Private Health Insurance: Markets Remained Concentrated through 2018, with Increases in the Individual and Small Group Markets

What GAO Found

Enrollment in private health insurance plans in the individual (coverage sold directly to individuals), small group (coverage offered by small employers), and large group (coverage offered by large employers) markets has historically been highly concentrated among a small number of issuers. GAO found that this pattern continued in 2017 and 2018. For example:

  • For each market in 2018, at least 43 states (including the District of Columbia) were highly concentrated.
  • Overall individual and small group markets have become more concentrated in recent years. The national median market share of the top three issuers increased by approximately 8 and 5 percentage points, respectively, from 2015 through 2018. With these increases, the median concentration was at least 94 percent in both markets in 2018.

Number of States and District of Columbia Where the Three Largest Issuers Had at Least 80 Percent of Enrollment, by Market, 2011-2018

GAO found similar patterns of high concentration across the 39 states in 2018 that used federal infrastructure to operate individual market exchanges— marketplaces where consumers can compare and select among insurance plans sold by participating issuers—established in 2014 by the Patient Protection and Affordable Care Act (PPACA) and known as federally facilitated exchanges. From 2015 through 2018, states that were already highly concentrated became even more concentrated, often because the number of issuers decreased or the existing issuers accrued the entirety of the market share within a state. In 2017 and 2018 all 39 states were highly concentrated.

GAO received technical comments on a draft of this report from the Department of Health and Human Services and incorporated them as appropriate.

Why GAO Did This Study

GAO previously reported that, from 2011 through 2016, enrollment in the individual, small group, and large group health insurance markets was concentrated among a few issuers in most states (GAO-19-306). GAO considered states’ markets or exchanges to be highly concentrated if three or fewer issuers held at least 80 percent of the market share. GAO also found similar concentration on the health insurance exchanges established in 2014 by PPACA. A highly 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 market concentration. This report describes changes in the concentration of enrollment among issuers in the overall individual, small group, and large group markets; and individual market federally facilitated exchanges.

GAO determined market share in the overall markets using enrollment data from 2017 and 2018 that issuers are required to report annually to the Centers for Medicare & Medicaid Services (CMS). GAO determined market share in the individual market federally facilitated exchanges in 2018 using enrollment data from CMS. For all analyses, GAO used the latest data available.

For more information, contact John Dicken at (202) 512-7114 or dickenj@gao.gov.

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    A federal grand jury in the U.S. District Court in Denver, Colorado, returned a superseding indictment charging six additional defendants for their roles in a previously indicted conspiracy to fix prices and rig bids for broiler chicken products, and containing additional allegations against the previously charged defendants in the same conspiracy, the Department of Justice announced today.  The superseding indictment also charges one defendant with making false statements and obstruction of justice. 
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  • Trinidad and Tobago Travel Advisory
    In Travel
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  • Maryland Lawyer Charged with Defrauding Financial Institutions and Other Entities to Obtain Control over $12.5 Million of Somali Sovereign Assets
    In Crime News
    A Maryland lawyer was charged in an 11-count indictment for his alleged role in a scheme to fraudulently obtain control of more than $12.5 million that was held by financial institutions on behalf of the Somali government, to improperly take part of those funds for fees and expenses, and to launder a portion of those funds to accounts for the benefit of his co-conspirators.
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  • Doctor Sentenced for Role in Unlawful Distribution of Opioids
    In Crime News
    An Ohio physician was sentenced to two years in prison today for his role in illegally distributing opioids.
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  • Former Indiana State Senator and Gaming Executive Indicted for Violations of Federal Campaign Finance Laws
    In Crime News
    A federal grand jury sitting in the Southern District of Indiana returned an indictment charging a former Indiana state senator and a gaming executive with violations of federal campaign finance laws, false statements, and falsification of Federal Election Campaign (FEC) records in connection with a series of illegal corporate contributions and conduit contributions they made to fund the congressional campaign of the former state politician.
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  • Secretary Michael R. Pompeo With Mark Levin of The Mark Levin Show
    In Crime Control and Security News
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  • United States Announces New Humanitarian Assistance for Displaced Rohingya and Members of Other Affected Communities in Bangladesh and Burma
    In Human Health, Resources and Services
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  • Notice of Intent to Publish a Notice of Funding Opportunity Announcement for NGO Programs Benefiting Displaced Iraqis and Syrian Refugees
    In Human Health, Resources and Services
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  • South Carolina Couple Pleaded Guilty to Scheme Involving Conspiracy and False Statements to Illegally Obtain a U.S. Passport
    In Crime News
    A Huger, South Carolina couple pleaded guilty today in South Carolina before the U.S. District Judge Brucie H. Hendricks in the District of South Carolina to charges stemming from their conspiracy to obtain a U.S. passport by falsely claiming they were the biological parents of a baby born in the Philippines and by using false birth records to apply for a U.S. passport for the baby.
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  • The President’s National Space Policy
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  • Investment Professional and Author is Sentenced for Defrauding National Women’s Sorority
    In Crime News
    A Florida woman was sentenced to 24 months in prison today for her role in an investment management scheme.
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  • The U.S.’ Action Against Belarusian Individuals Involved in Efforts To Undermine Belarusian Democracy
    In Crime Control and Security News
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  • Information Technology: DOD Software Development Approaches and Cybersecurity Practices May Impact Cost and Schedule
    In U.S GAO News
    GAO reported in June 2020 that, of the 15 major Department of Defense (DOD) information technology (IT) programs selected for review, 11 had decreased their cost estimates as of December 2019. The decreases in cost estimates ranged from a .03 percent decrease to a 33.8 percent decrease. In contrast, the remaining four programs experienced increases in their life-cycle cost estimates—--two with increases exceeding 20 percent. Program officials reported several reasons for the increases, including testing delays and development challenges. Ten of the 15 programs had schedule delays when compared to their original acquisition program baselines. Schedule delays ranged from a delay of 1 month to a delay of 5 years. Program officials reported a variety of reasons for significant delays (delays of over 1 year) in their planned schedules, including cyber and performance issues. Regarding software development, officials from the 15 selected major IT programs that GAO reviewed reported using software development approaches that may help to limit risks to cost and schedule outcomes. For example, 10 of the 15 programs reported using commercial off-the-shelf software, which is consistent with DOD guidance to use this software to the extent practicable. Such software can help reduce software development time, allow for faster delivery, and lower life-cycle costs. In addition, 14 of the 15 programs reported using an iterative software development approach which, according to leading practices, may help reduce cost growth and deliver better results to the customer. However, programs also reported using an older approach to software development, known as waterfall, which could introduce risk for program cost growth because of its linear and sequential phases of development that may be implemented over a longer period of time. Specifically, two programs reported using a waterfall approach in conjunction with an iterative approach, while one was solely using a waterfall approach. With respect to cybersecurity, programs reported mixed implementation of specific practices, contributing to program risks that might impact cost and schedule outcomes. For example, all 15 programs reported developing cybersecurity strategies, which are intended to help ensure that programs are planning for and documenting cybersecurity risk management efforts. In contrast, only eight of the 15 programs reported conducting cybersecurity vulnerability assessments—systematic examinations of an information system or product intended to, among other things, determine the adequacy of security measures and identify security deficiencies. These eight programs experienced fewer increases in planned program costs and fewer schedule delays relative to the programs that did not report using cybersecurity vulnerability assessments. For fiscal year 2020, DOD requested approximately $36.1 billion for IT investments. Those investments included major IT programs, which are intended to help the department sustain key operations. The National Defense Authorization Act for Fiscal Year 2019 included a provision for GAO to assess selected IT programs annually through March 2023. GAO's objectives for this review were to, among other things, (1) describe the extent to which selected major IT programs have changed their planned costs and schedules since the programs' initial baselines; and (2) describe what selected software development and cybersecurity risks or challenges, if any, may impact major IT programs' acquisition outcomes. GAO selected programs based on DOD's list of major IT programs, as of April 10, 2019. From this list, GAO identified 15 major IT programs that had established an initial acquisition program baseline and that were not fully deployed by December 31, 2019. GAO compared the 15 programs' initial cost and schedule baselines to current acquisition program estimates. In addition, GAO aggregated DOD program office responses to a GAO questionnaire about software development approaches and cybersecurity practices used by the 15 programs. GAO compared this information to leading practices to identify risks and challenges affecting cost, schedule, and performance outcomes. This report is a public version of a “for official use only” report issued in June 2020. For more information, contact Kevin Walsh at (202) 512-6151 or walshk@gao.gov.
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  • Federal Contractor Agrees to Pay More Than $6 Million to Settle Overbilling Allegations
    In Crime News
    Virginia-based Information Innovators Inc. (Triple-I) has agreed to pay the United States $6.05 million to resolve allegations that a predecessor company, Creative Computing Solutions Inc. (CCSi), violated the False Claims Act by knowingly overbilling the U.S. Department of Homeland Security (DHS) for work performed by CCSi employees who lacked required job qualifications.
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  • Justice Department Files Disability Discrimination Lawsuit Against Village of Hinsdale, Illinois Under Fair Housing Act
    In Crime News
    The Justice Department today filed a lawsuit against the Village of Hinsdale, Illinois, alleging disability discrimination in violation of the Fair Housing Act.  
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  • Economic Adjustment Assistance: Actions Needed to Better Address Workers’ Needs and Assess Program Effectiveness
    In U.S GAO News
    Workers who are eligible for federal economic adjustment assistance (EAA) programs may face challenges using them. There are four EAA programs and one tax credit that focus on assistance to individual workers displaced by policy and economic changes. These include programs administered by the Appalachian Regional Commission (ARC) and Department of Labor (DOL), which deliver services such as job training and counseling through state and local grantees. Selected grantees in all three states GAO visited described common challenges faced by workers from enrollment in EAA programs through re-entry into the job market. Grantees Described Common Challenges Workers Face in Accessing and Using Economic Adjustment Assistance (EAA) Program Services Interviews with selected grantees and GAO's data analysis revealed two key challenges with administering EAA programs and serving workers: Delays in grant decisions. From fiscal years 2015 through 2018, DOL took longer than legally required to process between 9 percent (3 out of 35) and 20 percent (3 out of 15) of National Dislocated Worker Grant applications. Grantees may serve fewer workers and may interrupt services to workers while awaiting decisions. DOL does not collect information on reasons for these delays and is missing opportunities to help ensure that dislocated workers receive timely assistance. Lack of information sharing. ARC and DOL do not share information about their EAA grant programs with grantees or each other, including information about grant projects that serve similar populations in similar geographic areas. As a result, ARC and DOL may fail to maximize program impact and reach across the 13-state Appalachian region. Regional officials said that coordination would enable them to better identify specific services needed by dislocated workers and which program might best be equipped to provide them. DOL has established performance measures to track outcomes for its EAA programs, but has experienced challenges with assessing the impact of job training offered under these programs. GAO reviewed two relevant studies on the impact of DOL's EAA programs containing some evidence that intensive services, such as one-on-one consultations and case management, were effective in improving earnings outcomes for dislocated workers. However, the studies were unable to effectively assess the impact of job training offered to dislocated workers under the programs due to methodological challenges. By collecting more quality evidence, DOL could be better able to determine if its EAA programs are helping workers achieve their employment goals. Federal EAA programs help workers adjust to various economic disruptions, such as policy changes on trade, defense, or energy, and shifts in immigration, globalization, or automation that cause a prolonged cyclical downturn and can dislocate workers. GAO was asked to review these programs. This report examines (1) what challenges eligible workers face in using EAA programs, (2) what challenges grantees face in implementing EAA programs and serving workers, and (3) what is known about the outcomes and impacts of selected EAA programs. GAO analyzed DOL grant processing data from fiscal years 2015 through 2018, the most recent data available at the time of GAO's analysis; reviewed outcome data from program year 2018 and program impact evaluations; interviewed ARC, DOL, and Department of the Treasury officials, as well as state and local officials in three states that experienced different economic disruptions and use different EAA programs; and reviewed relevant federal laws, regulations, and guidance. GAO is making seven recommendations, including that DOL address grant processing delays, DOL and ARC share information, and DOL prioritize improving the quality of evidence on the impact of job training for dislocated workers. DOL and ARC agreed with GAO's recommendations. For more information, contact Cindy S. Brown Barnes at (202) 512-7215 or brownbarnesc@gao.gov.
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  • VA Health Care: Community Living Centers Were Commonly Cited for Infection Control Deficiencies Prior to the COVID-19 Pandemic
    In U.S GAO News
    The Department of Veterans Affairs (VA) is responsible for overseeing the quality of nursing home care provided to residents in VA-owned and -operated community living centers (CLC). VA models its oversight process on the methods used by the Centers for Medicare & Medicaid Services, which uses inspections of nursing homes to determine whether the home meets federal quality standards. These standards require, for example, that CLCs establish and maintain an infection prevention and control program. VA uses a contractor to conduct annual inspections of the CLCs, and these contractors cite CLCs with deficiencies if they are not in compliance with quality standards. Infection prevention and control deficiencies cited by the inspectors can include situations where CLC staff did not regularly use proper hand hygiene or failed to correctly use personal protective equipment. Many of these practices can be critical to preventing the spread of infectious diseases, including COVID-19. GAO analysis of VA data shows that infection prevention and control deficiencies were the most common type of deficiency cited in inspected CLCs, with 95 percent (128 of the 135 CLCs inspected) having an infection prevention and control deficiency cited in 1 or more years from fiscal year 2015 through 2019. GAO also found that over the time period of its review, a significant number of inspected CLCs—62 percent—had infection prevention and control deficiencies cited in consecutive fiscal years, which may indicate persistent problems. An additional 19 percent had such deficiencies cited in multiple, nonconsecutive years. Why GAO Did This Study COVID-19 is a new and highly contagious respiratory disease causing severe illness and death, particularly among the elderly. Because of this, the health and safety of the nation’s nursing home residents—including veterans receiving nursing home care in CLCs—has been a particular concern.  GAO was asked to review the quality of care at CLCs. In this report, GAO describes the prevalence of infection prevention and control deficiencies in CLCs prior to the COVID-19 pandemic. Future GAO reports will examine more broadly the quality of care at CLCs and VA’s response to COVID-19 in the nursing home settings for which VA provides or pays for care. For this report, GAO analyzed VA data on deficiencies cited in CLCs from fiscal years 2015 through 2019. Using these data, GAO determined the most common type of deficiency cited among CLCs, the number of CLCs that had infection prevention and control deficiencies cited, and the number of CLCs with repeated infection prevention and control deficiencies over the period from fiscal years 2015 through 2019. GAO also obtained and reviewed inspection reports and corrective action plans to describe examples of the infection prevention and control deficiencies cited at CLCs and the CLCs’ plans to remedy the noncompliance. For more information, contact Sharon M. Silas at (202) 512-7114 or SilasS@gao.gov.
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  • Justice Department Finds Yale Illegally Discriminates Against Asians and Whites in Undergraduate Admissions in Violation of Federal Civil-Rights Laws
    In Crime News
    The Department of Justice today notified Yale University of its findings that Yale illegally discriminates against Asian American and white applicants in its undergraduate admissions process in violation of Title VI of the 1964 Civil Rights Act. The findings are the result of a two-year investigation in response to a complaint by Asian American groups concerning Yale’s conduct.   
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  • Texas Man Pleads Guilty to Conspiracy to Provide Material Support to ISIS
    In Crime News
    In San Antonio today, 22-year-old Cost resident Jaylyn Christopher Molina, aka Abdur Rahim, admitted to conspiring to provide material support to the designated foreign terrorist organization Islamic State of Iraq and al-Sham/Syria (ISIS), announced Assistant Attorney General for National Security John C. Demers, U.S. Attorney for the Western District of Texas Gregg N. Sofer and FBI Special Agent in Charge of the San Antonio Division Christopher Combs.
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  • Joint Statement on Rocket Attacks in Erbil
    In Crime Control and Security News
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  • U.S. Trustee Program Announces Streamlined Forms for Completing Chapter 11 Financial Reports
    In Crime News
    The Department of Justice’s U.S. Trustee Program (USTP) announced today the publication of a final rule in the Federal Register that streamlines the financial reports required under the Bankruptcy Code to be filed with the bankruptcy court by the vast majority of business and individual debtors in chapter 11 bankruptcy, including in the largest reorganization cases.
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  • Woman First in the Nation Charged with Misappropriating Monies Designed for COVID Medical Provider Relief
    In Crime News
    A Michigan woman was indicted on allegations that she intentionally misappropriated government funds that were designed to aid medical providers in the treatment of patients suffering from COVID-19 and used them for her own personal expenses.
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  • Brunei National Day
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  • Statement by Attorney General William P. Barr on the 19th Anniversary of the September 11, 2001 Terrorist Attacks
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