (8%), Kaiser Permanente (6%), Centene (3%), Blue Cross Blue Shield of Florida (2%), Blue Cross Blue Shield of Michigan (2%) and Highmark (2%). Collectively, however, Blue Cross Blue Shield insurers would lead the list with a combined commercial market share of 43%.
A lack of competition has spread in the last decade as more local markets have become highly concentrated. Under federal guidelines, 97% of metropolitan area markets were highly concentrated in 2024, up from 95% in 2014. In 9 of 10 metropolitan areas, at least one insurer held a commercial market share of 30% or greater, and in 47%, one health insurer held a market share of at least 50%.
Nationally, the 10 largest Medicare Advantage health insurers by market share are UnitedHealth Group (30%), Humana (19%), CVS (Aetna) (12%), Kaiser Permanente (6%), Elevance Health (5%), Centene (4%), Cigna (2%), Blue Cross Blue Shield of Michigan (2%), Highmark (1%) and SCAN (1%).
Competition slightly improved in the last seven years as fewer local markets were highly concentrated, although the vast majority of markets remain highly concentrated. Under federal guidelines, 97% of metropolitan area markets were highly concentrated in 2024, down from 99% in 2017. In 90% of metropolitan areas, at least one insurer held a market share of 30% or greater, and in 24%, one insurer's share was at least 50%.
Policymakers and regulators can benefit from this analysis as they work to identify markets where mergers and acquisitions involving health insurers may cause competitive harm to consumers and care providers.
“The prospect of future consolidation in the health insurance industry must be viewed in the context of the low levels of competition in most health insurance markets,” the report concluded.
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