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Competition in Health Insurance: a Comprehensive Study of U.S. Markets I

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Competition in Health Insurance: a Comprehensive Study of U.S. Markets I 2018 UPDATE COMPETITION in HEALTH INSURANCE A comprehensive study of U.S. markets Acknowledgments This report has been prepared by the American Medical Association Division of Economic and Health Policy Research. Acknowledgment goes to the following individuals for their contributions. José R. Guardado, PhD Senior economist, Economic and Health Policy Research Carol K. Kane, PhD Director, Economic and Health Policy Research ISBN: 978-1-62202-896-2 KGB:18-290773 © 2018 American Medical Association. All rights reserved. 2018 update | American Medical Association 1 Table of contents I. Introduction and background ..............................................................................................................................................2 II. Data and methodology.............................................................................................................................................................4 A. Product and geographic market definition ............................................................................................................................4 B. Data ...............................................................................................................................................................................................4 C. Market share and HHI calculations ...........................................................................................................................................6 D. DOJ/FTC merger guidelines .......................................................................................................................................................6 III. Summary of findings and conclusion...............................................................................................................................6 A. Market concentration (HHI) .......................................................................................................................................................7 B. Market shares................................................................................................................................................................................7 C. Conclusion . 8 IV. State and MSA tables ................................................................................................................................................................9 Table 1. Market concentration (HHI) and largest insurers’ market shares, as of Feb. 1, 2017 Combined HMO+PPO+POS+EXCH (total) product markets ............................................................................................................9 Table 2. Market concentration (HHI) and largest insurers’ market shares, as of Feb. 1, 2017 HMO product markets........................................................................................................................................................................ 19 Table 3. Market concentration (HHI) and largest insurers’ market shares, as of Feb. 1, 2017 PPO product markets ......................................................................................................................................................................... 26 Table 4. Market concentration (HHI) and largest insurers’ market shares, as of Feb. 1, 2017 POS product markets.......................................................................................................................................................................... 36 Table 5. Market concentration (HHI) and largest insurers’ market shares, as of Feb. 1, 2017 Exchanges .......................................................................................................................................................................................... 44 Table 6. State and MSA HHI by product type, as of Feb. 1, 2017 .............................................................................................. 53 © 2018 American Medical Association. All rights reserved. 2 Competition in health insurance: A comprehensive study of U.S. markets I. Introduction and background This is the 17th edition of the American Medical Association’s the 50 states and the District of Columbia.4 Due to a “Competition in health insurance: A comprehensive study of change in MSA definitions in the data used for this year’s U.S. markets.” This report presents new data on the degree “Competition in health insurance” update, not all data of competition in health insurance markets across the presented here for 2017 are directly comparable to data country. It is intended to help researchers, policymakers, for previous years.5 and federal and state regulators identify markets where consolidation among health insurers may cause Among the key findings in this year’s update is that, competitive harm to consumers and providers of care. based on the DOJ/FTC Horizontal Merger Guidelines, 73 percent of 380 MSAs studied were highly concentrated This study addresses the following questions: Are health (HHI>2,500).6 The average MSA was also highly insurance markets competitive, or do health insurers concentrated, with an HHI of 3464. Another finding is exercise market power? Are proposed mergers between that in 91 percent of MSAs, at least one insurer had a insurers likely to maintain, enhance or create such power? commercial market share of 30 percent or greater. Finally, These are important questions of public policy because in 46 percent of MSAs, a single insurer’s market share was the use of market power harms society in both output and at least 50 percent. input markets. When an insurer exercises market power in its output market (the sale of insurance coverage), High concentration levels in health insurance markets premiums are higher than in a competitive market. When are largely the result of consolidation (i.e., mergers and an insurer exercises market power in its input market (e.g., acquisitions), which can lead to the exercise of market physician services), payments to health care providers are power and, in turn, harm to consumers and providers of below competitive levels. In both settings, the quantity of care. Both consummated and proposed consolidation insurance coverage provided is lower than in a competitive of health insurers should raise serious antitrust concerns. market. In short, the exercise of market power adversely Conceptually, mergers and acquisitions can have beneficial affects health insurance coverage and health care. and harmful effects on consumers. However, only the latter has been observed. It appears that consolidation A first step in assessing the existence of or the potential has resulted in the possession and exercise of health for market power is to examine market concentration, insurer monopoly power—the ability to raise and maintain as high concentration tends to lower competition premiums above competitive levels—instead of the and facilitate the exercise of market power. The U.S. passing of any benefits obtained through to consumers. Department of Justice (DOJ) and the Federal Trade Commission (FTC) examine market concentration in Research suggests that health insurers exercise market their evaluation of proposed mergers between firms.1 4. For convenience, the District of Columbia (DC) is classified as a “state” in this study; Thus, it is critical to have this type of information readily this helps distinguish the state-level data (DC) from the MSA-level data (Washington- available. In this study we present new information on Arlington-Alexandria, DC-VA-MD-WV). market concentration in the health insurance industry. 5. DRG made two sets of changes to metropolitan area definitions. First, the DRG data for 2017 used in this Update defined all metropolitan areas as metropolitan statistical areas Using 2017 data from Decision Resources Group (DRG),2 (MSAs) based on the U.S. Office of Management and Budget (OMB), July 2015 delineations. In contrast, DRG data for previous years were based on older OMB delineations. In the most comprehensive and consistent source of data addition, DRG changed the level at which it reported enrollments for some metropolitan on enrollment in health maintenance organization (HMO), areas. In data used for previous Updates, metropolitan areas were mostly defined as MSAs, but some were metropolitan divisions and New England city town and areas (NECTAs). preferred provider organization (PPO), point-of-service Very large MSAs (e.g., New York) are divided into multiple metropolitan divisions, and (POS), public health exchange and consumer-driven NECTAs don’t line up exactly with the underlying areas covered by their correlate MSAs. In the 2018 Update, there are no metropolitan divisions or NECTAS; all metropolitan health plans (CDHP),3 we report the two largest insurers’ areas are defined as MSAs. As a result of those changes, about 16 percent of MSAs in the 2018 Update were not in previous Updates. Of those, 45 percent were formerly commercial market shares and Herfindahl-Hirschman micropolitan statistical areas, 24 percent were formerly included as NECTAs, 16 percent Indices (HHIs) for 380 metropolitan statistical areas (MSAs), were formerly included as metropolitan divisions, and 13 percent had some other change in delineation, such as in name. The areas that were formerly micropolitan experienced population growth large enough by the time of the July 2015 OMB delineations to newly 1. U.S. Department of Justice and Federal Trade Commission, Horizontal Merger Guidelines. be considered metropolitan.
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