New Data Highlights Monopolistic Nature of Health Insurance in Most States

New data reveals a stark lack of competition in U.S. health insurance, with some states effectively becoming single-insurer monopolies, according to a state-by-state ranking first published by Becker's Payer Issues. The analysis shows Delaware's top insurer controls 93% of the market, while Washington's holds just 24%, illustrating a national patchwork of competitive deserts.

• A concentrated affair: The trend isn't just a few outliers. A recent American Medical Association report deems 97% of U.S. metro areas "highly concentrated," with a single insurer commanding at least half the business in nearly 50% of those regions. "When one or two companies call the shots, premiums rise, options shrink, and patients suffer," said AMA CEO John J. Whyte.

• The usual suspects: While national giants like UnitedHealth Group, Elevance Health, and CVS (Aetna) dominate the field, the real power often lies with Blue Cross Blue Shield affiliates. Collectively, they control 43% of the commercial space and are the top insurer in more than 80% of metro areas, with the AMA flagging states like Alabama, Michigan, and Illinois as some of the least competitive in the nation.

For consumers, this widespread consolidation means fewer choices and higher costs are not just a possibility, but an increasing certainty. Meanwhile, the picture is more complex than just consolidation; the individual market has actually seen booming enrollment over the past decade. Market share data is also available at the county level, showing how competition can vary even within a state.