Two analyses released today demonstrate further that the proposed Anthem-Cigna and Aetna-Humana health insurance mergers would exceed federal antitrust guidelines designed to preserve competition and jeopardize patient access to affordable coverage and care.

The analyses are based on data from the 15th edition of Competition in Insurance: A Comprehensive Study of U.S. Markets, published today by the AMA, which continues to find the majority of commercial health insurance markets in the United States are highly concentrated.

High market concentration can lead to enhanced market power by health insurers on physicians and patients, wherein payments to physicians are lower than those resulting in a competitive market and premiums charged to patients are higher with no added benefits.


Using 2014 data from captured from commercial enrollment in fully and self-insured plans, Competition in Insurance presents the two largest insurers’ commercial market shares and the market concentrations for 388 metropolitan statistical areas (MSAs), the 50 states and the District of Columbia.

“This is the most complete picture available of competition in health insurance markets,” the report said.

In terms of market concentration, it shows:

  • Seventy-one percent of the combined health maintenance organization (HMO), preferred provider organization (PPO), point-of-service (POS) and health exchange (EXCH) markets are highly concentrated.
  • Ninety-three percent of HMO markets are highly concentrated.
  • Eighty-seven percent of PPO markets are highly concentrated.
  • One hundred percent of POS markets are highly concentrated.
  • Ninety-five percent of exchanges are highly concentrated.

In terms of market shares, it found:

  • In 40 percent of the MSAs, one insurer had a combined HMO+PPO+POS+EXCH market share of 50 percent or greater.
  • In 64 percent of the MSAs, one insurer had an HMO market share of 50 percent or greater.
  • In 59 percent of the MSAs, one insurer had a PPO market share of 50 percent or greater.
  • In 86 percent of the MSAs, one insurer had a POS market share of 50 percent or greater.
  • In 75 percent of the MSAs, one insurer had an exchange market share of 50 percent or greater.

In 2015, Anthem announced its intent to acquire Cigna, and Aetna announced plans to acquire Humana. All are among the five largest commercial health insurers in the country.

The motivation for Competition in Insurance has been to help identify markets where mergers would cause competitive harm. The analyses of those mergers using data from this year’s report calculated the changes in market concentration that would result from the mergers and then classified markets based on how anticompetitive the mergers would be.

They found:

  • The Anthem-Cigna merger would diminish competition in 121 metropolitan areas located in all of the 14 states where Anthem is licensed to provide commercial coverage, including California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, Virginia and Wisconsin.
  • The Aetna-Humana merger would diminish competition in 57 metropolitan areas in 15 states, including Arizona, Florida, Georgia, Illinois, Indiana, Kansas, Kentucky, Louisiana, Mississippi, Ohio, Tennessee, Texas, Utah, West Virginia and Wisconsin.

“The AMA analyses show that the Anthem-Cigna and Aetna-Humana mergers would significantly compromise market competition in the health insurance industry and threaten health care access, quality and affordability,” said AMA President Andrew W. Gurman, M.D. “With existing competition in health insurance markets already at alarmingly low levels, federal and state antitrust officials have powerful reasons to block harmful mergers and foster a more competitive marketplace that will operate in patients' best interests."

The AMA and state medical societies have worked behind the scenes in opposition to the two mergers.  The AMA has encouraged the Department of Justice (DOJ) and a number of state attorneys general to oppose both on antitrust grounds.

The AMA believes more can be done in states where state regulators have not yet taken a strong stance against the mergers, and it will work to expand the bi-partisan group of state attorneys general that has already joined the DOJ to block the massive deals.

Competition in Insurance: A Comprehensive Study of U.S. Markets is free to AMA members. It is also available to non-members. To order a copy, visit the AMA store or call (800) 621-8335 and mention OP number 427116.

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