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entitled 'Private Health Insurance: Concentration of Enrollees among 
Individual, Small Group, and Large Group Insurers from 2010 through 
2013' which was released on December 1, 2014. 

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GAO-14-101R: 

United States Government Accountability Office: 
GAO:
441 G St. N.W. 
Washington, DC 20548: 

December 1, 2014: 

Congressional Addressees: 

Private Health Insurance: Concentration of Enrollees among Individual, 
Small Group, and Large Group Insurers from 2010 through 2013: 

Millions of Americans obtain health coverage through private health 
plans, which include private health insurance sold in the individual 
and group insurance markets.[Footnote 1] Group health plans provided 
by both large and small employers are the leading source of health 
coverage in the United States. Specifically, in 2013, 58 percent of 
Americans under age 65 had health coverage through employer-sponsored 
group health plans.[Footnote 2] These employers may offer fully 
insured plans (by purchasing coverage from an insurance company) or 
self-funded plans (by setting aside funds to pay for employee health 
care). Most small employers purchase insured plans, while most large 
employers self-fund. Americans without access to group health 
insurance coverage, such as those with employers that do not offer 
health insurance coverage, may choose to purchase it directly from an 
insurer through the individual market. About 8 percent of Americans 
under age 65 had coverage through the individual market in 2013. 

Historically, there have been indications of high levels of 
concentration in the individual, small group, and large group markets-
-that is, markets in which a small number of insurers enroll a 
significant portion of the total number of beneficiaries. In a survey 
of the small group market, we previously found that the largest 
insurers increased their share of enrollment between 2002 and 2008, 
indicating that the small group market likely became more concentrated 
over time.[Footnote 3] For 2008, we found that the median share of 
enrollment for the largest insurer in the small group market across 
the states surveyed was about 47 percent, with a range of about 21 
percent in Arizona to about 96 percent in Alabama.[Footnote 4] More 
recent research has also identified high levels of market 
concentration. For example, an analysis based on 2010 data found the 
median share of enrollment held by the largest insurer in each state 
was 54 percent and 51 percent, respectively, for the individual and 
small group market segments.[Footnote 5] 

Several complex factors can affect concentration in these health 
insurance markets and the ability of new insurers to enter these 
markets.[Footnote 6] High concentration levels in health insurance 
markets have often been the result of consolidation--mergers and 
acquisitions--among existing insurers. In addition, concentration can 
persist because some factors may make it difficult for new insurers to 
enter the market. For example, new insurers that do not yet have large 
numbers of enrollees may have greater challenges negotiating discounts 
with providers. A highly concentrated market may indicate a less 
competitive market and could affect consumers' choice of health plans 
and their premiums. 

The Patient Protection and Affordable Care Act (PPACA), enacted in 
2010, contained a number of provisions that could affect market 
concentration and competition among health insurers.[Footnote 7] 
Specifically, the law required the establishment of health insurance 
exchanges--marketplaces where eligible individuals and small employers 
can compare and select among qualified insurance plans offered by 
participating private insurers--in each state by 2014.[Footnote 8] 
PPACA does not require insurers to offer plans through the individual 
and small group exchanges but instead, generally relies on market 
incentives to encourage their participation.[Footnote 9] In addition, 
PPACA required the establishment of the Consumer Operated and Oriented 
Plan (CO-OP) program, which provides loans to encourage new consumer-
governed, nonprofit insurers to offer health plans in the individual 
and small group exchanges.[Footnote 10] Other PPACA provisions may 
affect how health insurance companies compete. For example, PPACA 
established new rating rules that limit how much insurance companies 
can vary premiums charged for plans, as well as guaranteed issue 
requirements that prohibit insurers from denying coverage based on 
health status. 

PPACA also requires GAO to conduct an ongoing study on competition and 
market concentration in the health insurance market.[Footnote 11] For 
this study, we examined these markets prior to the implementation of 
key PPACA provisions that went into effect in 2014 and that could 
affect competition and market concentration among health insurers. 
Specifically, GAO examined (1) how enrollment in the individual, small 
group, and large group health insurance market segments in each state 
was distributed among insurers in 2013; and (2) how the concentration 
of insurers in the individual, small group, and large group health 
insurance market segments in each state changed from 2010 through 2013. 

To describe both how enrollment in the individual, small group, and 
large group health insurance market segments in each state was 
distributed among insurers in 2013, and how the concentration of 
insurers in these market segments in each state changed from 2010 
through 2013, we analyzed 2010 data reported by insurance companies to 
the National Association of Insurance Commissioners (NAIC), as well as 
2011 through 2013 data that PPACA requires insurers to report annually 
to the Department of Health and Human Services' (HHS) Centers for 
Medicare & Medicaid Services (CMS), beginning in 2011.[Footnote 12] 
Specifically, we identified the private health insurers that sold 
fully insured policies in each state's individual, small group, and 
large group markets.[Footnote 13] For both the NAIC and CMS data, 
insurers submitted data separately for each market segment and state 
in which they conducted business; these data were not submitted 
separately by health plan, product, or policy. We analyzed each 
insurer's enrollment share in each of the 51 states by calculating the 
total number of covered life-years.[Footnote 14] If there were 
multiple insurers in a state that shared a parent company, we 
aggregated the individual insurer data in order to determine the state-
wide experience of the parent company; otherwise, we analyzed the data 
by the individual insurers. For the individual, small group, and large 
group market segments in a state, we calculated the three-firm 
concentration ratio--the combined shares of covered life-years for the 
three largest insurers in each market segment. While states may have 
multiple local markets with differing concentrations of enrollees 
among health insurers, the data we used to measure this concentration 
by type of market segment are only available at the state level. 
Therefore, to make comparisons between state and local level estimates 
of concentration, we also analyzed a recent study by the American 
Medical Association (AMA). Although the AMA study does not report 
concentration by type of market segment, it does report concentration 
for Metropolitan Statistical Areas (MSA) within each state.[Footnote 
15] We assessed the reliability of the NAIC, CMS, and AMA data by 
reviewing documentation and discussing the data with knowledgeable 
officials. For the NAIC and CMS data, we analyzed the enrollment data 
as they were reported by insurers, and we did not independently verify 
the accuracy or completeness of the information. Also for the NAIC and 
CMS data, we performed data reliability checks, such as examining the 
data for missing values and obvious errors to test the internal 
consistency and reliability of the data. For analyses over time, we 
excluded data from California because the NAIC data did not include 
all insurers in that state. We did not assess the availability of 
insurers' health plans, products, or policy offerings, as these data 
were not submitted by insurers to NAIC and CMS. We assessed the 
reliability of the AMA data as it was reported in the study, and we 
did not independently verify the reliability of the original dataset 
used by AMA in its analysis. After taking these steps, we determined 
the data from each of these three sources were sufficiently reliable 
for our purposes. 

We conducted this performance audit from May 2014 to December 2014 in 
accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the 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. 

Results In Brief: 

We found that, while several insurers participated in each state's 
individual, small group, and large group health insurance markets in 
2013, enrollment was concentrated among the three largest insurers in 
most states. Specifically, in each of the three market segments, the 
three largest insurers had at least 80 percent of the total enrollment 
in at least 37 states. 

Further, these three market segments remained concentrated in most 
states from 2010 through 2013. Specifically, for each of these market 
segments, there were at least 30 states for which the three largest 
insurers had at least 80 percent of the total enrollment in each of 
the 4 years. 

We provided HHS with a draft of this report for review; it indicated 
that it had no comments. 

Enrollment in the Individual, Small Group, and Large Group Health 
Insurance Market Segments Was Concentrated among a Small Number of 
Insurers in Most States in 2013: 

While several insurers participated in each state's individual, small 
group, and large group health insurance markets in 2013, enrollment 
was concentrated among the three largest insurers in most states. On 
average in each state, there were several insurers participating, with 
about twice as many insurers participating in the individual market 
(24) as the small group (12) and large group (11) markets.[Footnote 
16] (See enclosure 2 for state-by-state trends.) However, in each of 
the three market segments, the three largest insurers had at least 80 
percent of the total enrollment in at least 37 states.[Footnote 17] 
(See the interactive map in figure 1.) Further, in more than half of 
these states, a single insurer had more than half of the total 
enrollees and in 5 of these states there was at least one market 
segment in which the largest insurer had at least 90 percent of all 
the enrollees. For example, in Alabama's small group market, the 
largest insurer--Blue Cross and Blue Shield of Alabama--had 97 percent 
of the total enrollment in the state. 

The interactive map can be accessed here: [hyperlink, 
http://www.gao.gov/products/GAO-15-101R]. 

Figure 1: Enrollment Share for the Three Largest Insurers, Name and 
Enrollment Share for the Largest Insurer, and Total Number of Insurers 
by State and Market Segment, 2013: 

[Refer to PDF for image: 3 illustrated U.S. maps] 

Individual; 
Small group; 
Large group. 

Enrollment share for the three largest insurers in each state: 
90% to 100%; 
80% to less than 90%; 
Less than 80%. 

Sources: GAO analysis of 2013 Medical Loss Ratio data from the Centers 
for Medicare & Medicaid Services. (data); Map Resources (map). 
GAO-15-101R. 

Notes: We measured enrollment share using covered life-years, which 
represent the average number of lives insured, including dependents, 
on a pre-specified day over the 12 months in the reporting year. 

[End of figure] 

In the remaining states, more insurers participated and the market 
segments were less concentrated, with enrollment spread out among more 
insurers. Specifically, in 12 states' individual markets, 14 states' 
small group markets, and 11 states' large group markets, the 3 largest 
insurers held less than 80 percent of the total enrollment. On average 
in each state, there were 30 insurers in the individual market, 16 in 
the small group market, and 17 in the large group market. In nearly 
all of these states' market segments, the largest insurer had less 
than half of the total enrollment. For example, in Wisconsin's large 
group market, the 3 largest insurers had 39 percent of the total 
enrollees in the state, and the largest of these insurers had 15 
percent of the total enrollees. 

While this report examines the concentration of enrollment at the 
state level, concentration can vary within a state. According to 2011 
data reported by AMA, which did not differentiate by market segment, 
the largest insurer in most states was also the largest insurer in at 
least three-quarters of the MSAs in that state. In the other states, 
the largest insurer varied across the MSAs. Specifically, insurers 
sometimes offer health plans that are only available in certain 
geographic areas, rather than statewide. For example, in Pennsylvania, 
the largest insurer in one MSA did not operate in all MSAs in the 
state and, therefore, was not the largest insurer in the state. 

The Individual, Small Group, and Large Group Health Insurance Market 
Segments in Most States Remained Concentrated from 2010 through 2013: 

In most states, the individual, small group, and large group markets 
remained concentrated from 2010 through 2013. Specifically, for each 
of these market segments, there were at least 30 states for which the 
three largest insurers had at least 80 percent of the total enrollment 
in each of the 4 years.[Footnote 18] For example, the largest three 
insurers had at least 80 percent of total enrollment in 30 states, 34 
states, and 38 states respectively in the individual, small group, and 
large group markets in 2010. In each market segment, the number of 
such states increased by 2013.[Footnote 19] The individual market 
increased to 38 states by 2013. While the small group and large group 
markets also increased overall by 2013, to 37 states and 40 states, 
respectively, each had a small decrease between 2012 and 2013. (See 
figure 2 for state counts and see enclosure 3 for state-by-state data.) 

Figure 2: The Number of States Where the Enrollment Share for the Top 
Three Insurers Was at Least 80 Percent, by Market Segment 2010-2013: 

[Refer to PDF for image: 3 vertical bar graphs] 

Individual: States where top 3 insurers' share was at least 80 percent: 

Year: 2010; 
Total number of states reviewed[A]: 30. 

Year: 2011; 
Total number of states reviewed[A]: 33. 

Year: 2012; 
Total number of states reviewed[A]: 36. 

Year: 2013; 
Total number of states reviewed[A]: 38. 

Small group: States where top 3 insurers' share was at least 80 
percent: 

Year: 2010; 
Total number of states reviewed[A]: 34. 

Year: 2011; 
Total number of states reviewed[A]: 36. 

Year: 2012; 
Total number of states reviewed[A]: 38. 

Year: 2013; 
Total number of states reviewed[A]: 37. 

Large group: States where top 3 insurers' share was at least 80 
percent: 

Year: 2010; 
Total number of states reviewed[A]: 38. 

Year: 2011; 
Total number of states reviewed[A]: 40. 

Year: 2012; 
Total number of states reviewed[A]: 41. 

Year: 2013; 
Total number of states reviewed[A]: 40. 

Source: GAO analysis of 2010 Supplemental Health Care Exhibit data 
from the National Association of Insurance Commissioners and 2011 
through 2013 Medical Loss Ratio data from the Centers for Medicare & 
Medicaid Services. GAO-15-101R. 

Note: We measured the enrollment share of the three largest insurers 
using covered life-years, which represent the average number of lives 
insured, including dependents, on a pre-specified day over the 12 
months in the reporting year. 

[A] We excluded data from California from all years because the 
National Association of Insurance Commissioners' 2010 data for this 
state did not include all insurers. 

[End of figure] 

We also examined the companies that comprised the largest insurers in 
each state and found that, in addition to having at least half of the 
enrollment in most states from 2010 through 2013, these same companies 
generally remained the top insurers during the time period.[Footnote 
20] Specifically, of the 50 states we analyzed, the largest insurer 
remained the same in 43 states in the individual market, 41 states in 
the small group market, and 43 states in the large group market. For 
example, in Iowa's small group market, the largest insurer--Wellmark 
Group--had at least 61 percent of the total enrollees from 2010 
through 2013. In addition, in most of the states where the largest 
insurer did not remain the same, the largest insurer generally had 
less than half of the total enrollees. For example, in Washington's 
individual market, the largest insurer in 2010 and 2011--Regence 
Group--had 45 percent and 37 percent of the total enrollees in the 
state, respectively. Premera Blue Cross Group replaced Regence Group 
as the largest insurer in 2012 and 2013 and had 40 percent and 39 
percent of the total enrollees in the state, respectively, in each 
year. (See enclosure 4 for state-by-state trends.) 

We also found that a Blue Cross and Blue Shield insurer was the 
largest insurer in most states in each of the market segments from 
2010 through 2013.[Footnote 21] Specifically, a Blue Cross and Blue 
Shield insurer was consistently the largest insurer in 44 states in 
the individual market, 38 states in the small group market, and 40 
states in the large group market across the time period. 

Agency Comments: 

We provided HHS with a draft of this report for review; it indicated 
that it had no comments. 

We are sending copies of this report to 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 [hyperlink, 
http://www.gao.gov]. If you or your staffs have any questions about 
this information, please contact me 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 who made key contributions to this report were 
William D. Hadley, Assistant Director; Laura Sutton Elsberg; Sandra 
George; Giselle Hicks; Sarah-Lynn McGrath; Laurie Pachter; and Vikki 
Porter. 

Signed by: 

John E. Dicken: 
Director, Health Care: 

Enclosures - 4: 

List of Addressees: 

The Honorable Tom Harkin: 
Chairman: 
The Honorable Lamar Alexander: 
Ranking Member: 
Committee on Health, Education, Labor, and Pensions: 
United States Senate: 

The Honorable Ron Wyden: 
Chairman: 
The Honorable Orrin G. Hatch: 
Ranking Member: 
Committee on Finance: 
United States Senate: 

The Honorable Fred Upton: 
Chairman: 
The Honorable Henry Waxman: 
Ranking Member: 
Committee on Energy and Commerce: 
House of Representatives: 

The Honorable John Kline: 
Chairman: 
The Honorable George Miller: 
Ranking Member: 
Committee on Education and the Workforce: 
House of Representatives: 

The Honorable Dave Camp: 
Chairman: 
The Honorable Sander Levin: 
Ranking Member: 
Committee on Ways and Means: 
House of Representatives: 

[End of section] 

Enclosure 1: Total Covered Life-Years by State in the Individual, 
Small Group, and Large Group Markets, 2013: 

State: Alabama; 
Individual: 174,370; 
Small group: 292,186; 
Large group: 491,750. 

State: Alaska; 
Individual: 14,917; 
Small group: 32,855; 
Large group: 49,487. 

State: Arizona; 
Individual: 270,470; 
Small group: 208,312; 
Large group: 547,992. 

State: Arkansas; 
Individual: 114,367; 
Small group: 133,682; 
Large group: 202,449. 

State: California; 
Individual: 1,571,566; 
Small group: 2,182,529; 
Large group: 11,170,956. 

State: Colorado; 
Individual: 275,631; 
Small group: 243,530; 
Large group: 688,456. 

State: Connecticut; 
Individual: 119,528; 
Small group: 226,684; 
Large group: 402,343. 

State: Delaware; 
Individual: 20,951; 
Small group: 47,530; 
Large group: 89,853. 

State: District of Columbia; 
Individual: 19,755; 
Small group: 86,054; 
Large group: 803,704. 

State: Florida; 
Individual: 854,167; 
Small group: 782,577; 
Large group: 1,848,192. 

State: Georgia; 
Individual: 353,593; 
Small group: 482,737; 
Large group: 830,215. 

State: Hawaii; 
Individual: 28,353; 
Small group: 148,481; 
Large group: 654,842. 

State: Idaho; 
Individual: 95,574; 
Small group: 86,882; 
Large group: 231,540. 

State: Illinois; 
Individual: 461,044; 
Small group: 629,598; 
Large group: 2,110,423. 

State: Indiana; 
Individual: 174,155; 
Small group: 326,423; 
Large group: 365,273. 

State: Iowa; 
Individual: 180,758; 
Small group: 159,174; 
Large group: 351,064. 

State: Kansas; 
Individual: 124,520; 
Small group: 192,966; 
Large group: 398,922. 

State: Kentucky; 
Individual: 131,663; 
Small group: 175,900; 
Large group: 376,001. 

State: Louisiana; 
Individual: 173,641; 
Small group: 276,836; 
Large group: 357,172. 

State: Maine; 
Individual: 32,855; 
Small group: 76,652; 
Large group: 189,564. 

State: Maryland; 
Individual: 188,624; 
Small group: 320,665; 
Large group: 945,595. 

State: Massachusetts; 
Individual: 88,546; 
Small group: 556,772; 
Large group: 1,263,142. 

State: Michigan; 
Individual: 339,410; 
Small group: 591,713; 
Large group: 1,950,458. 

State: Minnesota; 
Individual: 254,372; 
Small group: 315,473; 
Large group: 720,744. 

State: Mississippi; 
Individual: 83,244; 
Small group: 112,774; 
Large group: 197,304. 

State: Missouri; 
Individual: 257,861; 
Small group: 303,705; 
Large group: 708,075. 

State: Montana; 
Individual: 48,023; 
Small group: 54,937; 
Large group: 83,833. 

State: Nebraska; 
Individual: 124,966; 
Small group: 95,023; 
Large group: 209,633. 

State: Nevada; 
Individual: 94,882; 
Small group: 104,027; 
Large group: 402,033. 

State: New Hampshire; 
Individual: 36,192; 
Small group: 82,925; 
Large group: 147,505. 

State: New Jersey; 
Individual: 177,955; 
Small group: 646,930; 
Large group: 1,034,253. 

State: New Mexico; 
Individual: 58,879; 
Small group: 56,726; 
Large group: 169,347. 

State: New York; 
Individual: 248,495; 
Small group: 1,376,783; 
Large group: 6,084,031. 

State: North Carolina; 
Individual: 473,565; 
Small group: 309,032; 
Large group: 589,287. 

State: North Dakota; 
Individual: 45,937; 
Small group: 70,287; 
Large group: 155,103. 

State: Ohio; 
Individual: 330,315; 
Small group: 884,544; 
Large group: 959,784. 

State: Oklahoma; 
Individual: 122,598; 
Small group: 185,376; 
Large group: 488,160. 

State: Oregon; 
Individual: 167,095; 
Small group: 222,870; 
Large group: 685,508. 

State: Pennsylvania; 
Individual: 463,591; 
Small group: 884,908; 
Large group: 2,149,143. 

State: Rhode Island; 
Individual: 18,300; 
Small group: 78,838; 
Large group: 179,025. 

State: South Carolina; 
Individual: 129,263; 
Small group: 126,408; 
Large group: 332,032. 

State: South Dakota; 
Individual: 65,951; 
Small group: 50,790; 
Large group: 107,063. 

State: Tennessee; 
Individual: 243,526; 
Small group: 329,491; 
Large group: 496,229. 

State: Texas; 
Individual: 746,168; 
Small group: 1,293,831; 
Large group: 1,821,661. 

State: Utah; 
Individual: 140,289; 
Small group: 239,979; 
Large group: 444,548. 

State: Vermont; 
Individual: 20,291; 
Small group: 57,661; 
Large group: 73,718. 

State: Virginia; 
Individual: 319,580; 
Small group: 431,183; 
Large group: 1,423,171. 

State: Washington; 
Individual: 269,757; 
Small group: 268,282; 
Large group: 1,190,643. 

State: West Virginia; 
Individual: 28,061; 
Small group: 68,571; 
Large group: 133,181. 

State: Wisconsin; 
Individual: 161,048; 
Small group: 390,883; 
Large group: 985,288. 

State: Wyoming; 
Individual: 21,852; 
Small group: 24,087; 
Large group: 32,641. 

State: Total covered life-years; 
Individual: 10,960,513; 
Small group: 17,327,059; 
Large group: 48,322,334. 

Source: GAO analysis of 2013 Medical Loss Ratio data from the Centers 
for Medicare & Medicaid Services. GAO-15-101R. 

Notes: Covered life-years represent the average number of lives 
insured, including dependents, on a pre-specified day over the 12 
months in the reporting year. State covered life-years may not add to 
total due to rounding. 

[End of table] 

[End of section] 

Enclosure 2: Number of Insurers by State in the Individual, Small 
Group, and Large Group Markets, 2013: 

State: Alabama; 
Individual: 23; 
Small group: 8; 
Large group: 7. 

State: Alaska; 
Individual: 14; 
Small group: 6; 
Large group: 5. 

State: Arizona; 
Individual: 24; 
Small group: 12; 
Large group: 12. 

State: Arkansas; 
Individual: 24; 
Small group: 11; 
Large group: 9. 

State: California; 
Individual: 30; 
Small group: 22; 
Large group: 24. 

State: Colorado; 
Individual: 25; 
Small group: 9; 
Large group: 10. 

State: Connecticut; 
Individual: 19; 
Small group: 7; 
Large group: 5. 

State: Delaware; 
Individual: 16; 
Small group: 8; 
Large group: 6. 

State: District of Columbia; 
Individual: 18; 
Small group: 6; 
Large group: 6. 

State: Florida; 
Individual: 31; 
Small group: 14; 
Large group: 12. 

State: Georgia; 
Individual: 31; 
Small group: 20; 
Large group: 16. 

State: Hawaii; 
Individual: 12; 
Small group: 6; 
Large group: 7. 

State: Idaho; 
Individual: 19; 
Small group: 11; 
Large group: 9. 

State: Illinois; 
Individual: 34; 
Small group: 21; 
Large group: 18. 

State: Indiana; 
Individual: 28; 
Small group: 24; 
Large group: 19. 

State: Iowa; 
Individual: 25; 
Small group: 15; 
Large group: 14. 

State: Kansas; 
Individual: 28; 
Small group: 13; 
Large group: 13. 

State: Kentucky; 
Individual: 23; 
Small group: 9; 
Large group: 8. 

State: Louisiana; 
Individual: 26; 
Small group: 11; 
Large group: 10. 

State: Maine; 
Individual: 18; 
Small group: 5; 
Large group: 5. 

State: Maryland; 
Individual: 23; 
Small group: 8; 
Large group: 6. 

State: Massachusetts; 
Individual: 28; 
Small group: 13; 
Large group: 11. 

State: Michigan; 
Individual: 33; 
Small group: 24; 
Large group: 24. 

State: Minnesota; 
Individual: 26; 
Small group: 9; 
Large group: 11. 

State: Mississippi; 
Individual: 22; 
Small group: 8; 
Large group: 8. 

State: Missouri; 
Individual: 31; 
Small group: 17; 
Large group: 15. 

State: Montana; 
Individual: 21; 
Small group: 8; 
Large group: 7. 

State: Nebraska; 
Individual: 26; 
Small group: 12; 
Large group: 9. 

State: Nevada; 
Individual: 21; 
Small group: 14; 
Large group: 13. 

State: New Hampshire; 
Individual: 15; 
Small group: 6; 
Large group: 6. 

State: New Jersey; 
Individual: 20; 
Small group: 6; 
Large group: 8. 

State: New Mexico; 
Individual: 22; 
Small group: 7; 
Large group: 7. 

State: New York; 
Individual: 28; 
Small group: 14; 
Large group: 15. 

State: North Carolina; 
Individual: 25; 
Small group: 13; 
Large group: 11. 

State: North Dakota; 
Individual: 19; 
Small group: 6; 
Large group: 8. 

State: Ohio; 
Individual: 34; 
Small group: 25; 
Large group: 18. 

State: Oklahoma; 
Individual: 25; 
Small group: 15; 
Large group: 12. 

State: Oregon; 
Individual: 25; 
Small group: 8; 
Large group: 11. 

State: Pennsylvania; 
Individual: 36; 
Small group: 19; 
Large group: 18. 

State: Rhode Island; 
Individual: 13; 
Small group: 3; 
Large group: 4. 

State: South Carolina; 
Individual: 22; 
Small group: 12; 
Large group: 10. 

State: South Dakota; 
Individual: 25; 
Small group: 11; 
Large group: 12. 

State: Tennessee; 
Individual: 26; 
Small group: 14; 
Large group: 9. 

State: Texas; 
Individual: 36; 
Small group: 23; 
Large group: 22. 

State: Utah; 
Individual: 19; 
Small group: 12; 
Large group: 14. 

State: Vermont; 
Individual: 12; 
Small group: 3; 
Large group: 4. 

State: Virginia; 
Individual: 29; 
Small group: 17; 
Large group: 16. 

State: Washington; 
Individual: 25; 
Small group: 13; 
Large group: 12. 

State: West Virginia; 
Individual: 24; 
Small group: 12; 
Large group: 11. 

State: Wisconsin; 
Individual: 35; 
Small group: 24; 
Large group: 27. 

State: Wyoming; 
Individual: 21; 
Small group: 7; 
Large group: 7. 

State: Average number of insurers; 
Individual: 24; 
Small group: 12; 
Large group: 11. 

Source: GAO analysis of 2013 Medical Loss Ratio data from the Centers 
for Medicare & Medicaid Services. GAO-15-101R. 

[End of table] 

[End of section] 

Enclosure 3: Share of Enrollment for the Largest Three Insurers by 
State in the Individual, Small Group, and Large Group Markets from 
2010 through 2013: 

Below are three tables that show the share of enrollment for the 
largest three insurers in each state in the individual, small group, 
and large group markets from 2010 through 2013. 

Table 1: Share of Enrollment for the Largest Three Insurers by State 
in the Individual Market, 2010 through 2013: 

State: Alabama; 
Share of enrollment for the largest three insurers (%): 
2010: 94; 
2011: 97; 
2012: 98; 
2013: 98. 

State: Alaska; 
Share of enrollment for the largest three insurers (%): 
2010: 77; 
2011: 76; 
2012: 79; 
2013: 82. 

State: Arizona; 
Share of enrollment for the largest three insurers (%): 
2010: 75; 
2011: 77; 
2012: 80; 
2013: 80. 

State: Arkansas; 
Share of enrollment for the largest three insurers (%): 
2010: 89; 
2011: 91; 
2012: 94; 
2013: 94. 

State: California[A]; 
Share of enrollment for the largest three insurers (%): 
2010: [Empty]; 
2011: 78; 
2012: 87; 
2013: 84. 

State: Colorado; 
Share of enrollment for the largest three insurers (%): 
2010: 54; 
2011: 53; 
2012: 57; 
2013: 59. 

State: Connecticut; 
Share of enrollment for the largest three insurers (%): 
2010: 85; 
2011: 84; 
2012: 84; 
2013: 85. 

State: Delaware; 
Share of enrollment for the largest three insurers (%): 
2010: 88; 
2011: 85; 
2012: 83; 
2013: 92. 

State: District of Columbia; 
Share of enrollment for the largest three insurers (%): 
2010: 89; 
2011: 88; 
2012: 90; 
2013: 92. 

State: Florida; 
Share of enrollment for the largest three insurers (%): 
2010: 74; 
2011: 73; 
2012: 74; 
2013: 73. 

State: Georgia; 
Share of enrollment for the largest three insurers (%): 
2010: 74; 
2011: 68; 
2012: 70; 
2013: 70. 

State: Hawaii; 
Share of enrollment for the largest three insurers (%): 
2010: 100; 
2011: 99; 
2012: 99; 
2013: 99. 

State: Idaho; 
Share of enrollment for the largest three insurers (%): 
2010: 86; 
2011: 93; 
2012: 94; 
2013: 93. 

State: Illinois; 
Share of enrollment for the largest three insurers (%): 
2010: 77; 
2011: 79; 
2012: 82; 
2013: 83. 

State: Indiana; 
Share of enrollment for the largest three insurers (%): 
2010: 84; 
2011: 82; 
2012: 84; 
2013: 85. 

State: Iowa; 
Share of enrollment for the largest three insurers (%): 
2010: 92; 
2011: 92; 
2012: 92; 
2013: 95. 

State: Kansas; 
Share of enrollment for the largest three insurers (%): 
2010: 74; 
2011: 76; 
2012: 78; 
2013: 81. 

State: Kentucky; 
Share of enrollment for the largest three insurers (%): 
2010: 97; 
2011: 96; 
2012: 98; 
2013: 97. 

State: Louisiana; 
Share of enrollment for the largest three insurers (%): 
2010: 87; 
2011: 85; 
2012: 90; 
2013: 91. 

State: Maine; 
Share of enrollment for the largest three insurers (%): 
2010: 98; 
2011: 92; 
2012: 98; 
2013: 98. 

State: Maryland; 
Share of enrollment for the largest three insurers (%): 
2010: 90; 
2011: 89; 
2012: 89; 
2013: 92. 

State: Massachusetts; 
Share of enrollment for the largest three insurers (%): 
2010: 87; 
2011: 88; 
2012: 79; 
2013: 77. 

State: Michigan; 
Share of enrollment for the largest three insurers (%): 
2010: 78; 
2011: 77; 
2012: 77; 
2013: 77. 

State: Minnesota; 
Share of enrollment for the largest three insurers (%): 
2010: 86; 
2011: 85; 
2012: 87; 
2013: 87. 

State: Mississippi; 
Share of enrollment for the largest three insurers (%): 
2010: 78; 
2011: 83; 
2012: 88; 
2013: 89. 

State: Missouri; 
Share of enrollment for the largest three insurers (%): 
2010: 66; 
2011: 69; 
2012: 72; 
2013: 72. 

State: Montana; 
Share of enrollment for the largest three insurers (%): 
2010: 84; 
2011: 85; 
2012: 90; 
2013: 90. 

State: Nebraska; 
Share of enrollment for the largest three insurers (%): 
2010: 87; 
2011: 88; 
2012: 90; 
2013: 91. 

State: Nevada; 
Share of enrollment for the largest three insurers (%): 
2010: 84; 
2011: 83; 
2012: 86; 
2013: 91. 

State: New Hampshire; 
Share of enrollment for the largest three insurers (%): 
2010: 93; 
2011: 93; 
2012: 96; 
2013: 97. 

State: New Jersey; 
Share of enrollment for the largest three insurers (%): 
2010: 98; 
2011: 90; 
2012: 95; 
2013: 95. 

State: New Mexico; 
Share of enrollment for the largest three insurers (%): 
2010: 91; 
2011: 90; 
2012: 91; 
2013: 92. 

State: New York; 
Share of enrollment for the largest three insurers (%): 
2010: 71; 
2011: 56; 
2012: 57; 
2013: 60. 

State: North Carolina; 
Share of enrollment for the largest three insurers (%): 
2010: 90; 
2011: 90; 
2012: 92; 
2013: 93. 

State: North Dakota; 
Share of enrollment for the largest three insurers (%): 
2010: 94; 
2011: 90; 
2012: 90; 
2013: 93. 

State: Ohio; 
Share of enrollment for the largest three insurers (%): 
2010: 71; 
2011: 80; 
2012: 84; 
2013: 84. 

State: Oklahoma; 
Share of enrollment for the largest three insurers (%): 
2010: 81; 
2011: 79; 
2012: 86; 
2013: 88. 

State: Oregon; 
Share of enrollment for the largest three insurers (%): 
2010: 66; 
2011: 65; 
2012: 63; 
2013: 62. 

State: Pennsylvania; 
Share of enrollment for the largest three insurers (%): 
2010: 74; 
2011: 72; 
2012: 69; 
2013: 74. 

State: Rhode Island; 
Share of enrollment for the largest three insurers (%): 
2010: 100; 
2011: 100; 
2012: 100; 
2013: 99. 

State: South Carolina; 
Share of enrollment for the largest three insurers (%): 
2010: 78; 
2011: 80; 
2012: 82; 
2013: 82. 

State: South Dakota; 
Share of enrollment for the largest three insurers (%): 
2010: 86; 
2011: 89; 
2012: 89; 
2013: 90. 

State: Tennessee; 
Share of enrollment for the largest three insurers (%): 
2010: 75; 
2011: 80; 
2012: 83; 
2013: 81. 

State: Texas; 
Share of enrollment for the largest three insurers (%): 
2010: 72; 
2011: 74; 
2012: 77; 
2013: 79. 

State: Utah; 
Share of enrollment for the largest three insurers (%): 
2010: 82; 
2011: 86; 
2012: 88; 
2013: 88. 

State: Vermont; 
Share of enrollment for the largest three insurers (%): 
2010: 100; 
2011: 99; 
2012: 99; 
2013: 100. 

State: Virginia; 
Share of enrollment for the largest three insurers (%): 
2010: 86; 
2011: 86; 
2012: 89; 
2013: 89. 

State: Washington; 
Share of enrollment for the largest three insurers (%): 
2010: 92; 
2011: 96; 
2012: 96; 
2013: 95. 

State: West Virginia; 
Share of enrollment for the largest three insurers (%): 
2010: 78; 
2011: 78; 
2012: 85; 
2013: 87. 

State: Wisconsin; 
Share of enrollment for the largest three insurers (%): 
2010: 56; 
2011: 59; 
2012: 60; 
2013: 65. 

State: Wyoming; 
Share of enrollment for the largest three insurers (%): 
2010: 74; 
2011: 71; 
2012: 72; 
2013: 71. 

State: Average; 
Share of enrollment for the largest three insurers (%): 
2010: 83; 
2011: 83; 
2012: 85; 
2013: 86. 

Source: GAO analysis of 2010 Supplemental Health Care Exhibit data 
from the National Association of Insurance Commissioners and 2011 
through 2013 Medical Loss Ratio data from the Centers for Medicare & 
Medicaid Services. GAO-15-101R. 

Notes: We measured enrollment using covered life-years, which 
represent the average number of lives insured, including dependents, 
on a pre-specified day over the 12 months in the reporting year. 

[A] We excluded 2010 data for California because the National 
Association of Insurance Commissioners' data for this state did not 
include all insurers in this year. 

[End of table] 

Table 2: Share of Enrollment for the Largest Three Insurers by State 
in the Small Group Market, 2010 through 2013: 

State: Alabama; 
Share of enrollment for the largest three insurers (%): 
2010: 99; 
2011: 100; 
2012: 100; 
2013: 100. 

State: Alaska; 
Share of enrollment for the largest three insurers (%): 
2010: 88; 
2011: 87; 
2012: 89; 
2013: 88. 

State: Arizona; 
Share of enrollment for the largest three insurers (%): 
2010: 72; 
2011: 66; 
2012: 67; 
2013: 69. 

State: Arkansas; 
Share of enrollment for the largest three insurers (%): 
2010: 92; 
2011: 95; 
2012: 97; 
2013: 98. 

State: California[A]; 
Share of enrollment for the largest three insurers (%): 
2010: [Empty]; 
2011: 63; 
2012: 76; 
2013: 75. 

State: Colorado; 
Share of enrollment for the largest three insurers (%): 
2010: 75; 
2011: 81; 
2012: 82; 
2013: 81. 

State: Connecticut; 
Share of enrollment for the largest three insurers (%): 
2010: 80; 
2011: 83; 
2012: 85; 
2013: 84. 

State: Delaware; 
Share of enrollment for the largest three insurers (%): 
2010: 97; 
2011: 95; 
2012: 97; 
2013: 97. 

State: District of Columbia; 
Share of enrollment for the largest three insurers (%): 
2010: 96; 
2011: 94; 
2012: 96; 
2013: 96. 

State: Florida; 
Share of enrollment for the largest three insurers (%): 
2010: 87; 
2011: 80; 
2012: 82; 
2013: 84. 

State: Georgia; 
Share of enrollment for the largest three insurers (%): 
2010: 73; 
2011: 69; 
2012: 65; 
2013: 66. 

State: Hawaii; 
Share of enrollment for the largest three insurers (%): 
2010: 94; 
2011: 83; 
2012: 87; 
2013: 85. 

State: Idaho; 
Share of enrollment for the largest three insurers (%): 
2010: 95; 
2011: 96; 
2012: 96; 
2013: 94. 

State: Illinois; 
Share of enrollment for the largest three insurers (%): 
2010: 80; 
2011: 81; 
2012: 84; 
2013: 86. 

State: Indiana; 
Share of enrollment for the largest three insurers (%): 
2010: 73; 
2011: 76; 
2012: 77; 
2013: 80. 

State: Iowa; 
Share of enrollment for the largest three insurers (%): 
2010: 90; 
2011: 90; 
2012: 94; 
2013: 91. 

State: Kansas; 
Share of enrollment for the largest three insurers (%): 
2010: 81; 
2011: 81; 
2012: 84; 
2013: 79. 

State: Kentucky; 
Share of enrollment for the largest three insurers (%): 
2010: 98; 
2011: 93; 
2012: 94; 
2013: 95. 

State: Louisiana; 
Share of enrollment for the largest three insurers (%): 
2010: 93; 
2011: 95; 
2012: 96; 
2013: 97. 

State: Maine; 
Share of enrollment for the largest three insurers (%): 
2010: 98; 
2011: 98; 
2012: 98; 
2013: 99. 

State: Maryland; 
Share of enrollment for the largest three insurers (%): 
2010: 96; 
2011: 91; 
2012: 91; 
2013: 95. 

State: Massachusetts; 
Share of enrollment for the largest three insurers (%): 
2010: 83; 
2011: 81; 
2012: 83; 
2013: 82. 

State: Michigan; 
Share of enrollment for the largest three insurers (%): 
2010: 74; 
2011: 81; 
2012: 80; 
2013: 79. 

State: Minnesota; 
Share of enrollment for the largest three insurers (%): 
2010: 88; 
2011: 84; 
2012: 90; 
2013: 91. 

State: Mississippi; 
Share of enrollment for the largest three insurers (%): 
2010: 93; 
2011: 97; 
2012: 98; 
2013: 98. 

State: Missouri; 
Share of enrollment for the largest three insurers (%): 
2010: 71; 
2011: 78; 
2012: 79; 
2013: 78. 

State: Montana; 
Share of enrollment for the largest three insurers (%): 
2010: 87; 
2011: 90; 
2012: 88; 
2013: 91. 

State: Nebraska; 
Share of enrollment for the largest three insurers (%): 
2010: 80; 
2011: 89; 
2012: 91; 
2013: 88. 

State: Nevada; 
Share of enrollment for the largest three insurers (%): 
2010: 76; 
2011: 73; 
2012: 73; 
2013: 76. 

State: New Hampshire; 
Share of enrollment for the largest three insurers (%): 
2010: 97; 
2011: 99; 
2012: 99; 
2013: 99. 

State: New Jersey; 
Share of enrollment for the largest three insurers (%): 
2010: 94; 
2011: 92; 
2012: 90; 
2013: 87. 

State: New Mexico; 
Share of enrollment for the largest three insurers (%): 
2010: 82; 
2011: 87; 
2012: 89; 
2013: 88. 

State: New York; 
Share of enrollment for the largest three insurers (%): 
2010: 68; 
2011: 67;
2012: 70; 
2013: 74. 

State: North Carolina; 
Share of enrollment for the largest three insurers (%): 
2010: 95; 
2011: 95; 
2012: 95; 
2013: 93. 

State: North Dakota; 
Share of enrollment for the largest three insurers (%): 
2010: 100; 
2011: 99; 
2012: 98; 
2013: 98. 

State: Ohio; 
Share of enrollment for the largest three insurers (%): 
2010: 70; 
2011: 78; 
2012: 80; 
2013: 81. 

State: Oklahoma; 
Share of enrollment for the largest three insurers (%): 
2010: 74; 
2011: 76; 
2012: 81; 
2013: 88. 

State: Oregon; 
Share of enrollment for the largest three insurers (%): 
2010: 60; 
2011: 60; 
2012: 60; 
2013: 56. 

State: Pennsylvania; 
Share of enrollment for the largest three insurers (%): 
2010: 73; 
2011: 57; 
2012: 55; 
2013: 55. 

State: Rhode Island; 
Share of enrollment for the largest three insurers (%): 
2010: 99; 
2011: 99; 
2012: 100; 
2013: 100. 

State: South Carolina; 
Share of enrollment for the largest three insurers (%): 
2010: 90; 
2011: 90; 
2012: 89; 
2013: 89. 

State: South Dakota; 
Share of enrollment for the largest three insurers (%): 
2010: 91; 
2011: 90; 
2012: 91; 
2013: 90. 

State: Tennessee; 
Share of enrollment for the largest three insurers (%): 
2010: 95; 
2011: 95; 
2012: 96; 
2013: 95. 

State: Texas; 
Share of enrollment for the largest three insurers (%): 
2010: 77; 
2011: 80; 
2012: 85; 
2013: 87. 

State: Utah; 
Share of enrollment for the largest three insurers (%): 
2010: 82; 
2011: 78; 
2012: 78; 
2013: 77. 

State: Vermont; 
Share of enrollment for the largest three insurers (%): 
2010: 100; 
2011: 100; 
2012: 100; 
2013: 100. 

State: Virginia; 
Share of enrollment for the largest three insurers (%): 
2010: 75; 
2011: 76; 
2012: 79; 
2013: 76. 

State: Washington; 
Share of enrollment for the largest three insurers (%): 
2010: 77; 
2011: 78; 
2012: 77; 
2013: 75. 

State: West Virginia; 
Share of enrollment for the largest three insurers (%): 
2010: 89; 
2011: 92; 
2012: 95; 
2013: 94. 

State: Wisconsin; 
Share of enrollment for the largest three insurers (%): 
2010: 59; 
2011: 51; 
2012: 51; 
2013: 54. 

State: Wyoming; 
Share of enrollment for the largest three insurers (%): 
2010: 86; 
2011: 88; 
2012: 87; 
2013: 87. 

State: Average; 
Share of enrollment for the largest three insurers (%): 
2010: 85; 
2011: 84; 
2012: 86; 
2013: 85. 

Source: GAO analysis of 2010 Supplemental Health Care Exhibit data 
from the National Association of Insurance Commissioners and 2011 
through 2013 Medical Loss Ratio data from the Centers for Medicare & 
Medicaid Services. GAO-15-101R. 

Notes: We measured enrollment using covered life-years, which 
represent the average number of lives insured, including dependents, 
on a pre-specified day over the 12 months in the reporting year. 

[A] We excluded 2010 data for California because the National 
Association of Insurance Commissioners' data for this state did not 
include all insurers in this year. 

[End of table] 

Table 3: Share of Enrollment for the Largest Three Insurers by State 
in the Large Group Market, 2010 through 2013: 

State: Alabama; 
Share of enrollment for the largest three insurers (%): 
2010: 99; 
2011: 100; 
2012: 100; 
2013: 100. 

State: Alaska; 
Share of enrollment for the largest three insurers (%): 
2010: 99; 
2011: 99; 
2012: 100; 
2013: 99. 

State: Arizona; 
Share of enrollment for the largest three insurers (%): 
2010: 73; 
2011: 80; 
2012: 79; 
2013: 79. 

State: Arkansas; 
Share of enrollment for the largest three insurers (%): 
2010: 98; 
2011: 99; 
2012: 99; 
2013: 99. 

State: California[A]; 
Share of enrollment for the largest three insurers (%): 
2010: [Empty]; 
2011: 69; 
2012: 70; 
2013: 74. 

State: Colorado; 
Share of enrollment for the largest three insurers (%): 
2010: 83; 
2011: 84; 
2012: 86; 
2013: 86. 

State: Connecticut; 
Share of enrollment for the largest three insurers (%): 
2010: 77; 
2011: 73; 
2012: 72; 
2013: 71. 

State: Delaware; 
Share of enrollment for the largest three insurers (%): 
2010: 97; 
2011: 94; 
2012: 93; 
2013: 93. 

State: District of Columbia; 
Share of enrollment for the largest three insurers (%): 
2010: 83; 
2011: 75; 
2012: 77; 
2013: 80. 

State: Florida; 
Share of enrollment for the largest three insurers (%): 
2010: 77; 
2011: 76; 
2012: 81; 
2013: 83. 

State: Georgia; 
Share of enrollment for the largest three insurers (%): 
2010: 80; 
2011: 83; 
2012: 81; 
2013: 77. 

State: Hawaii; 
Share of enrollment for the largest three insurers (%): 
2010: 97; 
2011: 93; 
2012: 94; 
2013: 93. 

State: Idaho; 
Share of enrollment for the largest three insurers (%): 
2010: 96; 
2011: 97; 
2012: 97; 
2013: 97. 

State: Illinois; 
Share of enrollment for the largest three insurers (%): 
2010: 86; 
2011: 86; 
2012: 86; 
2013: 90. 

State: Indiana; 
Share of enrollment for the largest three insurers (%): 
2010: 78; 
2011: 82; 
2012: 86; 
2013: 89. 

State: Iowa; 
Share of enrollment for the largest three insurers (%): 
2010: 93; 
2011: 94; 
2012: 95; 
2013: 93. 

State: Kansas; 
Share of enrollment for the largest three insurers (%): 
2010: 93; 
2011: 92; 
2012: 90; 
2013: 81. 

State: Kentucky; 
Share of enrollment for the largest three insurers (%): 
2010: 94; 
2011: 88; 
2012: 89; 
2013: 92. 

State: Louisiana; 
Share of enrollment for the largest three insurers (%): 
2010: 87; 
2011: 88; 
2012: 83; 
2013: 87. 

State: Maine; 
Share of enrollment for the largest three insurers (%): 
2010: 95; 
2011: 94; 
2012: 95; 
2013: 94. 

State: Maryland; 
Share of enrollment for the largest three insurers (%): 
2010: 89; 
2011: 94; 
2012: 92; 
2013: 91. 

State: Massachusetts; 
Share of enrollment for the largest three insurers (%): 
2010: 85; 
2011: 85; 
2012: 84; 
2013: 85. 

State: Michigan; 
Share of enrollment for the largest three insurers (%): 
2010: 90; 
2011: 80; 
2012: 80; 
2013: 78. 

State: Minnesota; 
Share of enrollment for the largest three insurers (%): 
2010: 93; 
2011: 83; 
2012: 95; 
2013: 95. 

State: Mississippi; 
Share of enrollment for the largest three insurers (%): 
2010: 96; 
2011: 97; 
2012: 98; 
2013: 99. 

State: Missouri; 
Share of enrollment for the largest three insurers (%): 
2010: 78; 
2011: 75; 
2012: 79; 
2013: 78. 

State: Montana; 
Share of enrollment for the largest three insurers (%): 
2010: 97; 
2011: 99; 
2012: 99; 
2013: 99. 

State: Nebraska; 
Share of enrollment for the largest three insurers (%): 
2010: 94; 
2011: 99; 
2012: 99; 
2013: 95. 

State: Nevada; 
Share of enrollment for the largest three insurers (%): 
2010: 88; 
2011: 87; 
2012: 88; 
2013: 87. 

State: New Hampshire; 
Share of enrollment for the largest three insurers (%): 
2010: 93; 
2011: 94; 
2012: 94; 
2013: 95. 

State: New Jersey; 
Share of enrollment for the largest three insurers (%): 
2010: 83; 
2011: 86; 
2012: 86; 
2013: 85. 

State: New Mexico; 
Share of enrollment for the largest three insurers (%): 
2010: 94; 
2011: 93; 
2012: 94; 
2013: 94. 

State: New York; 
Share of enrollment for the largest three insurers (%): 
2010: 69; 
2011: 62; 
2012: 68; 
2013: 66. 

State: North Carolina; 
Share of enrollment for the largest three insurers (%): 
2010: 93; 
2011: 93; 
2012: 92; 
2013: 93. 

State: North Dakota; 
Share of enrollment for the largest three insurers (%): 
2010: 100; 
2011: 99; 
2012: 99; 
2013: 100. 

State: Ohio; 
Share of enrollment for the largest three insurers (%): 
2010: 76; 
2011: 79; 
2012: 80; 
2013: 80. 

State: Oklahoma; 
Share of enrollment for the largest three insurers (%): 
2010: 84; 
2011: 80; 
2012: 82; 
2013: 82. 

State: Oregon; 
Share of enrollment for the largest three insurers (%): 
2010: 74; 
2011: 77; 
2012: 77; 
2013: 78. 

State: Pennsylvania; 
Share of enrollment for the largest three insurers (%): 
2010: 73; 
2011: 69; 
2012: 71; 
2013: 67. 

State: Rhode Island; 
Share of enrollment for the largest three insurers (%): 
2010: 98; 
2011: 98; 
2012: 97; 
2013: 97. 

State: South Carolina; 
Share of enrollment for the largest three insurers (%): 
2010: 97; 
2011: 98; 
2012: 97; 
2013: 98. 

State: South Dakota; 
Share of enrollment for the largest three insurers (%): 
2010: 89; 
2011: 88; 
2012: 89; 
2013: 89. 

State: Tennessee; 
Share of enrollment for the largest three insurers (%): 
2010: 89; 
2011: 93; 
2012: 94; 
2013: 94. 

State: Texas; 
Share of enrollment for the largest three insurers (%): 
2010: 77; 
2011: 82; 
2012: 83; 
2013: 83. 

State: Utah; 
Share of enrollment for the largest three insurers (%): 
2010: 92; 
2011: 90; 
2012: 88; 
2013: 87. 

State: Vermont; 
Share of enrollment for the largest three insurers (%): 
2010: 99; 
2011: 100; 
2012: 100; 
2013: 100. 

State: Virginia; 
Share of enrollment for the largest three insurers (%): 
2010: 71; 
2011: 75; 
2012: 77; 
2013: 75. 

State: Washington; 
Share of enrollment for the largest three insurers (%): 
2010: 90; 
2011: 89; 
2012: 88; 
2013: 88. 

State: West Virginia; 
Share of enrollment for the largest three insurers (%): 
2010: 97; 
2011: 96; 
2012: 98; 
2013: 95. 

State: Wisconsin; 
Share of enrollment for the largest three insurers (%): 
2010: 41; 
2011: 41; 
2012: 38; 
2013: 39. 

State: Wyoming; 
Share of enrollment for the largest three insurers (%): 
2010: 95; 
2011: 96; 
2012: 95; 
2013: 96. 

State: Average; 
Share of enrollment for the largest three insurers (%): 
2010: 87; 
2011: 87; 
2012: 87; 
2013: 87. 

Source: GAO analysis of 2010 Supplemental Health Care Exhibit data 
from the National Association of Insurance Commissioners and 2011 
through 2013 Medical Loss Ratio data from the Centers for Medicare & 
Medicaid Services. GAO-15-101R. 

Notes: We measured enrollment using covered life-years, which 
represent the average number of lives insured, including dependents, 
on a pre-specified day over the 12 months in the reporting year. 

[A] We excluded 2010 data for California because the National 
Association of Insurance Commissioners' data for this state did not 
include all insurers in this year. 

[End of table] 

[End of section] 

Enclosure 4: Share of Enrollment for the Largest Insurer by State in 
the Individual, Small Group, and Large Group Markets from 2010 through 
2013: 

The three tables below show the share of enrollment for the largest 
insurer by state in the individual, small group, and large group 
markets from 2010 through 2013, as well as which of these insurers was 
a Blue Cross and Blue Shield insurer. 

Table 4: Share of Enrollment for the Largest Insurer by State in the 
Individual Market, 2010 through 2013: 

State: Alabama; 
Largest insurer: BCBS OF AL GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 86; 
2011: 90; 
2012: 91; 
2013: 90. 

State: Alaska; 
Largest insurer: PREMERA BLUE CROSS GROUP†; 
Share of enrollment for the largest insurer (%): 
2010: 58; 
2011: 58; 
2012: 60; 
2013: 61. 

State: Arizona; 
Largest insurer: BLUE CROSS AND BLUE SHIELD OF ARIZONA, INC.†; 
Share of enrollment for the largest insurer (%): 
2010: 49; 
2011: 49; 
2012: 50; 
2013: 49. 

State: Arkansas; 
Largest insurer: ARKANSAS BCBS GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 76; 
2011: 79; 
2012: 80; 
2013: 79. 

State: California[A]; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: [Empty]; 
2011: 37; 
2012: 47; 
2013: 46. 

State: Colorado; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 30; 
2011: 32; 
2012: 34; 
2013: 35. 

State: Connecticut; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 52; 
2011: 48; 
2012: 44; 
2013: 39. 

State: Delaware; 
Largest insurer: HIGHMARK GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 50; 
2011: 51; 
2012: 49; 
2013: 53. 

State: District of Columbia; 
Largest insurer: CAREFIRST INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 73; 
2011: 69; 
2012: 70; 
2013: 71. 

State: Florida; 
Largest insurer: BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC. †; 
Share of enrollment for the largest insurer (%): 
2010: 49; 
2011: 47; 
2012: 49; 
2013: 47. 

State: Georgia; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 47; 
2011: 48; 
2012: 46; 
2013: 42. 

State: Hawaii; 
Largest insurer: HAWAII MEDICAL SERVICE ASSOCIATION†; 
Share of enrollment for the largest insurer (%): 
2010: 52; 
2011: 52; 
2012: 52; 
2013: 50. 

State: Idaho; 
Largest insurer: REGENCE GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 38; 
2011: [A]; 
2012: [A]; 
2013: [A]. 

State: Idaho; 
Largest insurer: BLUE CROSS OF IDAHO HEALTH SERVICE, INC. †; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: 44; 
2012: 45; 
2013: 50. 

State: Illinois; 
Largest insurer: HCSC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 65; 
2011: 66; 
2012: 67; 
2013: 67. 

State: Indiana; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 64; 
2011: 62; 
2012: 62; 
2013: 59. 

State: Iowa; 
Largest insurer: WELLMARK GROUP†; 
Share of enrollment for the largest insurer (%): 
2010: 83; 
2011: 83; 
2012: 64; 
2013: 84. 

State: Kansas; 
Largest insurer: BCBS OF KS GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 45; 
2011: 47; 
2012: 42; 
2013: 39. 

State: Kentucky; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 83; 
2011: 79; 
2012: 81; 
2013: 79. 

State: Louisiana; 
Largest insurer: LOUISIANA HLTH SERV GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 73; 
2011: 72; 
2012: 74; 
2013: 73. 

State: Maine; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 49; 
2011: 45; 
2012: 49; 
2013: 55. 

State: Maryland; 
Largest insurer: CAREFIRST INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 71; 
2011: 70; 
2012: 67; 
2013: 64. 

State: Massachusetts; 
Largest insurer: BCBS OF MA GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 57; 
2011: 63; 
2012: 39; 
2013: 34. 

State: Michigan; 
Largest insurer: BCBS OF MI GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 59; 
2011: 56; 
2012: 54; 
2013: 54. 

State: Minnesota; 
Largest insurer: BCBS OF MN GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 66; 
2011: 63; 
2012: 59; 
2013: 57. 

State: Mississippi; 
Largest insurer: MISSISSIPPI INS GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 54; 
2011: 57; 
2012: 60; 
2013: 62. 

State: Missouri; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 31; 
2011: 32; 
2012: 33; 
2013: 34. 

State: Montana; 
Largest insurer: HCSC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: [A]; 
2012: [A]; 
2013: 57. 

State: Montana; 
Largest insurer: BLUE CROSS BLUE SHIELD OF MONTANA†; 
Share of enrollment for the largest insurer (%): 
2010: 51; 
2011: 56; 
2012: 62; 
2013: [A]. 

State: Nebraska; 
Largest insurer: BLUE CROSS AND BLUE SHIELD OF NEBRASKA†; 
Share of enrollment for the largest insurer (%): 
2010: 63; 
2011: 65; 
2012: 69; 
2013: 70. 

State: Nevada; 
Largest insurer: UNITEDHEALTH GRP; 
Share of enrollment for the largest insurer (%): 
2010: 39; 
2011: 42; 
2012: 45; 
2013: 46. 

State: New Hampshire; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 67; 
2011: 76; 
2012: 81; 
2013: 83. 

State: New Jersey; 
Largest insurer: BCBS OF NJ GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 73; 
2011: 63; 
2012: 75; 
2013: 78. 

State: New Mexico; 
Largest insurer: HCSC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 59; 
2011: 53; 
2012: 49; 
2013: 49. 

State: New York; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 33; 
2011: 25; 
2012: 25; 
2013: 24. 

State: North Carolina; 
Largest insurer: BLUE CROSS AND BLUE SHIELD OF NORTH CAROLINA†; 
Share of enrollment for the largest insurer (%): 
2010: 80; 
2011: 83; 
2012: 85; 
2013: 86. 

State: North Dakota; 
Largest insurer: NORIDIAN MUTUAL INSURANCE COMPANY†; 
Share of enrollment for the largest insurer (%): 
2010: 77; 
2011: 75; 
2012: 75; 
2013: 78. 

State: Ohio; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: 36; 
2012: 36; 
2013: [A]. 

State: Ohio; 
Largest insurer: MEDICAL MUTUAL OF OHIO; 
Share of enrollment for the largest insurer (%): 
2010: 36; 
2011: [A]; 
2012: [A]; 
2013: 35. 

State: Oklahoma; 
Largest insurer: HCSC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 59; 
2011: 58; 
2012: 63; 
2013: 64. 

State: Oregon; 
Largest insurer: REGENCE GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 38; 
2011: 35; 
2012: 33; 
2013: 31. 

State: Pennsylvania; 
Largest insurer: HIGHMARK GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 32; 
2011: 33; 
2012: 35; 
2013: 35. 

State: Rhode Island; 
Largest insurer: UNITEDHEALTH GRP; 
Share of enrollment for the largest insurer (%): 
2010: 52; 
2011: [A]; 
2012: [A]; 
2013: [A]. 

State: Ohio; 
Largest insurer: BLUE CROSS & BLUE SHIELD OF RHODE ISLAND†; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: 95; 
2012: 94; 
2013: 92. 

State: South Carolina; 
Largest insurer: BCBS OF SC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 53; 
2011: 55; 
2012: 57; 
2013: 58. 

State: South Dakota; 
Largest insurer: WELLMARK GROUP†; 
Share of enrollment for the largest insurer (%): 
2010: 73; 
2011: 74; 
2012: 74; 
2013: 73. 

State: Tennessee; 
Largest insurer: BCBS OF TN INC†; 
Share of enrollment for the largest insurer (%): 
2010: 36; 
2011: [A]; 
2012: 39; 
2013: 42. 

State: Ohio; 
Largest insurer: TRH HEALTH INSURANCE COMPANY; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: 37; 
2012: [A]; 
2013: [A]. 

State: Texas; 
Largest insurer: HCSC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 55; 
2011: 57; 
2012: 59; 
2013: 60. 

State: Utah; 
Largest insurer: IHC INC GRP; 
Share of enrollment for the largest insurer (%): 
2010: 44; 
2011: 43; 
2012: 41; 
2013: 41. 

State: Vermont; 
Largest insurer: BCBS OF VT GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 75; 
2011: 77; 
2012: 90; 
2013: 92. 

State: Virginia; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 74; 
2011: 74; 
2012: 75; 
2013: 74. 

State: Washington; 
Largest insurer: PREMERA BLUE CROSS GROUP†; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: [A]; 
2012: 40; 
2013: 39. 

State: Washington; 
Largest insurer: REGENCE GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 45; 
2011: 37; 
2012: [A]; 
2013: [A]. 

State: West Virginia; 
Largest insurer: HIGHMARK GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 41; 
2011: 44; 
2012: 54; 
2013: 54. 

State: Wisconsin; 
Largest insurer: WISCONSIN PHYSICIANS SERV INS GRP; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: 23; 
2012: 24; 
2013: 26. 

State: Washington; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 21; 
2011: [A]; 
2012: [A]; 
2013: [A]. 

State: Wyoming; 
Largest insurer: BLUE CROSS BLUE SHIELD OF WYOMING†; 
Share of enrollment for the largest insurer (%): 
2010: 42; 
2011: 38; 
2012: 38; 
2013: 40. 

Legend: [A] This symbol indicates that this insurer was not the 
largest in that particular year. †This symbol indicates an insurer 
that we identified as being an independent licensee of the Blue Cross 
and Blue Shield Association in the designated state. An insurer may or 
may not be the Blue Cross and Blue Shield licensee in all counties 
within the state. 

Source: GAO analysis of 2010 Supplemental Health Care Exhibit data 
from the National Association of Insurance Commissioners and 2011 
through 2013 Medical Loss Ratio data from the Centers for Medicare & 
Medicaid Services. GAO-15-101R. 

Notes: We measured enrollment using covered life-years, which 
represent the average number of lives insured, including dependents, 
on a pre-specified day over the 12 months in the reporting year. We 
reprinted insurer names as they were reported in the data from the 
Centers for Medicare & Medicaid Services and the National Association 
of Insurance Commissioners. 

We excluded 2010 data for California because the National Association 
of Insurance Commissioners' data for this state did not include all 
insurers in this year. 

[End of table] 

Table 5: Share of Enrollment for the Largest Insurer by State in the 
Small Group Market, 2010 through 2013: 

State: Alabama; 
Largest insurer: BCBS OF AL GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 96; 
2011: 97; 
2012: 97; 
2013: 97. 

State: Alaska; 
Largest insurer: PREMERA BLUE CROSS GROUP†; 
Share of enrollment for the largest insurer (%): 
2010: 71; 
2011: 72; 
2012: 69; 
2013: 65. 

State: Arizona; 
Largest insurer: AETNA GRP; 
Share of enrollment for the largest insurer (%): 
2010: 26; 
2011: [A]; 
2012: [A]; 
2013: [A]. 

State: Arizona; 
Largest insurer: BLUE CROSS AND BLUE SHIELD OF ARIZONA, INC. †; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: 26; 
2012: 26; 
2013: 24. 

State: Arkansas; 
Largest insurer: ARKANSAS BCBS GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 51; 
2011: 56; 
2012: 61; 
2013: 65. 

State: California[A]; 
Largest insurer: KAISER FOUNDATION GRP; 
Share of enrollment for the largest insurer (%): 
2010: [Empty]; 
2011: 30; 
2012: 31; 
2013: 31. 

State: Colorado; 
Largest insurer: UNITEDHEALTH GRP; 
Share of enrollment for the largest insurer (%): 
2010: 32; 
2011: 31; 
2012: 32; 
2013: 30. 

State: Connecticut; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: 31; 
2012: 37; 
2013: 40. 

State: Connecticut; 
Largest insurer: UNITEDHEALTH GRP; 
Share of enrollment for the largest insurer (%): 
2010: 31; 
2011: [A]; 
2012: [A]; 
2013: [A]. 

State: Delaware; 
Largest insurer: HIGHMARK GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 57; 
2011: 61; 
2012: 65; 
2013: 64. 

State: District of Columbia; 
Largest insurer: CAREFIRST INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 63; 
2011: 76; 
2012: 81; 
2013: 81. 

State: Florida; 
Largest insurer: UNITEDHEALTH GRP; 
Share of enrollment for the largest insurer (%): 
2010: 39; 
2011: 36; 
2012: 36; 
2013: 36. 

State: Georgia; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 31; 
2011: 41; 
2012: 36; 
2013: 34. 

State: Hawaii; 
Largest insurer: HAWAII MEDICAL SERVICE ASSOCIATION†; 
Share of enrollment for the largest insurer (%): 
2010: 67; 
2011: 50; 
2012: 45; 
2013: 48. 

State: Idaho; 
Largest insurer: REGENCE GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 45; 
2011: [A]; 
2012: [A]; 
2013: [A]. 

State: Idaho; 
Largest insurer: BLUE CROSS OF IDAHO HEALTH SERVICE, INC. †; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: 48; 
2012: 50; 
2013: 49. 

State: Illinois; 
Largest insurer: HCSC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 51; 
2011: 57; 
2012: 59; 
2013: 59. 

State: Indiana; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 52; 
2011: 56; 
2012: 55; 
2013: 54. 

State: Iowa; 
Largest insurer: WELLMARK GROUP†; 
Share of enrollment for the largest insurer (%): 
2010: 61; 
2011: 61; 
2012: 62; 
2013: 63. 

State: Kansas; 
Largest insurer: BCBS OF KS GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 61; 
2011: 58; 
2012: 59; 
2013: 61. 

State: Kentucky; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 63; 
2011: 72; 
2012: 70; 
2013: 67. 

State: Louisiana; 
Largest insurer: LOUISIANA HLTH SERV GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 80; 
2011: 81; 
2012: 81; 
2013: 81. 

State: Maine; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 46; 
2011: 50; 
2012: 48; 
2013: 40. 

State: Maryland; 
Largest insurer: CAREFIRST INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 70; 
2011: 72; 
2012: 73; 
2013: 69. 

State: Massachusetts; 
Largest insurer: BCBS OF MA GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 46; 
2011: 40; 
2012: 40; 
2013: 41. 

State: Michigan; 
Largest insurer: BCBS OF MI GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 62; 
2011: 52; 
2012: 55; 
2013: 57. 

State: Minnesota; 
Largest insurer: BCBS OF MN GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 50; 
2011: 37; 
2012: 36; 
2013: 37. 

State: Mississippi; 
Largest insurer: MISSISSIPPI INS GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 80; 
2011: 73; 
2012: 87; 
2013: 84. 

State: Missouri; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 42; 
2011: 48; 
2012: 46; 
2013: 48. 

State: Montana; 
Largest insurer: HCSC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: [A]; 
2012: [A]; 
2013: 68. 

State: Montana; 
Largest insurer: BLUE CROSS BLUE SHIELD OF MONTANA†; 
Share of enrollment for the largest insurer (%): 
2010: 71; 
2011: 72; 
2012: 69; 
2013: [A]. 

State: Nebraska; 
Largest insurer: BLUE CROSS AND BLUE SHIELD OF NEBRASKA†; 
Share of enrollment for the largest insurer (%): 
2010: 42; 
2011: 42; 
2012: 56; 
2013: 61. 

State: Nevada; 
Largest insurer: UNITEDHEALTH GRP; 
Share of enrollment for the largest insurer (%): 
2010: 47; 
2011: 35; 
2012: 35; 
2013: 36. 

State: New Hampshire; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 60; 
2011: 67; 
2012: 75; 
2013: 73. 

State: New Jersey; 
Largest insurer: BCBS OF NJ GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 47; 
2011: 59; 
2012: 59; 
2013: 59. 

State: New Mexico; 
Largest insurer: PRESBYTERIAN HLTHCARE SERV GRP; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: [A]; 
2012: 31; 
2013: 33. 

State: New Mexico; 
Largest insurer: HCSC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 34; 
2011: 31; 
2012: [A]; 
2013: [A]. 

State: New York; 
Largest insurer: UNITEDHEALTH GRP; 
Share of enrollment for the largest insurer (%): 
2010: 41; 
2011: 36; 
2012: 44; 
2013: 48. 

State: North Carolina; 
Largest insurer: BLUE CROSS AND BLUE SHIELD OF NORTH CAROLINA†; 
Share of enrollment for the largest insurer (%): 
2010: 63; 
2011: 63; 
2012: 62; 
2013: 62. 

State: North Dakota; 
Largest insurer: NORIDIAN MUTUAL INSURANCE COMPANY†; 
Share of enrollment for the largest insurer (%): 
2010: 88; 
2011: 85; 
2012: 86; 
2013: 86. 

State: Ohio; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 34; 
2011: 41; 
2012: 40; 
2013: 40. 

State: Oklahoma; 
Largest insurer: HCSC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 46; 
2011: 48; 
2012: 55; 
2013: 60. 

State: Oregon; 
Largest insurer: REGENCE GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 24; 
2011: 21; 
2012: [A]; 
2013: [A]. 

State: Oregon; 
Largest insurer: PACIFICSOURCE HLTH PLAN GRP; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: [A]; 
2012: 22; 
2013: 23. 

State: Pennsylvania; 
Largest insurer: AETNA GRP; 
Share of enrollment for the largest insurer (%): 
2010: 37; 
2011: [A]; 
2012: [A]; 
2013: [A]. 

State: Pennsylvania; 
Largest insurer: HIGHMARK GRP†; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: 24; 
2012: 22; 
2013: [A]. 

Largest insurer: State: Pennsylvania; INDEPENDENCE BLUE CROSS GRP†; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: [A]; 
2012: [A]; 
2013: 21. 

State: Rhode Island; 
Largest insurer: BLUE CROSS & BLUE SHIELD OF RHODE ISLAND†; 
Share of enrollment for the largest insurer (%): 
2010: 70; 
2011: 74; 
2012: 75; 
2013: 76. 

State: South Carolina; 
Largest insurer: BCBS OF SC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 67; 
2011: 70; 
2012: 67; 
2013: 69. 

State: South Dakota; 
Largest insurer: WELLMARK GROUP†; 
Share of enrollment for the largest insurer (%): 
2010: 66; 
2011: 62; 
2012: 60; 
2013: 59. 

State: Tennessee; 
Largest insurer: BCBS OF TN INC†; 
Share of enrollment for the largest insurer (%): 
2010: 70; 
2011: 70; 
2012: 70; 
2013: 69. 

State: Texas; 
Largest insurer: HCSC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 39; 
2011: 46; 
2012: 51; 
2013: 53. 

State: Utah; 
Largest insurer: IHC INC GRP; 
Share of enrollment for the largest insurer (%): 
2010: 40; 
2011: 42; 
2012: 41; 
2013: 40. 

State: Vermont; 
Largest insurer: CIGNA HLTH GRP; 
Share of enrollment for the largest insurer (%): 
2010: 38; 
2011: [A]; 
2012: [A]; 
2013: [A]. 

Largest insurer: BCBS OF VT GRP†; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: 43; 
2012: 74; 
2013: 74. 

State: Virginia; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 47; 
2011: 50; 
2012: 48; 
2013: 46. 

State: Washington; 
Largest insurer: PREMERA BLUE CROSS GROUP†; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: 33; 
2012: 36; 
2013: 37. 

Largest insurer: REGENCE GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 50; 
2011: [A]; 
2012: [A]; 
2013: [A]. 

State: West Virginia; 
Largest insurer: HIGHMARK GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 50; 
2011: 57; 
2012: 66; 
2013: 73. 

State: Wisconsin; 
Largest insurer: UNITEDHEALTH GRP; 
Share of enrollment for the largest insurer (%): 
2010: 35; 
2011: 30; 
2012: 30; 
2013: 33. 

State: Wyoming; 
Largest insurer: BLUE CROSS BLUE SHIELD OF WYOMING†; 
Share of enrollment for the largest insurer (%): 
2010: 55; 
2011: 61; 
2012: 58; 
2013: 60. 

Legend: [A] This symbol indicates that this insurer was not the 
largest in that particular year. †This symbol indicates an insurer 
that we identified as being an independent licensee of the Blue Cross 
and Blue Shield Association in the designated state. An insurer may or 
may not be the Blue Cross and Blue Shield licensee in all counties 
within the state. 

Source: GAO analysis of 2010 Supplemental Health Care Exhibit data 
from the National Association of Insurance Commissioners and 2011 
through 2013 Medical Loss Ratio data from the Centers for Medicare & 
Medicaid Services. GAO-15-101R. 

Notes: We measured enrollment using covered life-years, which 
represent the average number of lives insured, including dependents, 
on a pre-specified day over the 12 months in the reporting year. We 
reprinted insurer names as they were reported in the data from the 
Centers for Medicare & Medicaid Services and the National Association 
of Insurance Commissioners. 

We excluded 2010 data for California because the National Association 
of Insurance Commissioners' data for this state did not include all 
insurers in this year. 

[End of table] 

Table 6: Share of Enrollment for the Largest Insurer by State in the 
Large Group Market, 2010 through 2013: 

State: Alabama; 
Largest insurer: BCBS OF AL GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 93; 
2011: 92; 
2012: 92; 
2013: 92. 

State: Alaska; 
Largest insurer: PREMERA BLUE CROSS GROUP†; 
Share of enrollment for the largest insurer (%): 
2010: 79; 
2011: 79; 
2012: 84; 
2013: 85. 

State: Arizona; 
Largest insurer: UNITEDHEALTH GRP; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: 39; 
2012: [A]; 
2013: [A]. 

State: Arizona; 
Largest insurer: BLUE CROSS AND BLUE SHIELD OF ARIZONA, INC. †; 
Share of enrollment for the largest insurer (%): 
2010: 40; 
2011: [A]; 
2012: 31; 
2013: 33. 

State: Arkansas; 
Largest insurer: ARKANSAS BCBS GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 80; 
2011: 78; 
2012: 77; 
2013: 78. 

State: California[A]; 
Largest insurer: KAISER FOUNDATION GRP; 
Share of enrollment for the largest insurer (%): 
2010: [Empty]; 
2011: 42; 
2012: 41; 
2013: 41. 

State: Colorado; 
Largest insurer: KAISER FOUNDATION GRP; 
Share of enrollment for the largest insurer (%): 
2010: 47; 
2011: 47; 
2012: 48; 
2013: 47. 

State: Connecticut; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 48; 
2011: 38; 
2012: 35; 
2013: 34. 

State: Delaware; 
Largest insurer: HIGHMARK GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 63; 
2011: 71; 
2012: 69; 
2013: 66. 

State: District of Columbia; 
Largest insurer: AETNA INC; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: 29; 
2012: 31; 
2013: 34. 

State: District of Columbia; 
Largest insurer: KAISER FOUNDATION GRP; 
Share of enrollment for the largest insurer (%): 
2010: 30; 
2011: [A]; 
2012: [A]; 
2013: [A]. 

State: Florida; 
Largest insurer: BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC. †; 
Share of enrollment for the largest insurer (%): 
2010: 42; 
2011: 42; 
2012: 49; 
2013: 54. 

State: Georgia; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 56; 
2011: 52; 
2012: 50; 
2013: 44. 

State: Hawaii; 
Largest insurer: HAWAII MEDICAL SERVICE ASSOCIATION†; 
Share of enrollment for the largest insurer (%): 
2010: 60; 
2011: 62; 
2012: 70; 
2013: 69. 

State: Idaho; 
Largest insurer: BLUE CROSS OF IDAHO HEALTH SERVICE, INC. †; 
Share of enrollment for the largest insurer (%): 
2010: 71; 
2011: 68; 
2012: 67; 
2013: 67. 

State: Illinois; 
Largest insurer: HCSC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 74; 
2011: 68; 
2012: 69; 
2013: 72. 

State: Indiana; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 59; 
2011: 55; 
2012: 60; 
2013: 62. 

State: Iowa; 
Largest insurer: WELLMARK GROUP†; 
Share of enrollment for the largest insurer (%): 
2010: 76; 
2011: 74; 
2012: 77; 
2013: 76. 

State: Kansas; 
Largest insurer: BCBS OF KS GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 56; 
2011: 47; 
2012: 45; 
2013: 46. 

State: Kentucky; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 65; 
2011: 62; 
2012: 63; 
2013: 67. 

State: Louisiana; 
Largest insurer: LOUISIANA HLTH SERV GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 61; 
2011: 65; 
2012: 64; 
2013: 64. 

State: Maine; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 74; 
2011: 74; 
2012: 73; 
2013: 73. 

State: Maryland; 
Largest insurer: CAREFIRST INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 51; 
2011: 62; 
2012: 70; 
2013: 70. 

State: Massachusetts; 
Largest insurer: BCBS OF MA GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 53; 
2011: 54; 
2012: 54; 
2013: 56. 

State: Michigan; 
Largest insurer: BCBS OF MI GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 62; 
2011: 52; 
2012: 51; 
2013: 52. 

State: Minnesota; 
Largest insurer: HEALTHPARTNERS GRP; 
Share of enrollment for the largest insurer (%): 
2010: 45; 
2011: 39; 
2012: 48; 
2013: 45. 

State: Mississippi; 
Largest insurer: MISSISSIPPI INS GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 84; 
2011: 81; 
2012: 84; 
2013: 83. 

State: Missouri; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 39; 
2011: 33; 
2012: 36; 
2013: 36. 

State: Montana; 
Largest insurer: HCSC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: [A]; 
2012: [A]; 
2013: 80. 

State: Montana; 
Largest insurer: BLUE CROSS BLUE SHIELD OF MONTANA†; 
Share of enrollment for the largest insurer (%): 
2010: 66; 
2011: 66; 
2012: 81; 
2013: [A]. 

State: Nebraska; 
Largest insurer: BLUE CROSS AND BLUE SHIELD OF NEBRASKA†; 
Share of enrollment for the largest insurer (%): 
2010: 77; 
2011: 86; 
2012: 80; 
2013: 82. 

State: Nevada; 
Largest insurer: UNITEDHEALTH GRP; 
Share of enrollment for the largest insurer (%): 
2010: 66; 
2011: 66; 
2012: 68; 
2013: 66. 

State: New Hampshire; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 52; 
2011: 55; 
2012: 60; 
2013: 57. 

State: New Jersey; 
Largest insurer: BCBS OF NJ GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 52; 
2011: 54; 
2012: 54; 
2013: 56. 

State: New Mexico; 
Largest insurer: HCSC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 47; 
2011: 40; 
2012: 39; 
2013: 40. 

State: New York; 
Largest insurer: UNITEDHEALTH GRP; 
Share of enrollment for the largest insurer (%): 
2010: 29; 
2011: 26; 
2012: 26; 
2013: [A]. 

State: New York; 
Largest insurer: HIP INS GRP; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: [A]; 
2012: [A]; 
2013: 23. 

State: North Carolina; 
Largest insurer: BLUE CROSS AND BLUE SHIELD OF NORTH CAROLINA†; 
Share of enrollment for the largest insurer (%): 
2010: 78; 
2011: 73; 
2012: 73; 
2013: 76. 

State: North Dakota; 
Largest insurer: NORIDIAN MUTUAL INSURANCE COMPANY†; 
Share of enrollment for the largest insurer (%): 
2010: 97; 
2011: 97; 
2012: 96; 
2013: 97. 

State: Ohio; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 45; 
2011: 42; 
2012: 41; 
2013: 41. 

State: Oklahoma; 
Largest insurer: HCSC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 53; 
2011: 52; 
2012: 52; 
2013: 54. 

State: Oregon; 
Largest insurer: KAISER FOUNDATION GRP; 
Share of enrollment for the largest insurer (%): 
2010: 39; 
2011: 41; 
2012: 41; 
2013: 41. 

State: Pennsylvania; 
Largest insurer: HIGHMARK GRP†; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: 32; 
2012: 36; 
2013: 36. 

State: Pennsylvania; 
Largest insurer: INDEPENDENCE BLUE CROSS GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 31; 
2011: [A]; 
2012: [A]; 
2013: [A]. 

State: Rhode Island; 
Largest insurer: BLUE CROSS & BLUE SHIELD OF RHODE ISLAND†; 
Share of enrollment for the largest insurer (%): 
2010: 83; 
2011: 74; 
2012: 77; 
2013: 78. 

State: South Carolina; 
Largest insurer: BCBS OF SC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 92; 
2011: 93; 
2012: 90; 
2013: 91. 

State: South Dakota; 
Largest insurer: WELLMARK GROUP†; 
Share of enrollment for the largest insurer (%): 
2010: 56; 
2011: 56; 
2012: 59; 
2013: 60. 

State: Tennessee; 
Largest insurer: BCBS OF TN INC†; 
Share of enrollment for the largest insurer (%): 
2010: 63; 
2011: 72; 
2012: 75; 
2013: 78. 

State: Texas; 
Largest insurer: HCSC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 46; 
2011: 46; 
2012: 46; 
2013: 48. 

State: Utah; 
Largest insurer: IHC INC GRP; 
Share of enrollment for the largest insurer (%): 
2010: 48; 
2011: 49; 
2012: 48; 
2013: 45. 

State: Vermont; 
Largest insurer: BCBS OF VT GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 62; 
2011: 73; 
2012: 78; 
2013: 79. 

State: Virginia; 
Largest insurer: WELLPOINT INC GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 45; 
2011: 52; 
2012: 46; 
2013: 44. 

State: Washington; 
Largest insurer: PREMERA BLUE CROSS GROUP†; 
Share of enrollment for the largest insurer (%): 
2010: 33; 
2011: [A]; 
2012: [A]; 
2013: [A]. 

State: Washington; 
Largest insurer: GROUP HLTH COOP GRP; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: 33; 
2012: 33; 
2013: 31. 

State: West Virginia; 
Largest insurer: HIGHMARK GRP†; 
Share of enrollment for the largest insurer (%): 
2010: 74; 
2011: 81; 
2012: 82; 
2013: 84. 

State: Wisconsin; 
Largest insurer: UNITEDHEALTH GRP; 
Share of enrollment for the largest insurer (%): 
2010: 16; 
2011: 16; 
2012: [A]; 
2013: [A]. 

State: Wisconsin; 
Largest insurer: DEAN HEALTH GRP; 
Share of enrollment for the largest insurer (%): 
2010: [A]; 
2011: [A]; 
2012: 16; 
2013: 15. 

State: Wyoming; 
Largest insurer: BLUE CROSS BLUE SHIELD OF WYOMING†; 
Share of enrollment for the largest insurer (%): 
2010: 66; 
2011: 73; 
2012: 75; 
2013: 76. 

Legend: [A] This symbol indicates that this insurer was not the 
largest in that particular year. †This symbol indicates an insurer 
that we identified as being an independent licensee of the Blue Cross 
and Blue Shield Association in the designated state. An insurer may or 
may not be the Blue Cross and Blue Shield licensee in all counties 
within the state. 

Source: GAO analysis of 2010 Supplemental Health Care Exhibit data 
from the National Association of Insurance Commissioners and 2011 
through 2013 Medical Loss Ratio data from the Centers for Medicare & 
Medicaid Services. GAO-15-101R. 

Notes: We measured enrollment using covered life-years, which 
represent the average number of lives insured, including dependents, 
on a pre-specified day over the 12 months in the reporting year. We 
reprinted insurer names as they were reported in the data from the 
Centers for Medicare & Medicaid Services and the National Association 
of Insurance Commissioners. 

We excluded 2010 data for California because the National Association 
of Insurance Commissioners' data for this state did not include all 
insurers in this year. 

[End of table] 

[End of section] 

Footnotes: 

[1] Private health insurance includes individual and group coverage--
including small and large group health plans. Insurance offered by 
small employers is known as small group insurance and insurance 
offered by large employers is known as large group insurance. 

[2] U.S. Census Bureau, Table HI01, Health Insurance Coverage Status 
and Type of Coverage by Selected Characteristics: 2013, Current 
Population Survey, 2014 Annual Social and Economic Supplement, 
accessed October 6, 2014, [hyperlink, 
http://www.census.gov/hhes/www/cpstables/032014/health/hi01_1.xls]. 

[3] GAO, Private Health Insurance: 2008 Survey Results on Number and 
Market Share of Carriers in the Small Group Health Insurance Market, 
[hyperlink, http://www.gao.gov/products/GAO-09-363R] (Washington, 
D.C.: Feb. 27, 2009). Also see GAO, Private Health Insurance: Number 
and Market Share of Carriers in the Small Group Health Insurance 
Market in 2004, [hyperlink, http://www.gao.gov/products/GAO-06-155R] 
(Washington, D.C.: Oct. 13, 2005); and GAO, Private Health Insurance: 
Number and Market Share of Carriers in the Small Group Health 
Insurance Market, [hyperlink, http://www.gao.gov/products/GAO-02-536R] 
(Washington, D.C.: Mar. 25, 2002). 

[4] These figures are based on data from the 39 states that provided 
us with market share information. See [hyperlink, 
http://www.gao.gov/products/GAO-09-363R]. 

[5] Kaiser Initiative on Health Reform and Private Health Insurance, 
Focus on Health Reform: How Competitive are State Insurance Markets? 
(Menlo Park, Calif: Kaiser Family Foundation, October 2011). 

[6] In 2009, we conducted a structured literature review that examined 
the concentration of private health insurance markets. See GAO, 
Private Health Insurance: Research on Competition in the Insurance 
Industry, [hyperlink, http://www.gao.gov/products/GAO-09-864R] 
(Washington, D.C.: July 31, 2009). 

[7] See Pub. L. No. 111-148, 124 Stat. 119 (Mar. 23, 2010) (hereafter, 
"PPACA"), as amended by the Health Care and Education Reconciliation 
Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (Mar. 30, 2010) 
("HCERA"). In this report, all references to PPACA include any 
amendments made by HCERA. 

[8] Prior to PPACA, federal law defined a small employer, in 
connection with a group health plan, as having a maximum of 50 
employees. Under PPACA, states have the option of defining a small 
employer as having 50 or fewer employees, but starting in 2016, they 
must define small employers as having from 1 to 100 employees. PPACA, 
§ 1304(b), 124 Stat. at 172 (codified at 42 U.S.C. § 18024(b)). 

[9] For example, it is only through the exchanges that eligible 
individuals may qualify for premium tax credits and cost-sharing 
reductions to lower the cost of their health plans, and certain small 
employers may qualify for tax credits to lower the cost of the 
coverage they purchase on behalf of their employees. We examined 
insurer participation in health insurance exchanges in a recent 
report. See GAO, Patient Protection and Affordable Care Act: Largest 
Issuers of Health Coverage Participated in Most Exchanges, and Number 
of Plans Available Varied, [hyperlink, 
http://www.gao.gov/products/GAO-14-657] (Washington, D.C: Aug. 29, 
2014). 

[10] PPACA, § 1322, Stat. at 187 (codified at 42 U.S.C. § 18042). 

[11] PPACA, § 1322(i), 124 Stat. at 192. Specifically, PPACA directs 
GAO to conduct an ongoing study on competition and market 
concentration in the health insurance market in the United States 
after the implementation of PPACA health insurance reforms and to 
report to Congress biennially beginning in 2014. 

[12] NAIC is the organization of insurance commissioners from the 50 
states, the District of Columbia, and the five U.S. territories that 
regulate the conduct of insurance companies in their respective state 
or territory. All insurers, with some exceptions, report financial 
statements to NAIC each year that include data for all health 
insurance markets offered by an insurer, including Medical Loss Ratio 
(MLR) data, or the percent of premiums the insurers spent on their 
enrollees' medical claims and quality initiatives. The largest 
exception to the NAIC reporting requirements is insurers that are 
regulated by the California Department of Managed Health Care, which 
report directly to that department and not to NAIC. Insurers began 
reporting MLR data to CMS in 2011, as required by PPACA. Both the NAIC 
and CMS data collected from insurers also include enrollment data that 
can be used to calculate the share of covered life-years for fully 
insured health plans. Insurers reported their 2010 data to NAIC by 
April 2011 based on their experience for the prior calendar year and 
insurers reported their 2011, 2012, and 2013 data to CMS by June 2012, 
June 2013, and June 2014, respectively, based on their experience for 
the prior calendar year. At the time of our analysis, 2013 data was 
the most recent year available. 

For purposes of this report, the term "state" includes the District of 
Columbia. 

[13] For the purposes of this report, insurer refers to the parent 
company of the insurance entity that is licensed by the state to 
engage in the insurance business. In cases where there is no parent 
company, the insurer refers to the insurance entity that is licensed 
by the state. 

[14] One way to measure beneficiary enrollment is by measuring covered 
life-years, which represent the average number of lives insured, 
including dependents, on a pre-specified day over the 12 months in the 
reporting year. 

[15] AMA reported data collected by HealthLeaders-InterStudy through 
its Managed Market Surveyor from January 1, 2011, for self-funded and 
fully insured plans and, according to the study's authors, includes 
plans from the individual, small group, and large group markets. 
However, the data reported by AMA do not differentiate by these market 
segments. AMA reported market concentration by state and by MSA, which 
includes a county or counties associated with a city or urbanized area 
that has a population of at least 50,000. In some cases, AMA reported 
the data at other geographic levels such as metropolitan divisions, 
which are smaller geographic units located within MSAs. As is done in 
the AMA study, we refer to these as "MSAs" for the purposes of this 
report. American Medical Association, Competition in Health Insurance: 
A Comprehensive Study of U.S. Markets (2013). 

[16] While, on average, more insurers participated in the individual 
market segment, enrollment was higher in the small and large group 
markets. Specifically, in 2013, there were about 11.0 million total 
covered life-years in the individual market, 17.3 million total 
covered life-years in the small group market, and 48.3 million total 
covered life-years in the large group market. (See enclosure 1 for 
state-by-state trends.) 

[17] Specifically, the three largest insurers in a particular state 
had at least 80 percent of the total enrollment in the individual 
market in 39 states, in the small group market in 37 states, and in 
the large group market in 40 states. 

[18] For all analyses of trends from 2010 through 2013, we excluded 
data from California for all years because the NAIC 2010 data for this 
state did not include all insurers. Therefore, these counts are out of 
50, rather than 51, states. 

[19] In each of the three market segments, for most of the states in 
which the largest three insurers had an enrollment share of at least 
80 percent in 2010, this was also the case in 2013--specifically, 29 
of the 30 states in the individual market, 32 of the 34 states in the 
small group market, and 36 of the 38 states in the large group market. 

[20] Specifically, in the individual market, there were 31 states 
where the largest insurer had at least half of the enrollment in 2010 
and also in 2013. In the small group market, there were 27 states in 
2010 and 29 states in 2013. In the large group market, there were 33 
states in 2010 and 32 states in 2013. 

[21] We identified insurers that were independent licensees of the 
Blue Cross and Blue Shield Association in a particular state. An 
insurer may or may not be the Blue Cross and Blue Shield licensee in 
all counties within a particular state. In 2002, 2005, and 2009, we 
reported that a Blue Cross and Blue Shield insurer was the largest 
insurer in most states in the small group market. See [hyperlink, 
http://www.gao.gov/products/GAO-09-363R], [hyperlink, 
http://www.gao.gov/products/GAO-06-155R], and [hyperlink, 
http://www.gao.gov/products/GAO-02-536R]. 

[End of section] 

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