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Premiums Soaring in Consolidated Health Insurance Market

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					    Premiums Soaring in
Consolidated Health Insurance
           Market
Lack of Competition Hurts Rural States,
          Small Businesses
                      MAY 2009




 HEALTH CARE
 FOR AMERICA              NOW!
 QUALITY, AFFORDABLE HEALTH CARE WE ALL CAN COUNT ON.
            www.HealthCareforAmericaNow.org
Acknowledgments
Health Care for America Now would like to thank Alex Lawson, Justin Berrier, Thomas M. Hunt,
Deepika Mehta, Doneg McDonough, Diane Archer, Julie Chinitz, Monica Sanchez, Margarida Jorge,
Dennis P. Osorio, Toby Chaudhuri, the Northwest Federation of Community Organizations and the
Institute for America’s Future.




Note
This report makes use of data published by the American Medical Association (AMA), which is not
a member of the Health Care for America Now coalition. The AMA did not collaborate with HCAN
on this report.




2                                                                          HEALTH CARE FOR AMERICA NOW!
 Families, Businesses Suffer as Insurers Pursue
         Local Monopolies Across U.S.
                       150

                                                                              120

                                                                               90
HeALTH CAre COSTS have surged in recent          employers—and the U.S. economy as a whole—
                                                60
years, outpacing the growth in Americans’        cannot sustain that kind of cost growth. “The
income. Commercial health insurance premiums consequences of lax [antitrust] enforcement
                                                30
have risen four times faster than wages and      for consumers are clear,” then-Senator Barack
have more than doubled in the last nine          Obama said in a September 2007 address to the
                                                 0
years. Shrinking competition among health
      1
                                                 American Antitrust Institute. “The number of
insurance companies is a major cause of these    insurers has fallen by just under 20 percent since
spiraling costs. In the past 13 years more than  2000. These changes were supposed to make the
400 corporate mergers have involved health       industry more efficient, but instead premiums
insurers, and a small number of companies        have skyrocketed.”4
now dominate local markets. The American
Medical Association reports that 94 percent      Insurer consolidation of market share
of insurance markets in the United States are    disproportionately disadvantages rural and
now highly concentrated. Contrary to industry    lower-population states. In Hawaii, rhode
assertions, these mergers have undermined        Island, Alaska, Vermont, Alabama, Maine,
market efficiency; premiums have skyrocketed,    Montana, Wyoming, Arkansas and Iowa, the
increasing more than 87 percent, on average,     two largest health insurers control at least 80
over the past six years. Families and
                        2,3
                                                 percent of the statewide market.5 In Alabama,



   Percentage of Statewide Commercial                                               Percent Increase in Premiums vs Income
    Health Insurance Markets Deemed                                                         Nationwide, 1999–2007
        “Highly Concentrated” Under
   U.S. Department of Justice Guidelines
                                                                                150

                                                      Highly                                                120%
                                                      Concentrated              120

                                         94%                                        90

                                                                                    60

                                                                                                                                             29%
                                                                                    30

                                 6%
                                                                                     0
                                                                                                      Average U.S.                   Average U.S .Wage
                             Not Highly                                                             Premium Growth                        Growth
                             Concentrated

    Source: American Medical Association, “Competition in Health Insurance:              Sources: The Henry J. Kaiser Family Foundation. Employee Health Benefits:
    A Comprehensive Study of U.S. Markets: 2008 Update.”                                 2008 Annual Survey.



                                                                                                            Insurance
HEALTH CARE FOR AMERICA NOW!                                                                                                                                         3
the biggest insurer holds 89 percent of the                              of the market.10 In Bangor, Maine, the biggest
statewide market, the highest rate in the nation                         insurer controls 74 percent of the market.11 The
for a single company. More populous states                               market leader in the Battle Creek, Michigan, area
have serious market concentration problems as                            holds 83 percent, and 57 percent of the Lincoln,
well. Virginia’s largest health insurer controls                         Nebraska, market is served by a lone insurer.12
a 50 percent share of the statewide market.6
Small business especially suffers from insurers’                         Americans are paying for this unchecked private
growing market consolidation. According                                  insurance industry consolidation in the form
to a nationwide survey by the Government                                 of higher health premiums and a growing
Accountability Office, the median statewide                              number of uninsured people. Meanwhile,
market share of the largest insurer selling                              insurance company profits and compensation
coverage to small employer groups increased to                           for the industry’s top executives are surging,
47 percent in 2008 from 33 percent in 2002.7                             and the industry invests more in rewarding
                                                                         its shareholders than it does in ensuring
At the local level, where distinct provider                              good health outcomes for people with costly
markets exist in metropolitan areas,8 the health                         conditions. In several recent reports, leading
insurance industry’s market concentration is                             experts on the American health care system
even more severe. The U.S. Justice Department                            have detailed how the injection of a robust new
considers a market “highly concentrated” if one                          public health insurance plan as a competitor
company holds more than a 42 percent share of                            for private plans would expand choice for
that market,9 a level that is common in Virginia                         individuals and business and drive competition
and more than 30 other states. In Abilene, Texas,                        on price and quality in local markets across the
for example, the top insurer controls 85 percent                         country.13,14,15,16


           150                                                                                                                                    150

                          Median Statewide Market Share of Largest
           120          Health Insurer Covering Small-Business Groups
                                                                                                                                                  120

            90                                                                                                                                         90

            60                                                      43%                             47%                                                60
                                   33%
            30                                                                                                                                         30

              0                   2002                             2005                            2008
                                                                                                                                                        0


                    Source: Government Accountability Office,”Private Health Insurance: 2008 Survey Results on Number and
                    Market Share of Carriers in the Small Group Health Insurance Market,” 2009.




4                                                                                                                       HEALTH CARE FOR AMERICA NOW!
Insurance Market Concentration: Ranked List (2007)
                                                                                                                                           Combined
                                                                                     Market                                        Market
                                             Health Insurer with                                      Health Insurer with                 Market Share
 Rank             State                                                              Share                                         Share
                                            Largest Market Share                                      No. 2 Market Share                  % of Top Two
                                                                                       %                                             %
                                                                                                                                            Insurers
   1       Hawaii                    Blue Cross Blue Shield HI                          78        Kaiser Permanente                 20         98
   2       Rhode Island              Blue Cross Blue Shield RI                          79        UnitedHealth Group Inc.           16         95
   3       Alaska                    Premera Blue Cross                                 60        Aetna Inc.                        35         95
   4       Vermont                   Blue Cross Blue Shield VT                          77        CIGNA Corp.                       13         90
   5       Alabama                   Blue Cross Blue Shield AL                          83        Health Choice                      5         88
   6       Maine                     WellPoint Inc. (BCBS)                              78        Aetna Inc.                        10         88
   7       Montana                   Blue Cross Blue Shield MT                          75        New West Health Services          10         85
   8       Wyoming                   Blue Cross Blue Shield WY                          70        UnitedHealth Group Inc.           15         85
   9       Arkansas                  Blue Cross Blue Shield AR                          75        UnitedHealth Group Inc.            6         81
  10       Iowa                      Wellmark BC and BS                                 71        UnitedHealth Group Inc.            9         80
  11       Missouri                  WellPoint Inc. (BCBS)                              68        UnitedHealth Group Inc.           11         79
  12       Minnesota                 Blue Cross Blue Shield MN                          50        Medica                            26         76
  13       South Carolina            Blue Cross Blue Shield SC                          66        CIGNA Corp.                        9         75
  14       Indiana                   WellPoint Inc. (BCBS)                              60        M*Plan (HealthCare Group)         15         75
  15       New Hampshire             WellPoint Inc. (BCBS)                              51        CIGNA Corp.                       24         75
  16       Idaho                     Blue Cross of ID                                   46        Regence BS of Idaho               29         75
  17       Louisiana                 Blue Cross Blue Shield LA                          61        UnitedHealth Group Inc.           13         74
  18       Michigan                  Blue Cross Blue Shield MI                          65        Henry Ford Health System           8         73
  19       North Carolina            Blue Cross Blue Shield NC                          53        UnitedHealth Group Inc.           20         73
  20       Maryland                  CareFirst Blue Cross Blue Shield                   52        UnitedHealth Group Inc.           19         71
  21       Oklahoma                  BCBS OK                                            45        CommunityCare                     26         71
  22       Georgia                   WellPoint Inc. (BCBS)                              61        UnitedHealth Group Inc.            8         69
  23       Kentucky                  WellPoint Inc. (BCBS)                              59        Health Partners                   10         69
  24       Illinois                  HCSC (Blue Cross Blue Shield)                      47        WellPoint Inc. (BCBS)             22         69
  25       Nebraska                  Blue Cross Blue Shield NE                          44        UnitedHealth Group Inc.           25         69
  26       Utah                      Regence Blue Cross Blue Shield                     47        Intermountain Healthcare          21         68
  27       Massachusetts             Blue Cross Blue Shield MA                          50        Tufts Health Plan                 17         67
  28       Connecticut               WellPoint Inc. (BCBS)                              55        Health Net Inc.                   11         66
  29       Arizona                   Blue Cross Blue Shield AZ                          43        UnitedHealth Group Inc.           22         65
  30       Delaware                  CareFirst Blue Cross Blue Shield                   42        Coventry Health Care Inc.         23         65
  31       New Mexico                HCSC (Blue Cross Blue Shield)                      35        Presbyterian Hlth                 30         65
  32       Tennessee                 Blue Cross Blue Shield TN                          50        Total Choice                      12         62
  33       Virginia                  WellPoint Inc. (BCBS)                              50        Aetna Inc.                        11         61
  34       Washington                Premera Blue Cross                                 38        Regence Blue Shield               23         61
  35       Texas                     HCSC (Blue Cross Blue Shield )                     39        Aetna Inc.                        20         59
  36       New Jersey                Horizon Blue Cross Blue Shield                     34        Aetna Inc.                        25         59
  37       Ohio                      WellPoint Inc. (BCBS)                              41        Medical Mutual of Ohio            17         58
  38       Nevada                    Sierra Health                                      29        WellPoint Inc. (BCBS)             28         57
  39       Colorado                  WellPoint Inc. (BCBS)                              29        UnitedHealth Group Inc.           24         53
  40       Oregon                    Providence Health & Services                       25        Regence Blue Cross Blue Shield    23         48
  41       New York                  GHI                                                26        WellPoint Inc. (Empire BCBS)      21         47
  42       Florida                   Blue Cross Blue Shield FL                          30        Aetna Inc.                        15         45
  43       California                Kaiser Permanente                                  24        WellPoint Inc. (Blue Cross)       20         44
Source: American Medical Association, “Competition in health insurance: A comprehensive study of U.S. Markets: 2007 Update.”
Some states are not presented because available data does not reliably capture a sufficient portion of the insured population.

HEALTH CARE FOR AMERICA NOW!                                                                                                                         5
                          A National Problem

Anti-Competitive Behavior                           in 2002, according to the GAO report. Of the
Lack of competition in the insurance market-        29 states providing information in the 2002
place poses unique dangers to consumers.            and 2008 surveys, 24 states saw increases in the
David Balto, former policy director of the          market share of the top carrier. Those increases
Bureau of Competition of the Federal Trade          ranged from about two to 39 percentage
Commission, said of the health insurance            points.20 The combined market share of the
industry that a “vital component to assuring the    five largest insurers providing coverage to
competitive marketplace is protecting the ability   small business groups represented at least
of consumers to choose between alternatives.        three-quarters of the market in 34 of 39 states,
Antitrust enforcement against anti-competitive      compared to 26 of 34 states reported in 2005
mergers and exclusionary conduct is essential to    and 19 of 34 states reported in 2002.21
a competitive marketplace. This unprecedented
level of concentration and the lack of antitrust    Health insurers play a unique role as both sellers
enforcement pose serious policy and health          of insurance and buyers of health care services.
care concerns.”17 Other experts agree, saying       These companies use their power as buyers
increases in the number of competitors are          against the smaller medical providers while
associated with lower health plan costs and         cooperating with larger providers to increase
premiums and that decreases in the number           profits for both.22,23 With only a handful of
of competitors are associated with higher plan      large insurers, physician practices often have no
costs and premiums.18                               choice but to accept the prices offered without
                                                    bargaining effectively. Larger providers, such
On May 5, 2009, the Senate Finance Committee        as academic medical centers, can use their size
held a roundtable discussion on health reform.      and stature to negotiate rates. However, as long
Scott Serota, the chief executive officer of the    as insurers can continue to pass costs on to
Blue Cross and Blue Shield Association, asserted    consumers in the form of higher premiums and
that “it is a mischaracterization to indicate the   cost-sharing, insurers are not necessarily hurt by
markets are not competitive today. The median       paying higher fees to select providers; insurers
number of competitors in any market today is        would only be affected if other insurance
27, so there are sufficient competitors today in    companies were to get the same medical
the marketplace to create a competitive market.”    services for less and use the savings to woo away
The same Government Accountability Office           customers.
study that counted the 27 competitors in each
state’s market for small-group coverage also        Without competition among insurers, insurers
reported that the median market share for Blue      have no reason to drive costs down, and
Cross Blue Shield carriers in 38 states was about   without additional choices in the marketplace,
51 percent, up from 44 percent in 2005 and 34       consumers have no choice but to continue to
percent in 2002.19                                  pay inflated prices.

The median market share of the largest carrier      These are not theoretical behaviors. Insurers
that provides small-group coverage increased to     have been exposed numerous times rigging the
about 47 percent in 2008 from the 43 percent        system. An investigation by the Boston Globe
reported in 2005 and the 33 percent reported        in December 2008 exposed a, “gentleman’s


6                                                                               HEALTH CARE FOR AMERICA NOW!
agreement that accelerated [the] health cost           unable or unwilling to ‘push back’ and restrain
crisis.”24 The chiefs of the largest provider          payments to providers, they have been able to
group in Massachusetts and the state’s largest         pass costs on to the purchasers of insurance
health insurer made a handshake deal to avoid          and maintain their profit margins.”33 In a
creating written evidence of the arrangement.          recent paper Jacob Hacker of the University
In that agreement, Blue Cross Blue Shield of           of California, Berkeley, showed that Medicare
Massachusetts pledged to increase payments             demonstrates it is possible for savings to be
if the provider group, Partners HealthCare,            shared with individuals instead of being taken
ensured that no other health plan would be             as profit. Between 1997 and 2006, private health
charged less.25                                        insurance spending per enrollee grew at an
                                                       annual rate of 7.3 percent, compared with an
When small, independent providers want to              annual growth rate of 4.6 percent in Medicare-a
negotiate with multiple health plans, large            37 percent difference.34
insurers exert enormous pressure to stop them.
The statewide trade group for doctors in New           Oversized Profits, Executive Pay
York sued UnitedHealth Group Inc., the nation’s        Profits at 10 of the country’s largest publicly-
second-largest health insurer by enrollment, for       traded health insurance companies in 2007
allegedly using illegal coercion in just such a        rose 428 percent from 2000 to 2007, from
scheme to limit competition.26                         $2.4 billion to $12.9 billion, according to U.S.
                                                       Securities and exchange Commission filings.
In a separate matter UnitedHealth agreed to pay        In 2007 alone the chief executive officers at
$400 million to settle multiple suits alleging         these companies collected combined total
price fixing and other anti-competitive                compensation of $118.6 million—an average of
behavior.27,28 The attorney general of New York,       $11.9 million each. That is 468 times more than
Andrew Cuomo, stated that this was, “a huge            the $25,434 an average American worker made
scam that affected hundreds of millions of             that year.35
Americans [who were] ripped off by their health
insurance companies.”29 Numerous other insurers        The rising premiums paid by employers and
were implicated in the same scheme, including          families not only generate oversized net
Aetna Inc., Cigna Corp. and WellPoint Inc.30           earnings, they also fuel controversial financial
                                                       maneuvers designed to pump up insurers’ stock
If they chose to, private insurers could use their     prices, which in turn help executives reach their
market power to drive hard bargains and lower          personal bonus targets. From 2003 through 2008
costs, but instead they have passed along these        the seven largest publicly traded health insurers,
costs through higher premiums to enrollees and         which cover 116 million Americans, spent $52.4
employers. John Holahan and Linda Blumberg             billion buying back their own shares. Buybacks
of the Urban Institute note that “[d]ominant           reduce the number of shares that are publicly
insurers do not seem to use their market power         traded, raising the value of existing shareholders’
to drive hard bargains with providers.”31 Large        stakes. Companies make share repurchases with
insurers do not face pressure from smaller             excess cash on hand or with borrowed funds.
insurers, which use premiums that “shadow”             Buybacks are a way of removing money from
those of dominant insurers. Consequently,              a company’s balance sheet for the benefit of
insurers are able to pass costs on to individuals.32   investors, reflecting management’s decision
                                                       not to invest in improving a company’s
The Medicare Payment Advisory Commission, a            operations, making the health system run more
respected expert panel appointed by Congress,          efficiently or reducing customers’ premiums.
reported that while, “insurers appear to be            The companies prefer to hand over the money


HEALTH CARE FOR AMERICA NOW!                                                                            7
to Wall Street investors and executives whose                                           marketplace.36 Instead health insurance
soaring compensation packages depend on                                                 companies use their size to engage in anti-
reaching earnings-per-share goals that often                                            competitive behavior, rig the system to impose
would not be achieved without buybacks.                                                 premium increases that grow faster than
                                                                                        individuals, families, and businesses can afford,
Insurers have demonstrated through their                                                and ensure “astounding levels of profit” for
actions that they do not use consolidation                                              themselves and their shareholders.37
to bring efficiency to the health insurance


Profits and CEO Compensation for 10 Major Private Health Insurance Companies

                                            2000 Net              2007 Net          % Change                                                  Value of Total 2007
                                                                                                        Chief Executive Officer
             Company                         Income                Income           2007 vs.                                                    Compensation
                                                                                                                2007
                                            (millions)            (millions)          2000                                                         (millions)

    Aetna                                   $     127          $ 1,831                 1,342            Ronald A. Williams                           $ 23.0
    Amerigroup Corp.                                19                 116                511           Jeffrey L. McWaters*                                 8.2
    Centene Corp.                                     7                  73              943            Michael F. Neidorff                                  8.8
    CIGNA Corp.                                   987                1,115                  13          H. Edward Hanway                                    25.8
    Coventry Health Care Inc.                       61                 626               926            Dale B. Wolf*                                       14.9
    Health Net Inc.                               164                  194                  18          Jay M. Gellert                                       3.7
    Humana Inc.                                     90                 834               827            Michael McCallister                                 10.3
    UnitedHealth Group Inc                        736               4,654                532            Stephen J. Hemsley                                  13.2
    Universal American Corp.                        23                   84              265            Richard A. Barasch                                   1.6
    WellPoint                                     226               3,345              1,380            Angela F. Braly                                      9.1
    Total                                   $ 2,440            $ 12,873                  428                                                         $ 118.6
Source: U.S. Secutiries and Exchange Commission filings. The companies are listed in the Corporate Library’s “Insurance Health and Disability” category.
All companies are members of America’s Health Insurance Plans, the industry trade group.
*No longer CEO.




Stock Repurchases (in millions)
                                                                                                                  United
                                                                                                                                                           Annual Total
                   Aetna               Cigna          Coventry          Health Net           Humana               Health            Wellpoint
                                                                                                                                                               All
                                                                                                                  Group
    2003         $ 445             $        0         $       6            $ 288              $ 44              $ 1,607             $      217              $ 2,608
    2004            1,493                676                97                   89               67                3,446                    82                5,950
    2005            1,650              1,618                17                  0.4                 2               2,557                  333                 6,178
    2006            2,323              2,765              269                  254                26                2,345               4,550                 12,532
    2007            1,696              1,185              439                  232                27                6,599                6,151                16,330
    2008            1,788               378               323                  243               106                2,684                3,276                 8,798
    Total        $ 9,394           $ 6,622            $ 1,152              $ 1,106            $ 273            $ 19,238             $ 14,611                $ 52,396
Source: Annual 10-K filings, Securities and Exchange Commission.




8                                                                                                                                       HEALTH CARE FOR AMERICA NOW!
Premiums Rising Out of Reach                         For a typical family that moves from group to
rising health premiums are exacerbating income       individual coverage with identical benefits,
inequality and making coverage too costly for        annual premiums will rise by more than
many Americans. The Kaiser Family Foundation         $2,000.43 The biggest losers in the individual
found that employer-sponsored health                 market are those who are less healthy or coping
insurance premiums have more than doubled in         with a chronic illness. Two-thirds of respondents
the last nine years, a rate four times faster than   in a recent survey said they found it difficult or
wage increases.38 A study by McKinsey Global         impossible to find affordable coverage in the
Institute of widening income gaps among U.S.         individual market.44 The chronically ill aren’t the
households found that rising employer-health         only ones whose applications for coverage are
insurance premiums constitute a much larger          rejected or whose rates are aggressively raised by
share of the income of lower-paid employees          insurers; people who don’t consider themselves
than higher-paid ones, and consume a bigger          to be sick, such as women with a history of
share of the household budget for lower income       cesarean section, are treated in the same way.45
individuals who are lucky enough to have access
to a workplace health plan. McKinsey found           With premiums rising faster than peoples’ ability
that in the bottom income group only one in          to pay them, many Americans are being forced
five workers is covered. Moreover, families in       to choose between no coverage and inadequate
the lowest income category spend 20 percent          coverage. Through a wave of consolidation,
of household income on contributions to              private health insurers have rigged the system to
employer-sponsored health plan premiums,             manufacture oversized profits while the country
compared with only 3.3 percent for families in       pays the price in the form of high premiums and
the top income group. The report concludes           poorer health.
that rising health costs, reflected by spiraling
insurance premiums, are widening income-             Creating Healthy Competition
group discrepancies as measured by participation     A public health insurance plan option would
rates in employer-paid health plans and insured      introduce a healthy dose of competition in the
workers’ ability to afford premiums and out-of-      arenas of cost and quality. In a recent proposal
pocket health care costs.39                          the Commonwealth Fund recommended the
                                                     creation of a public health insurance plan,
As premiums have skyrocketed, many businesses        saying it “plays a central role in harnessing
have found themselves unable to offer their          markets for positive change.”46 establishing
workers health benefits. One result is that          a public health insurance plan, according to
more than 47 million people, or one out of           Commonwealth, would introduce “a new
seven Americans under age 65, are uninsured.40       competitive dynamic in insurance markets and
Low-wage workers are especially hard hit. The        provide a strong foundation for payment and
McKinsey survey found that 78 percent of low-        system reforms.”47
wage workers don’t receive health benefits from
their employers.41 Those not offered employer-       In a March 2009 report, the Center for American
sponsored health coverage must find insurance        Progress said, “Fortunately, our nation’s health
in the individual market.                            insurance market can be fixed with a big dose
                                                     of what fixes most sectors of our economy—
The individual market generally provides             healthy, well-supervised competition. One of
more expensive plans with less comprehensive         the best ways to introduce this much-needed
benefits. Insurers base individual coverage          competition is for the federal government
premiums on sex, age and health status,              to offer a public health insurance plan that
and they deny applications at a higher rate          can compete with private insurers within an
because risk usually isn’t pooled effectively.42     insurance ‘exchange’ that ensures public and

HEALTH CARE FOR AMERICA NOW!                                                                            9
private health insurance plans compete equally       Private and public insurance plans should
and transparently in the public marketplace.”48      compete side by side on a level playing field
The public plan would induce innovations in          to reward those that deliver better value and
treatment, thereby improving the quality of care     do the best job of improving their enrollees’
received by patients, according to the Urban         health. Public health insurance can offer a
Institute.49                                         benchmark for private plans and a source of
                                                     stability for enrollees, especially those with the
Berkeley political scientist Jacob Hacker recently   greatest medical needs. Private plans would
detailed how a public health insurance plan          provide an alternative for those who feel public
could be implemented on a level playing field        insurance wouldn’t serve their needs, as well
with private health insurers, ensuring that          as maintain pressure for the public health
quality of care would improve and cost growth        insurance plan and other private competitors
would be slowed.                                     to find innovations in benefit design and care
                                                     management.51 A critical element of a functional
Without the introduction of real competition         competitive marketplace is to protect the ability
by means of a public health insurance plan, he       of consumers to choose between genuine
concluded, “private health insurers, regardless      alternatives. The highly consolidated health
of the degree of regulation, will still be able to   insurance industry we have today, with its
game the system to maximize their profits while      unacceptable concentration of market power,
failing to provide health security over the long     does not allow this.
run—the same ‘heads, I win; tails, you lose’ deal
we have seen in our financial sector.”50




10                                                                               HEALTH CARE FOR AMERICA NOW!
ENDNOTES
1
 Kaiser Family Foundation & Health research And education Trust, “employer Health Benefits: 2008 Annual Survey.” Accessed at http://
ehbs.kff.org/pdf/7790.pdf.
2
 David Balto, “The right Prescription? Consolidation in The Pennsylvania Health Insurance Industry,” Senate Judiciary Subcommittee
on Antitrust, Competition Policy, and Consumer rights, July 31, 2008. Accessed at http://www.americanprogressaction.org/issues/2008/
balto_testimony.html.
3
 Karen Davis, “Slowing the Growth of US Health Care expenditures: What Are the Options?,” The Commonwealth Fund, 2007. Accessed
at http://www.commonwealthfund.org/usr_doc/Davis_slowinggrowthUShltcareexpenditureswhatareoptions_989.pdf.
4
 Barack Obama, “Statement of Senator Barack Obama for the American Antitrust Institute,” September 2007. Accessed at http://www.
antitrustinstitute.org/archives/files/aai-%20Presidential%20campaign%20-%20Obama%209-07_092720071759.pdf.
5
 AMA data in this report are based on combined enrollment in preferred provider organizations (PPOs) and health maintenance
organizations (HMOs) in states and metropolitan statistical areas (MSAs) as defined by the U.S. Census Bureau. The AMA calculates
market share by dividing an insurer’s enrollment in a given product by the total enrollment across all insurers in a market multiplied by
100. Total enrollment is for commercial products only, including self-insured employer-sponsored PPO plans and individual coverage,
and does not include Medicare, Medicaid, or Children’s Health Insurance Program enrollments. Self-insured employer plans refer to PPOs
only.
6
    American Medical Association, “Competition in health insurance: A comprehensive study of U.S. Markets: 2008 update.”
7
 Government Accountability Office, “Private Health Insurance: 2008 Survey results on Number and Market Share of Carriers in the Small
Group Health Insurance Market, “February, 2009. Accessed at http://www.gao.gov/new.items/d09363r.pdf.
8
  Local markets are defined using the U.S. Census Bureau standard for metropolitan statistical areas. each of the 363 metropolitan areas
in the U.S. has a core urbanized area of 50,000 or more inhabitants forming a population nucleus, together with adjacent communities
having a high degree of social and economic integration with that core. Census reports that 83.6 percent of the U.S. population lives in
metropolitan areas. See http://www.census.gov/Press-release/www/releases/archives/population/013426.html.
9
 US Department of Justice, “The Herfindahl-Hirschman Index.” Accessed at http://www.usdoj.gov/atr/public/guidelines/horiz_book/
15.html.
10
     American Medical Association, “Competition in health insurance: A comprehensive study of U.S. Markets: 2008 update.”
11
     American Medical Association, “Competition in health insurance: A comprehensive study of U.S. Markets: 2008 update.”
12
     Ibid.
13
  Jacob Hacker, “The Case for Public Plan Choice In National Health reform,” 2008. Accessed at http://institute.ourfuture.org/files/
Jacob_Hacker_Public_Plan_Choice.pdf.
 John Holahan & Linda Blumberg, “Can a Public Insurance Plan Increase Competition and Lower the Costs of Health reform?,”
14

Urban Institute Health Policy Center, 2008.
15
  Commission on a High Performance Health System “The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies
to Pave the Way,” The Commonwealth Fund, Feburary, 2009. Accessed at http://www.commonwealthfund.org/Content/Publications/
Fund-reports/2009/Feb/The-Path-to-a-High-Performance-US-Health-System.aspx.
 Peter Harbage and Karen Davenport, “A Public Health Insurance Plan that Delivers Market Discipline,” Center for American Progress,
16

March 2009. Accessed at http://www.americanprogressaction.org/issues/2009/03/public_plan.html.
 David Balto, “The right Prescription? Consolidation in The Pennsylvania Health Insurance Industry,” Senate Judiciary Subcommittee
17

on Antitrust, Competition Policy, and Consumer rights, July 31, 2008. Accessed at http://www.americanprogressaction.org/issues/2008/
balto_testimony.html.
 Lawton Burns, “Testimony at Hearings on IBC - Highmark Merger,” Senate Judiciary Committee, Subcommittee on Antitrust April 9,
18

2007. Accessed at http://judiciary.senate.gov/hearings/testimony.cfm?id=2677&wit_id=6272.
 Government Accountability Office, “Private Health Insurance: 2008 Survey results on Number and Market Share of Carriers in the
19

Small Group Health Insurance Market, “February, 2009. Accessed at http://www.gao.gov/new.items/d09363r.pdf.
20
     Ibid.
21
     Ibid.
 Stephen Foreman, “Written Comments of the Pennsylvania Medical Society: Federal Trade Commission Workshop on Health Care
22

Competition Law and Policy,” September, 2002. Accessed at http://www.ftc.gov/ogc/healthcare/pms.pdf.
 Medicare Payment Advisory Commission, “report to the Congress: Medicare Payment Policy,” March 2009. Accessed at http://www.
23

medpac.gov/documents/Mar09_entirereport.pdf.
 Globe Spotlight Team, “A handshake that made healthcare history,” The Boston Globe, December, 2008. Accessed at http://www.
24

boston.com/news/health/articles/2008/12/28/a_handshake_that_made_healthcare_history/.
25
     Ibid.
 richard Perez-Pena, “Doctors’ Group Sues Two Insurers, Charging Unfair Coercion,”The New York Times, September, 2006.
26

Accessed at http://www.nytimes.com/2006/09/21/nyregion/21oxford.html.


HEALTH CARE FOR AMERICA NOW!                                                                                                           11
27
  Lewis Krauskopf, “UnitedHealth settles payment suits for $350 million,” reuters, January 15 2009. Accessed at http://www.reuters.com/
article/rbssFinancialServicesAndrealestateNews/idUSN1531133620090115.
28
  Melissa Dahl, “Health Insurerer Accused of Overcharging Millions,” MSNBC, January 13, 2009. Accessed at http://www.msnbc.msn.
com/id/28635329/.
29
     Ibid.
30
     Ibid.
 John Holahan and Linda Blumberg, “Can a Public Insurance Plan Increase Competition and Lower the Costs of Health reform?,”
31

Urban Institute Health Policy Center, 2008.
32
     Ibid.
 Medicare Payment Advisory Commission, “report to the Congress: Medicare Payment Policy,” March 2009 Pg. 59. Accessed at http://
33

www.medpac.gov/documents/Mar09_entirereport.pdf.
 Jacob Hacker, “The Case for Public Plan Choice In National Health reform,” 2008. Accessed at http://institute.ourfuture.org/files/Jacob_
34

Hacker_Public_Plan_Choice.pdf.
35
     U.S. Census Bureau, “2007 American Community Survey 1-Year estimate.” See http://factfinder.census.gov.
 Stephen Foreman, “Written Comments of the Pennsylvania Medical Society: Federal Trade Commission Workshop on Health Care
36

Competition Law and Policy,” September, 2002. Accessed at http://www.ftc.gov/ogc/healthcare/pms.pdf.
 Stephen Foreman, “Proposed Consolidation of Highmark and Independence Blue Cross,” July 2008. Accessed at http://www.ins.state.
37

pa.us/ins/lib/ins/highmark-ibc/0943.pdf.
 Kaiser Family Foundation & Health research And education Trust, “employer Health Benefits: 2008 Annual Survey.” Accessed at
38

http://ehbs.kff.org/pdf/7790.pdf.
 Byron Auguste, et al., “How Health Care Costs Contribute to Income Disparity in the United States,” The McKinsey Global Institute,
39

March 2009.
40
     David Balto, “The right Prescription? Consolidation in The Pennsylvania Health Insurance Industry.”
 Byron Auguste, et al.,”How Health Care Costs Contribute to Income Disparity in the United States,” The McKinsey Global Institute,
41

March 2009.
42
  Buntin, Melinda Beeuwkes, M. Susan Marquis, and Jill M. Yegian, “The role of the Individual Health Insurance Market and Prospects
for Change,” Health Affairs 23, No. 6, p.79, 2004.
 Buchmueller, Thomas, Sherry A. Glied, Anne royalty, and Katherine Swartz, “Cost and Coverage Implications Of the McCain Plan to
43

restructure Health Insurance,” Health Affairs 27, no. 6, 2008.
44
     Ibid.
 Grady, D., “After Caesareans, Some See Higher Insurance Cost,” New York Times, June 1, 2008, accessed March 26, 2009 at http://www.
45

nytimes.com/2008/06/01/health/01insure.html.
46
  The Commonwealth Fund Commission on a High Performance Health System, The Path to a High Performance U.S. Health System:
A 2020 Vision and the Policies to Pave the Way, February 2009.
47
     Ibid.
 Peter Harbage and Karen Davenport, “Competitive Health Care: A Public Health Insurance Plan that Delivers Market Discipline,” http://
48

www.americanprogressaction.org/issues/2009/03/public_plan.html.
 John Holahan and Linda Blumberg, “Can a Public Insurance Plan Increase Competition and Lower the Costs of Health reform?,”
49

Urban Institute Health Policy Center, 2008.
 Jacob Hacker, “Healthy Competition: How to Structure Public Health Insurance Plan Choice to ensure risk-Sharing, Cost Control,
50

and Quality Improvment,” April 2009. Accessed at http://www.ourfuture.org/files/Hacker_Healthy_Competition_FINAL.pdf.
51
     Ibid.




12                                                                                                         HEALTH CARE FOR AMERICA NOW!
Appendix A
 State Data
         Alabama Consumers Pay the Price
        For Health-Insurance Market Failure

•	Blue	Cross	Blue	Shield	of	Alabama,	the	state’s	                             •	For	family	health	coverage	in	Alabama,	
  dominant	health	insurer,	controls	83	percent	                                 the	average	employer’s	portion	of	annual	
  of	the	commercial	market.1                                                    premiums	rose	78	percent,	while	the	average	
•	Blue	Cross	Blue	Shield	of	Alabama’s	net	                                      worker’s	share	grew	by	83	percent.5
  income	grew	by	148	percent	from	2004	to	                                    •	Between	2000	and	2007,	the	median	earnings	
  2007,	rising	from	$28.9	million	to	$71.7	                                     of	Alabama	workers	increased	17	percent,	from	 	
  million.	In	the	same	time	its	membership	grew	                                $21,627	to	$25,298.	During	that	time	health	
  by	only	5.5	percent.2                                                         insurance	premiums	for	Alabama	working	families		
•	Health	insurance	premiums	for	Alabama	                                        rose	4.7	times	faster	than	median	earnings.6
  working	families	have	skyrocketed,	increasing	
  79	percent	from	2000	to	2007.3                                              When	a	firm	has	more	than	a	42	percent	share		
•	For	family	health	coverage	in	Alabama	during	                               of	a	single	market,	the	U.S.	Justice	Department	
  that	time,	the	average	annual	combined	                                     considers	that	market	to	be	“highly	concentrated.”		
  premium	for	employers	and	employees	rose	                                   This	means	that	an	insurer	could	raise	premiums	
  from	$6,262	to	$11,216.4                                                    and/or	reduce	the	variety	of	plans	or	quality	of	
                                                                              services	offered	to	customers	with	impunity.7




  Alabama Commercial Health Insurance                                           Percent Increase in Premiums vs Income
         Market Concentration                                                            in Alabama, 2000–2007
                                                                              150
                                                        Blue Cross
                                                        and Blue Shield       120
                                                        of Alabama
                                         83%
                                                                              90                    79%

                                                                              60

                         12%                                                  30
                                                                                                                                    17%
            All
                                5%
            Others                                                             0
                                                                                                 Premiums                  Individual Income
                             Health Choice


    Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
    A Comprehensive Study of U.S. Markets: 2007 Update.”




HEALTH CARE FOR AMERICA NOW!                                                                                                                  ALABAMA • A1
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Northwest	Federation	of	Community	Organizations,	“Insuring	Health	or	Ensuring	Profit?”	2008.	Accessed	at	http://www.nwfco.org/
pubs/2008.0727_insuring.health.or.ensuring.profit.pdf.
3	
  Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
4	
  Ibid.
5
 Ibid.
6
 Ibid.
7
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/15.
html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	Anticompetitive	
Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.aha.org/aha/
content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A2 • ALABAMA                                                                                                HEALTH CARE FOR AMERICA NOW!
           Alaska Consumers Pay the Price
          For Health-Insurance Market Failure
  •	Premera	Blue	Cross,	the	state’s	most	powerful	                                premiums	rose	81	percent,	while	the	average	
    insurer,	controls	60	percent	of	the	commercial	                               worker’s	share	grew	by	54	percent.4
    market.	Together	with	Aetna	Inc.,	Alaska’s	                                 •	Between	2000	and	2007,	the	median	earnings	
    second	largest	health	insurer,	they	control	95	                               of	Alaska	workers	increased	13	percent,	from	
    percent	of	the	market.1                                                       $27,373	to	$30,931.	During	that	time	health	
  •	Health	insurance	premiums	for	Alaska	working	                                 insurance	premiums	for	Alabama	working	families		
    families	have	skyrocketed,	increasing	74	                                     rose	5.7	times	faster	than	median	earnings.5
    percent	from	2000	to	2007.2
  •	For	family	health	coverage	in	Alaska	during	                                When	a	firm	has	more	than	a	42	percent	share		
    that	time,	the	average	annual	premium	                                      of	a	single	market,	the	U.S.	Justice	Department	
    (employer	and	worker	share	of	premiums	                                     considers	that	market	to	be	“highly	concentrated.”		
    combined)	rose	from	$7,456	to	$12,942.3                                     This	means	that	an	insurer	could	raise	premiums	
  •	For	family	health	coverage	in	Alaska,	the	                                  and/or	reduce	the	variety	of	plans	or	quality	of	
    average	employer’s	portion	of	annual		                                      services	offered	to	customers	with	impunity.6
    	
    	


      Alaska Commercial Health Insurance                                          Percent Increase in Premiums vs Income
             Market Concentration                                                           in Alaska, 2000–2007
                                                                                150

             Others                                 Premera Blue Cross          120
                      5%
                                                                                90
                                                                                                      74%
                                              60%
                                                                                60
                       35%
                                                                                30
                                                                                                                                      13%

                                                                                 0
                  Aetna                                                                            Premiums                  Individual Income



      Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
      A Comprehensive Study of U.S. Markets: 2007 Update.”




  HEALTH CARE FOR AMERICA NOW!                                                                                                                   ALASKA • A3


150
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2	
  Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
3	
  Ibid.
4	
  Ibid.
5	
  Ibid.
6	
  US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/15.
html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	Anticompetitive	
Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.aha.org/aha/
content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A4 • ALASKA                                                                                                 HEALTH CARE FOR AMERICA NOW!
         Arizona Consumers Pay the Price
        For Health-Insurance Market Failure
•	Blue	Cross	and	Blue	Shield	of	Arizona,	the	                                 •	For	family	health	coverage	in	Arizona,	
  state’s	dominant	insurer,	controls	43	percent	of	                             the	average	employer’s	portion	of	annual	
  the	commercial	market.1                                                       premiums	rose	83	percent,	while	the	average	
•	In	2007,	Blue	Cross	and	Blue	Shield	of	Arizona	                               worker’s	share	grew	by	76	percent.6
  recorded	a	profit	of	$96	million.2		                                        •	Between	2000	and	2007,	the	median	earnings	
•	From	2004	to	2007	another	top	Arizona	                                        of	Arizona	workers	increased	23	percent,	from	
  insurers,	PacifiCare	(which	was	acquired	by	                                  $22,961	to	$28,283.	During	that	time	health	
  UnitedHealth	Group	in	2005)	saw	its	profit	                                   insurance	premiums	for	Arizona	working	
  in	the	state	grow	by	59	percent,	even	as	                                     families	rose	3.5	times	faster	than	median	
  membership	fell	32	percent.3                                                  earnings.7
•	Health	insurance	premiums	for	Arizona	
  working	families	have	skyrocketed,	increasing	                              If	one	company	holds	more	than	a	42	percent		
  81	percent	from	2000	to	2007.4                                              share	of	a	market	the	U.S.	Justice	Department	
•	For	family	health	coverage	in	Arizona	during	                               would	consider	that	market	“highly	
  that	time,	the	average	annual	combined	                                     concentrated.”8	This	means	that	an	insurer,	with	
  premium	for	employers	and	employees	rose	                                   impunity,	could	raise	premiums	and/or	reduce	
  from	$6,767	to	$12,253.5                                                    the	variety	of	plans	or	quality	of	services	offered	
                                                                              to	customers.9




   Arizona Commercial Health Insurance                                          Percent Increase in Premiums vs Income
          Market Concentration                                                           in Arizona, 2000–2007

                                                                              150
                                                      Blue Cross and
                                                      Blue Shield of
             Others                                                           120
                                                      Arizona

                           35%                                                90                    81%


                                               43%                            60


                            22%                                               30                                                    23%


                                                                               0
             UnitedHealth                                                                        Premiums                  Individual Income
             Group Inc.

    Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
    A Comprehensive Study of U.S. Markets: 2007 Update.”




                                                                                                Arizona
HEALTH CARE FOR AMERICA NOW!                                                                                                                   ARIZONA • A5
ENDNOTES
1
 AMA	data	in	this	report	is	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Northwest	Federation	of	Community	Organizations,	“Insuring	Health	or	Ensuring	Profit?,”	2008.	Accessed	at	http://www.nwfco.org/
pubs/2008.0727_insuring.health.or.ensuring.profit.pdf.
3
 Northwest	Federation	of	Community	Organizations,	“Insuring	Health	or	Ensuring	Profit?,”	2008.	Accessed	at	http://www.nwfco.org/
pubs/2008.0727_insuring.health.or.ensuring.profit.pdf.
4
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
5
 Ibid.
6
 Ibid.
7
 Ibid.
8
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html.
9
 American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	Anticompetitive	
Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.aha.org/aha/
content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A6 • ARIZONA                                                                                                HEALTH CARE FOR AMERICA NOW!
        Arkansas Consumers Pay the Price
        For Health-Insurance Market Failure
•	Arkansas	Blue	Cross	and	Blue	Shield,	the	state’s	                           •	From	2000	to	2007,	the	median	earnings	of	
  leading	health	insurer,	controls	75	percent	of	                               Arkansas	workers	increased	12	percent,	from	
  the	commercial	market.1                                                       $20,328	to	$22,692.	During	that	time	health	
•	Health	insurance	premiums	for	Arkansas	                                       insurance	premiums	for	Arkansas	working	
  working	families	have	skyrocketed,	increasing	                                families	rose	5.7	times	faster	than	median	
  66	percent	from	2000	to	2007.2                                                earnings.5
•	For	family	health	coverage	in	Arkansas	during	
  that	time,	the	average	annual	combined	                                     When	a	firm	has	more	than	a	42	percent	share		
  premium	for	employers	and	employees	rose		                                  of	a	single	market,	the	U.S.	Justice	Department	
  66	percent,	from	$6,355	to	$10,534.3                                        considers	that	market	to	be	“highly	concentrated.”		
•	For	family	health	coverage	in	Arkansas,	                                    This	means	that	an	insurer	could	raise	premiums	
  the	average	employer’s	portion	of	annual	                                   and/or	reduce	the	variety	of	plans	or	quality	of	
  premiums	rose	56	percent,	and	the	average	                                  services	offered	to	customers	with	impunity.6
  worker’s	share	grew	by	91	percent.4




  Arkansas Commercial Health Insurance                                         Percent Increase in Premiums vs Income
         Market Concentration                                                          in Arkansas, 2000–2007


                                                       Arkansas Blue
                                                       Cross and Blue
                                                       Shield
                                         75%

                                                                                                 66%


                        19%

          Others
                                 6%                                                                                              12%

                             UnitedHealth                                                     Premiums                   Individual Income
                             Group

    Source: American Medical Association, “Competition in Health Insurance:       Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
    A Comprehensive Study of U.S. Markets: 2007 Update.”




                                                                                                  Arkansas
HEALTH CARE FOR AMERICA NOW!                                                                                                               ARKANSAS • A7
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
3
 Ibid.
4
 Ibid.
5
 Ibid.
6
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/15.
html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	Anticompetitive	
Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.aha.org/aha/
content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A8 • ARKANSAS                                                                                               HEALTH CARE FOR AMERICA NOW!
              California Consumers Pay the Price
              For Health-Insurance Market Failure
      •	In	2008,	WellPoint	Inc.,	the	state’s	largest	                                 premiums	rose	91	percent,	while	the	average	
        insurer,	controlled	30	percent	of	the	commercial		                            worker’s	share	grew	by	111	percent.5
        market.	Together	with	Kaiser	Permanente,	they	                              •	From	2000	to	2007,	the	median	earnings	of	
        hold	58	percent	of	the	market.1                                               California	workers	increased	19	percent,	from	
      •	Local	markets	are	even	more	concentrated.	In	                                 $25,740	to	$30,702.	During	that	time	health	
        Salinas,	WellPoint	Inc.	controls	60	percent	of	                               insurance	premiums	for	California	working	
        the	market.2                                                                  families	rose	five	times	faster	than	median	
      •	Health	insurance	premiums	for	California	                                     earnings.6
        working	families	have	skyrocketed,	increasing	
        96	percent	from	2000	to	2007.3                                              When	a	firm	has	more	than	a	42	percent	share		
      •	For	family	health	coverage	in	California	during	                            of	a	single	market,	the	U.S.	Justice	Department	
        that	time,	the	average	annual	combined	                                     considers	that	market	to	be	“highly	concentrated.”7	
        premium	for	employers	and	employees	rose	                                   This	means	that	an	insurer	could	raise	premiums	
        from	$6,227	to	$12,194.4                                                    and/or	reduce	the	variety	of	plans	or	quality	of	
      •	For	family	health	coverage	in	California,	                                  services	offered	to	customers	with	little	fear	of	
        the	average	employer’s	portion	of	annual	                                   resistance.8




         Commercial Health Insurance Market                                           Percent Increase in Premiums vs Income
               Concentration in Salinas, California, Metro Area                               in California, 2000–2007
                                                                                    150

                                                                                    120
                                                                                                          96%
           Others                                            WellPoint Inc.
                                                                                    90
                        18%
                                                 60%
                                                                                    60


                              22%                                                   30                                                    19%


                   Kaiser
                                                                                     0
                                                                                                       Premiums                  Individual Income



          Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
          A Comprehensive Study of U.S. Markets: 2008 Update.”




ona                                                                                               California

      HEALTH CARE FOR AMERICA NOW!                                                                                                                CALIFORNIA • A9
ENDNOTES
1	
  AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	American	Medical	Association,	“Competition	in	health	insurance:	A	comprehensive	study	of	U.S.	markets:	2008	update.”
2	
  Ibid.
3	
  Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
4	
  Ibid.
5	
  Ibid.
6	
  Ibid.
7
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/testimony/hhi.htm.
8	
  American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	Anticompetitive	
Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.aha.org/aha/
content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A10 • CALIFORNIA                                                                                            HEALTH CARE FOR AMERICA NOW!
        colorado consumers Pay the Price
        For Health-Insurance Market Failure
•	WellPoint	Inc.’s	Anthem	Blue	Cross	and	                                     •	For	family	health	coverage	in	Colorado,	
  Blue	Shield	subsidiary	is	Colorado’s	biggest	                                 the	average	employer’s	portion	of	annual	
  for-profit	health	insurer,	with	29	percent	                                   premiums	rose	68	percent,	while	the	average	
  of	the	commercial	market.	Together	with	                                      worker’s	share	grew	by	97	percent.7
  UnitedHealth	Group	Inc.,	the	companies	hold	                                •	From	2000	to	2007,	the	median	earnings	of	
  53	percent	of	the	market.1                                                    Colorado	workers	increased	16	percent	from	
•	Local	markets	are	even	more	concentrated.	In	                                 $26,390	to	$30,476.	During	that	time	health	
  Pueblo,	WellPoint	controls	76	percent	of	the	                                 insurance	premiums	for	Colorado	working	
  market.2                                                                      families	rose	4.8	times	faster	than	median	
•	In	2007,	Colorado’s	top	three	insurers	reported	                              earnings.8
  $258	million	in	profit.3	
•	In	2007,	UnitedHealth’s	PacifiCare	subsidiary	                              When	a	company	has	more	than	a	42	percent	
  recorded	profit	of	$75	million,	an	increase	                                share	of	a	single	market,	the	U.S.	Justice	
  of	293	percent	from	2004,	even	though	its	                                  Department	considers	that	market	to	be	“highly	
  membership	dropped	by	42	percent.4	                                         concentrated.”9	The	U.S	Justice	Department	
•	Health	insurance	premiums	for	Colorado	                                     uses	a	rating	system	based	on	market	share	to	
  working	families	have	skyrocketed,	increasing	                              determine	if	a	market	is	concentrated	or	highly	
  75	percent	from	2000	to	2007.5                                              concentrated.	If	the	market	is	rated	from	1,000	
•	For	family	health	coverage	in	Colorado	during	                              to	1,800,	it	is	considered	to	be	“concentrated.”	
  that	time,	the	average	annual	combined	                                     Markets	rated	higher	than	1,800	are	deemed	to	
  premium	for	employers	and	employees	rose	                                   be	“highly	concentrated.”10
  from	$6,797	to	$11,878.6



   Commercial Health Insurance Market                                           Percent Increase in Premiums vs Income
         concentration in Pueblo, colorado, Metro area                        150       in Colorado, 2000–2007

                                                     WellPoint Inc.           120

                                        76%                                   90
                                                                                                   75%

                                                                              60

                        19%
                                                                              30                                                   16%
        others
                                 5%
                                                                               0
                                                                                                Premiums                   Individual Income
                           cigna corp.


    Source: american Medical association, “competition in Health Insurance:         Sources: Families USa, “Premiums Versus Paychecks,” September 2008.
    a comprehensive Study of U.S. Markets: 2007 Update.”




HEalTH carE For aMErIca NoW!                                                                       North Dakota                            colorado • a11
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Ibid.
3
 Northwest	Federation	of	Community	Organizations,	“Insuring	Health	or	Ensuring	Profit?,”	2008.	Accessed	at	http://www.nwfco.org/
pubs/2008.0727_insuring.health.or.ensuring.profit.pdf.
4	
  Ibid.
5	
  Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
6
 Ibid.
7
 Ibid.
8
 Ibid.
17
   US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html.
10
   The	HHI	is	used	by	the	Department	of	Justice	and	the	Federal	Trade	Commission		in	anti-trust	proceedings.	The	HHI	is	the	sum	of	the	
squared	market	shares	of	each	firm	in	the	market.	The	more	competitive	the	market,	the	lower	the	HHI.	The	less	competitive	the	market,	
the	higher	the	HHI.	An	HHI	above	1,800	is	rated	“highly	concentrated.”	An	HHI	between	1,000	and	1,800	is	considered	“concentrated.”	
Accessed	at	http://www.usdoj.gov/atr/public/testimony/hhi.htm.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




a12 • colorado                                                                                              HEalTH carE For aMErIca NoW!
       Results of Market Failure in Connecticut
      •	According	to	a	2007	report	by	the	American	                                    coverage	in	Connecticut	rose	75	percent,		
        Medical	Association,	WellPoint	Inc.,	                                          while	the	average	worker’s	share	grew	by		
        Connecticut’s	biggest	health	insurer,	holds		                                  104	percent.4
        55	percent	of	the	commercial	market.	Together	                               •	From	2000	to	2007,	the	median	earnings	of	
        with	Health	Net	Inc.,	the	second	largest,	they	                                Connecticut	workers	increased	10	percent,	
        control	66	percent	of	the	state	market.1                                       from	$32,106	to	$35,281.	During	that	time	
      •	Health	insurance	premiums	for	Connecticut	                                     health	insurance	premiums	for	Connecticut	
        working	families	have	skyrocketed,	increasing	                                 working	families	rose	8.2	times	faster	than	
        81	percent	from	2000	to	2007.2                                                 median	earnings.5
      •	For	family	health	coverage	in	Connecticut	
        during	that	time,	the	average	annual	                                        When	a	firm	has	more	than	a	42	percent	share		
        combined	premium	for	employers	and	                                          of	a	single	market,	the	U.S.	Justice	Department	
        employees	rose	from	$7,292	to	$13,173.3                                      considers	that	market	to	be	“highly	concentrated.”		
      •	From	2000	to	2007	the	average	employer’s	                                    This	means	that	an	insurer	could	raise	premiums	
        portion	of	annual	premiums	for	family		                                      and/or	reduce	the	variety	of	plans	or	quality	of	
        	                                                                            services	offered	to	customers	with	impunity.6




             Connecticut Commercial Health                                            Percent Increase in Premiums vs Income
             Insurance Market Concentration                                                 in Connecticut, 2000–2007
                                                                                    150

                                                             Well Point Inc.        120
                Others

                                                                                    90                   81%
                            34%                     55%
                                                                                    60


                                    11%                                             30
                                                                                                                                         10%
                                                                                     0
                       Health Net Inc.                                                                Premiums                   Individual Income


          Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
          A Comprehensive Study of U.S. Markets: 2007 Update.”




                                                                                                      Connecticut

150   HEALTH CARE FOR AMERICA NOW!
                                                                                                                              150             CONNECTICUT • A13
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2	
  Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
3	
  Ibid.
4	
  Ibid.
5	
  Ibid.
6	
  US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/15.
html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	Anticompetitive	
Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.aha.org/aha/
content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A14 • CONNECTICUT                                                                                           HEALTH CARE FOR AMERICA NOW!
            Delaware Consumers Pay the Price
            For Health-Insurance Market Failure
    •	CareFirst	BlueCross	BlueShield,	Delaware’s	                                   premiums	rose	81	percent,	while	the	average	
      biggest	health	insurer,	controls	42	percent	                                  worker’s	share	grew	by	62	percent.4
      of	the	commercial	market.	Together	with	                                    •	From	2000	to	2007,	the	median	earnings	of	
      Coventry	Health	Care	Inc.,	the	state’s	second	                                Delaware	workers	increased	15	percent,	from	
      largest,	they	hold	65	percent	of	the	market.1                                 $27,717	to	$31,837.	During	that	time	health	
    •	Health	insurance	premiums	for	Delaware	                                       insurance	premiums	for	Delaware	working	
      working	families	have	skyrocketed,	increasing	                                families	rose	5.2	times	faster	than	median	
      77	percent	from	2000	to	2007.2                                                earnings.5
    •	For	family	health	coverage	in	Delaware,	the	
      average	annual	combined	premium	for		                                       When	a	firm	has	more	than	a	42	percent	share		
      employers	and	employees	rose	from	$7,553		                                  of	a	single	market,	the	U.S.	Justice	Department	
      to	$13,370.3                                                                considers	that	market	to	be	“highly	concentrated.”		
    •	For	family	health	coverage	in	Delaware,		                                   This	means	that	an	insurer	could	raise	premiums	
      the	average	employer’s	portion	of	annual		                                  and/or	reduce	the	variety	of	plans	or	quality	of	
      	                                                                           services	offered	to	customers	with	impunity.6
      	


      Delaware Commercial Health Insurance                                          Percent Increase in Premiums vs Income
             Market Concentration                                                           in Delaware, 2000–2007
                                                                                  150
                                                        CareFirst BlueCross
                                                        BlueShield                120
               Others
                              35%
                                                                                  90                   77%

                                                  42%                             60

                                23%                                               30
                                                                                                                                       15%
            Coventry
                                                                                   0
            Health Care                                                                             Premiums                   Individual Income
            Inc.

        Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
        A Comprehensive Study of U.S. Markets: 2007 Update.”




necticut                                                                                         Delaware
    HEALTH CARE FOR AMERICA NOW!                                                                                                               DELAWARE • A15

     150                                                                                                           150
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
3
 Ibid.
4
 Ibid.
5
 Ibid.
6
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/15.
html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	Anticompetitive	
Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.aha.org/aha/
content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A16 • DELAWARE                                                                                              HEALTH CARE FOR AMERICA NOW!
         Florida Consumers Pay the Price
        For Health-Insurance Market Failure
•	Blue	Cross	and	Blue	Shield	of	Florida,	the	                                  •	Between	2000	and	2007,	the	median	earnings	
  state’s	biggest	insurer,	controls	30	percent	of	                               of	Florida	workers	increased	20	percent	from	
  the	state	commercial	market.	Together	with	                                    $22,753	to	$27,353.	During	that	time	health	
  Aetna	Inc.,	the	second	leading	health	insurer,	                                insurance	premiums	for	Florida	working	
  they	hold	45	percent	of	the	market.1                                           families	rose	3.6	times	faster	than	median	
•	Local	markets	are	more	concentrated;	in	                                       earnings.6
  Jacksonville,	Blue	Cross	and	Blue	Shield	of		
  Florida	holds	48	percent	of	the	commercial	                                  If	one	company	holds	more	than	a	42	percent		
  market,	and	together	with	Aetna	they	control	                                share	of	a	market	the	U.S.	Justice	Department	
  72	percent.2                                                                 would	consider	that	market	“highly	
•	Health	insurance	premiums	for	Florida	                                       concentrated.”7	The	U.S	Justice	Department	
  working	families	have	skyrocketed,	increasing	                               uses	a	rating	system	based	on	market	share	to	
  72	percent	from	2000	to	2007.3                                               determine	if	a	market	is	concentrated	or	highly	
•	For	family	health	coverage	in	Florida	during	                                concentrated.	If	the	market	is	rated	from	1,000	
  that	time,	the	average	annual	combined	                                      to	1,800,	it	is	considered	to	be	“concentrated.”	
  premium	for	employers	and	employees	rose	                                    Markets	rated	higher	than	1,800	are	deemed	to	
  from	$6,812	to	$11,720.4                                                     be	“highly	concentrated.”	This	means	that	an	
•	For	family	health	coverage	in	Florida,	                                      insurer	could	raise	premiums	and/or	reduce	the	
  the	average	employer’s	portion	of	annual	                                    variety	of	plans	or	quality	of	services	offered	to	
  premiums	rose	63	percent,	while	the	average	                                 customers	with	impunity.8
  worker’s	share	grew	by	94	percent.5



 Jacksonville, Florida Commercial Health                                        Percent Increase in Premiums vs Income
    Insurance Market Concentration                                                        in Florida, 2000–2007
                                                                              150

                                                      Blue Cross
                                                      and Blue Shield         120
           Others                                       of Florida
                          28%                                                 90
                                                                                                   72%

                                                                              60
                                              48%

                            24%                                               30                                                   20%

         Aetna
                                                                               0
                                                                                                Premiums                   Individual Income


    Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
    A Comprehensive Study of U.S. Markets: 2007 Update.”




HEALTH CARE FOR AMERICA NOW!                                                                                                                  FLORIDA • A17
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Ibid.
3
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
4
 Ibid.
5
 Ibid.
6	
  Ibid.
7
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/15.
html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	Anticompetitive	
Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.aha.org/aha/
content/2009/pdf/09-05-11-antitrust-rep.pdf.
8
 The	HHI	is	used	by	the	Department	of	Justice	and	the	Federal	Trade	Commission		in	anti-trust	proceedings.	The	HHI	is	the	sum	of	the	
squared	market	shares	of	each	firm	in	the	market.	The	more	competitive	the	market,	the	lower	the	HHI.	The	less	competitive	the	market,	
the	higher	the	HHI.	An	HHI	above	1,800	is	rated	“highly	concentrated.”	An	HHI	between	1,000	and	1,800	is	considered	“concentrated.”	
Accessed	at	http://www.usdoj.gov/atr/public/testimony/hhi.htm.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A18 • FLORIDA                                                                                               HEALTH CARE FOR AMERICA NOW!
         Georgia Consumers Pay the Price
        For Health-Insurance Market Failure
•	WellPoint	Inc.,	Georgia’s	biggest	insurer,	                                   rose	68	percent,	while	the	average	worker’s	
  controls	61	percent	of	the	commercial	market.	                                share	grew	by	85	percent.4
  Together	with	UnitedHealth	Group	Inc.,	the	                                 •	Between	2000	and	2007,	the	median	earnings	
  second	largest	health	insurer,	they	hold	69	                                  of	Georgia	workers	increased	10	percent,	from	
  percent	of	the	market.1	                                                      $25,525	to	$28,178.	During	that	time	health	
•	Health	insurance	premiums	for	Georgia	                                        insurance	premiums	for	Georgia	working	
  working	families	have	skyrocketed,	increasing	                                families	rose	seven	times	faster	than	median	
  73	percent	from	2000	to	2007.2                                                earnings.5
•	For	family	health	coverage	in	Georgia	during	
  that	time,	the	average	annual	combined		                                    When	a	firm	has	more	than	a	42	percent	share		
  premium	for	employers	and	employees	rose	                                   of	a	single	market,	the	U.S.	Justice	Department	
  from	$6,637	to	$11,451.3                                                    considers	that	market	to	be	“highly	concentrated.”		
•	For	family	health	coverage	in	Georgia,	the		                                This	means	that	an	insurer	could	raise	premiums	
  average	employer’s	portion	of	annual	premiums	 	                            and/or	reduce	the	variety	of	plans	or	quality	of	
  	                                                                           services	offered	to	customers	with	impunity.6




   Georgia Commercial Health Insurance                                          Percent Increase in Premiums vs Income
          Market Concentration                                                           in Georgia, 2000–2007
                                                                              150
                                                  Well Point Inc.
        Others
                                                                              120

                                                                              90
                                                                                                    73%
                                            61%
                    31%                                                       60

                                                                              30
                                                                                                                                   10%
                                8%
                                                                               0
                                                                                                Premiums                   Individual Income
               UnitedHealth Group


    Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
    A Comprehensive Study of U.S. Markets: 2007 Update.”




                                                                                                Georgia


HEALTH CARE FOR AMERICA NOW!                                                                                                                  GEORGIA • A19
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
3
 Ibid.
4
 Ibid.
5
 Ibid.
6
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/15.
html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	Anticompetitive	
Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.aha.org/aha/
content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A20 • GEORGIA                                                                                               HEALTH CARE FOR AMERICA NOW!
                Hawaii Consumers Pay the Price
               For Health-Insurance Market Failure
       •	Hawaii	Medical	Service	Association,	doing	                                  •	For	family	health	coverage	in	Hawaii,	
         business	as	Blue	Cross	Blue	Shield	of	Hawaii,		                               the	average	employer’s	portion	of	annual	
         is	the	state’s	leading	health	insurer	with	78	                                premiums	rose	56	percent,	while	the	average	
         percent	of	the	commercial	market.	Together	                                   worker’s	share	grew	101	percent.5
         with	Kaiser	Permanente,	they	hold	98	percent	                               •	From	2000	to	2007,	the	median	earnings	of	
         of	the	market.1                                                               Hawaii	workers	increased	19	percent,	from	
       •	Between	2004	and	2007	Blue	Cross	Blue	Shield	                                 $26,180	to	$31,252.	During	that	time	health	
         of	Hawaii’s	surplus	grew	by	5.2	percent	to	$569	                              insurance	premiums	for	Hawaii	working	families		
         million.2                                                                     rose	3.4	times	faster	than	median	earnings.6
       •	Health	insurance	premiums	for	Hawaii	
         working	families	have	skyrocketed,	increasing	                              When	a	firm	has	more	than	a	42	percent	share		
         65	percent	from	2000	to	2007.3                                              of	a	single	market,	the	U.S.	Justice	Department	
       •	For	family	health	coverage	in	Hawaii	during	                                considers	that	market	to	be	“highly	concentrated.”		
         that	time,	the	average	annual	combined	                                     This	means	that	an	insurer	could	raise	premiums	
         premium	for	employers	and	employees	rose	                                   and/or	reduce	the	variety	of	plans	or	quality	of	
         from	$6,047	to	$10,001.4                                                    services	offered	to	customers	with	impunity.7




           Hawaii Commercial Health Insurance                                          Percent Increase in Premiums vs Income
                  Market Concentration                                               150
                                                                                                 in Hawaii, 2000–2007

                                                                   Blue Cross        120
                                                                   Blue Shield
                                                                   of Hawaii
                                                                                     90
                                                    78%                                                    65%
                                                                                     60
              Others      2%
                                   20%                                               30                                                   19%

          Kaiser Permanente                                                           0
                                                                                                       Premiums                   Individual Income


           Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
           A Comprehensive Study of U.S. Markets: 2007 Update.”




rgia                                                                                               Hawaii

       HEALTH CARE FOR AMERICA NOW!                                                                                                                   HAWAII • A21
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Northwest	Federation	of	Community	Organizations,	“Insuring	Health	or	Ensuring	Profit?,”	2008.	Accessed	at	http://www.nwfco.org/
pubs/2008.0727_insuring.health.or.ensuring.profit.pdf.
3
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
4
 Ibid.
5
 Ibid.
6
 Ibid.
7
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/15.
html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	Anticompetitive	
Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.aha.org/aha/
content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A22 • HAWAII                                                                                                HEALTH CARE FOR AMERICA NOW!
           Idaho Consumers Pay the Price
         For Health-Insurance Market Failure
 •	Blue	Cross	of	Idaho,	the	state’s	top	health	                                •	Between	2000	and	2007,	the	median	earnings	
   insurer,	holds	46	percent	of	the	state	market.	                               of	Idaho	workers	increased	31	percent,	from	
   Its	closest	competitor,	Regence	BlueShield	of	                                $19,004	to	$24,798.	During	that	time	health	
   Idaho,	has	29	percent.1                                                       insurance	premiums	for	Idaho	working	
 •	Health	insurance	premiums	for	Idaho	working	                                  families	rose	four	times	faster	than	median	
   families	have	skyrocketed,	increasing	122	                                    earnings.5
   percent	from	2000	to	2007.2
 •	For	family	health	coverage	in	Idaho	during	                                 When	a	firm	has	more	than	a	42	percent	share		
   that	time,	the	average	annual	combined	                                     of	a	single	market,	the	U.S.	Justice	Department	
   premium	for	employers	and	employees	rose	                                   considers	that	market	to	be	“highly	concentrated.”		
   from	$5,160	to	$11,432.3                                                    This	means	that	an	insurer	could	raise	premiums	
 •	For	family	health	coverage	in	Idaho,	the	                                   and/or	reduce	the	variety	of	plans	or	quality	of	
   average	employer’s	portion	of	annual	                                       services	offered	to	customers	with	impunity.6
   premiums	rose	160	percent,	while	the	average	
   worker’s	share	grew	40	percent.4




      Idaho Commercial Health Insurance                                          Percent Increase in Premiums vs Income
             Market Concentration                                                          in Idaho, 2000–2007
                                                                               150
                 Others                                                                             122%
                                                         Blue Cross            120
                             25%                         of Idaho

                                                                               90

                                               46%                             60

                        29%                                                                                                         31%
                                                                               30


             Regence
                                                                                0
                                                                                                 Premiums                   Individual Income
             Blue Shield


     Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
     A Comprehensive Study of U.S. Markets: 2007 Update.”




Hawaii                                                                                                      Idaho


 HEALTH CARE FOR AMERICA NOW!                                                                                                                   IDAHO • A23
ENDNOTES
1
 Stephen	Foreman,	“Proposed	Consolidation	of	Highmark	and	Independence	Blue	Cross,”	July	2008.	Accessed	at	http://www.ins.state.
pa.us/ins/lib/ins/highmark-ibc/0943.pdf.
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
3
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
4
 Ibid.
5
 Ibid.
6
 Ibid.
13
  US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/15.
html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	Anticompetitive	
Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.aha.org/aha/
content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A24 • IDAHO                                                                                                 HEALTH CARE FOR AMERICA NOW!
          Illinois Consumers Pay the Price
        For Health-Insurance Market Failure
•	Health	Care	Services	Corp.,	doing	business	as	                                 of	annual	premiums	rose	72	percent,	while	the	
  Blue	Cross	and	Blue	Shield	of	Illinois,	is	the	                                average	worker’s	share	increased	78	percent.4
  state’s	leading	health	insurer	with	47	percent	                              •	From	2000	to	2007,	the	median	earnings	of	
  of	the	commercial	market.	Together	with	                                       Illinois	workers	increased	13	percent,	from	
  WellPoint	Inc.,	they	control	69	percent	of	the	                                $26,806	to	$30,322.	During	that	time	health	
  state	market.1                                                                 insurance	premiums	for	Illinois	working	families		
•	Health	insurance	premiums	for	Illinois	                                        rose	5.6	times	faster	than	median	earnings.5
  working	families	have	skyrocketed,	increasing	
  73	percent	from	2000	to	2007.2                                               When	a	firm	has	more	than	a	42	percent	share		
•	For	family	health	coverage	in	Illinois	during	                               of	a	single	market,	the	U.S.	Justice	Department	
  that	time,	the	average	annual	premium	                                       considers	that	market	to	be	“highly	concentrated.”		
  (employer	and	worker	share	of	premiums	                                      This	means	that	an	insurer	could	raise	premiums	
  combined)	rose	from	$7,220	to	$12,500.3                                      and/or	reduce	the	variety	of	plans	or	quality	of	
•	For	family	health	coverage	in	Illinois	from	                                 services	offered	to	customers	with	impunity.1
  2000	to	2007,	the	average	employer’s	portion	




    Illinois Commercial Health Insurance                                        Percent Increase in Premiums vs Income
             Market Concentration                                                         in Illinois, 2000–2007
                                                 Health Care Service
                                                 Corp. (Blue Cross and        150
                                                 Blue Shield of Illinois)
            Others                                                            120
                           31%
                                                                              90                   73%

                                                47%
                                                                              60

                          22%                                                 30                                                   13%

                                                                               0
                 WellPoint Inc.                                                                 Premiums                   Individual Income


    Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
    A Comprehensive Study of U.S. Markets: 2007 Update.”




                                                                                                 Illinois

HEALTH CARE FOR AMERICA NOW!                                                                                                                  ILLINOIS • A25
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	
PPOs	only.	Accessed	at	http://www.ama-assn.org/go/competition2007.itan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	census	bureau.	
Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
3
 Ibid.
4
 Ibid.
5
 Ibid.
6
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/15.
html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	Anticompetitive	
Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.aha.org/aha/
content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A26 • ILLINOIS                                                                                               HEALTH CARE FOR AMERICA NOW!
                Indiana Consumers Pay the Price
               For Health-Insurance Market Failure
       •	WellPoint	Inc.,	the	state’s	top	health	insurer,	                               of	annual	premiums	rose	75	percent,	while	the	
         controls	60	percent	of	the	state	market	through	                               average	worker’s	share	grew	by	116	percent.5
         its	Anthem	subsidiary.	In	2007,	together	with	                               •	From	2000	to	2007,	the	median	earnings	of	
         M*Plan,1	then	the	second	largest	health	insurer	                               Indiana	workers	increased	11	percent,	from	
         in	the	state,	they	controlled	75	percent	of	the	                               $24,531	to	$27,330.	During	that	time	health	
         commercial	market.2                                                            insurance	premiums	for	Indiana	working	
       •	Health	insurance	premiums	for	Indiana	                                         families	rose	7.3	times	faster	than	median	
         working	families	have	skyrocketed,	increasing	                                 earnings.6
         83	percent	from	2000	to	2007.3
       •	For	family	health	coverage	in	Indiana	during	                                When	a	firm	has	more	than	a	42	percent	share		
         that	time,	the	average	annual	combined	                                      of	a	single	market,	the	U.S.	Justice	Department	
         premium	for	employers	and	employees	rose	                                    considers	that	market	to	be	“highly	concentrated.”		
         from	$6,628	to	$12,153.4                                                     This	means	that	an	insurer	could	raise	premiums	
       •	For	family	health	coverage	in	Indiana	from	                                  and/or	reduce	the	variety	of	plans	or	quality	of	
         2000	to	2007,	the	average	employer’s	portion	                                services	offered	to	customers	with	impunity.7




          Indiana Commercial Health Insurance                                          Percent Increase in Premiums vs Income
                  Market Concentration                                               150        in Indiana, 2000–2007
                                                                                     120
                                                               WellPoint Inc.
                  Others                                                                                   83%
                                                                                     90
                                                    60%
                            25%                                                      60

                                                                                     30
                                                                                                                                          11%
                                   15%
                                                                                      0
                                                                                                       Premiums                   Individual Income
                              M*Plan


           Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
           A Comprehensive Study of U.S. Markets: 2007 Update.”




nois                                                                                                  Indiana



       HEALTH CARE FOR AMERICA NOW!                                                                                                                  INDIANA • A27
ENDNOTES
1
 M*Plan	ceased	operations	in	2008.
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
3
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
4
 Ibid.
5
 Ibid.
6
 Ibid.
7
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A28 • INDIANA                                                                                               HEALTH CARE FOR AMERICA NOW!
          Iowa Consumers Pay the Price
        For Health-Insurance Market Failure
•	Wellmark	Blue	Cross	and	Blue	Shield	is	                                       68	percent,	while	the	average	worker’s	share	
  Iowa’s	biggest	health	insurer,	with	71	percent	                               increased	87	percent.4
  of	the	commercial	market.	Together	with	                                    •	Between	2000	and	2007,	the	median	earnings	
  UnitedHealth	Group	Inc.,	the	second	largest,	                                 of	Iowa	workers	increased	19	percent,	from	
  they	hold	80	percent	of	the	market.1                                          $22,147	to	$26,247.	During	that	time	health	
•	Health	insurance	premiums	for	Iowa	working	                                   insurance	premiums	for	Iowa	working	families	
  families	have	skyrocketed,	increasing	73	                                     rose	3.9	times	faster	than	median	earnings.5
  percent	from	2000	to	2007.2
•	For	family	health	coverage	in	Iowa	from	                                    When	a	firm	has	more	than	a	42	percent	share		
  2000	to	2007,	the	average	annual	combined	                                  of	a	single	market,	the	U.S.	Justice	Department	
  premium	for	employers	and	employees	rose	                                   considers	that	market	to	be	“highly	concentrated.”		
  from	$6,487	to	$11,194.3                                                    This	means	that	an	insurer	could	raise	premiums	
•	For	family	health	coverage	in	Iowa,	the	average	                            and/or	reduce	the	variety	of	plans	or	quality	of	
  employer’s	portion	of	annual	premiums	rose	                                 services	offered	to	customers	with	impunity.6




     Iowa Commercial Health Insurance                                           Percent Increase in Premiums vs Income
           Market Concentration                                               150         in Iowa, 2000–2007

                                                         Wellmark             120
                                                         Blue Cross
                                                         and Blue Shield
                                                                              90
                                                                                                    73%
                                           71%
     Others                                                                   60
                     20%
                                                                              30                                                   19%
                               9%
                                                                               0
                                                                                                Premiums                   Individual Income
                 UnitedHealth Group


    Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
    A Comprehensive Study of U.S. Markets: 2007 Update.”




                                                                                                  Iowa



HEALTH CARE FOR AMERICA NOW!                                                                                                                     IOWA • A29
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
3
 Ibid.
4
 Ibid.
5
 Ibid.
6
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/15.
html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	Anticompetitive	
Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.aha.org/aha/
content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A30 • IOWA                                                                                                  HEALTH CARE FOR AMERICA NOW!
             Kansas Consumers Pay the Price
            For Health-Insurance Market Failure
    •	Premier	Health	Inc.,1	the	state’s	biggest	insurer,	                           $22,351	to	$26,307.	During	that	time	health	
      controls	37	percent	of	the	state	market	for	                                  insurance	premiums	for	Kansas	working	
      health	insurance.	Together	with	Coventry	                                     families	rose	five	times	faster	than	median	
      Health	Care	Inc.,	they	control	56	percent	of	                                 earnings.6
      the	commercial	market.2
    •	Health	insurance	premiums	for	Kansas	                                       If	one	company	holds	more	than	a	42	percent		
      working	families	have	skyrocketed,	increasing	                              share	of	a	market	the	U.S.	Justice	Department	
      88	percent	from	2000	to	2007.3                                              would	consider	that	market	“highly	
    •	For	family	health	coverage	in	Kansas	during	                                concentrated.”7	The	U.S	Justice	Department	
      that	time,	the	average	annual	combined	                                     uses	a	rating	system	based	on	market	share	to	
      premium	for	employers	and	employees	rose	                                   determine	if	a	market	is	concentrated	or	highly	
      from	$6,237	to	$11,722.4                                                    concentrated.	If	the	market	is	rated	from	1,000	
    •	For	family	health	coverage	in	Kansas	from	                                  to	1,800,	it	is	considered	to	be	“concentrated.”	
      2000	to	2007,	the	average	employer’s	portion	                               Markets	rated	higher	than	1,800	are	deemed	to	
      of	annual	premiums	rose	98	percent,	while	the	                              be	“highly	concentrated.”	This	means	that	an	
      average	worker’s	share	grew	by	65	percent.5                                 insurer	could	raise	premiums	and/or	reduce	the	
    •	Between	2000	and	2007,	the	median	earnings	                                 variety	of	plans	or	quality	of	services	offered	to	
      of	Kansas	workers	increased	18	percent,	from	                               customers	with	impunity.8




       Kansas Commercial Health Insurance                                           Percent Increase in Premiums vs Income
              Market Concentration                                                           in Kansas, 2000–2007
                                                                                  150

              Others                                                              120
                                                                Premier
                                 44%
                                                                Health Inc.                             88%
                                                                                  90


                                                   37%
                                                                                  60

                                19%                                               30                                                   18%

                                                                                   0
                       Conventry                                                                    Premiums                   Individual Income
                       Health Care Inc.

        Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
        A Comprehensive Study of U.S. Markets: 2007 Update.”




a   HEALTH CARE FOR AMERICA NOW!
                                                                                                  kansas                                          KANSAS • A31
ENDNOTES
1
 Premier	Health	Inc.	is	a	joint	venture	of	multiple	insurers,	BlueCross	BlueShield	of	Kansas	has	a	financial	interest	in	Premier	Health.	
2
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	American	Medical	Association,	“Competition	in	health	insurance:	A	comprehensive	study	of	U.S.	markets:	2008	update.”
3
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
4
 Ibid.
5
 Ibid.
6
 Ibid.
7
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.
8
 The	HHI	is	used	by	the	Department	of	Justice	and	the	Federal	Trade	Commission		in	anti-trust	proceedings.	The	HHI	is	the	sum	of	the	
squared	market	shares	of	each	firm	in	the	market.	The	more	competitive	the	market,	the	lower	the	HHI.	The	less	competitive	the	market,	
the	higher	the	HHI.	An	HHI	above	1,800	is	rated	“highly	concentrated.”	An	HHI	between	1,000	and	1,800	is	considered	“concentrated.”	
Accessed	at	http://www.usdoj.gov/atr/public/testimony/hhi.htm.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A32 • KANSAS                                                                                                HEALTH CARE FOR AMERICA NOW!
         Kentucky Consumers Pay the Price
         For Health-Insurance Market Failure
 •	Anthem	Blue	Cross	and	Blue	Shield,	a	                                       •	For	family	health	coverage	in	Kentucky,	
   subsidiary	of	WellPoint	Inc.,	is	Kentucky’s	                                  the	average	employer’s	portion	of	annual	
   biggest	health	insurer,	with	51	percent	of	                                   premiums	rose	44	percent,	while	the	average	
   the	state	commercial	market.	Together	with	                                   worker’s	share	grew	58	percent.5
   Humana	Inc.,	they	hold	71	percent	of	the	                                   •	Between	2000	and	2007,	the	median	earnings	
   market.1                                                                      of	Kentucky	workers	increased	17	percent,	
 •	Local	markets	are	even	more	concentrated	in	                                  from	$21,512	to	$25,134.	During	that	time	
   Kentucky.	In	Elizabethtown,	WellPoint	and	                                    health	insurance	premiums	for	Kentucky	
   Aetna	Inc.	together	hold	92	percent	of	the	                                   working	families	rose	2.8	times	faster	than	
   market.2                                                                      median	earnings.6
 •	Health	insurance	premiums	for	Kentucky	
   working	families	have	skyrocketed,	increasing	                              When	a	firm	has	more	than	a	42	percent	share		
   48	percent	from	2000	to	2007.3                                              of	a	single	market,	the	U.S.	Justice	Department	
 •	For	family	health	coverage	in	Kentucky	during	                              considers	that	market	to	be	“highly	concentrated.”		
   that	time,	the	average	annual	combined	                                     This	means	that	an	insurer	could	raise	premiums	
   premium	for	employers	and	employees	rose	                                   and/or	reduce	the	variety	of	plans	or	quality	of	
   from	$7,096	to	$10,466.4                                                    services	offered	to	customers	with	impunity.7




   Kentucky Commercial Health Insurance                                          Percent Increase in Premiums vs Income
          Market Concentration                                                 150
                                                                                         in Kentucky, 2000–2007

                                                                               120
            Others
                                                           WellPoint Inc.
                         29%                                                   90


                                                  51%                          60                    48%


                             20%
                                                                               30                                                   17%

                                                                                0
                                                                                                 Premiums                   Individual Income
                     Humana


     Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
     A Comprehensive Study of U.S. Markets: 2008 Update.”




kansas                                                                                                       Kentucky

 HEALTH CARE FOR AMERICA NOW!                                                                                                                KENTUCKY • A33
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	American	Medical	Association,	“Competition	in	health	insurance:	A	comprehensive	study	of	U.S.	markets:	2008	update.”
2
 Ibid.
3
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
4
 Ibid.
5
 Ibid.
6
 Ibid.
7
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A34 • KENTUCKY                                                                                              HEALTH CARE FOR AMERICA NOW!
          Louisiana Consumers Pay the Price
          For Health-Insurance Market Failure
  •	Blue	Cross	and	Blue	Shield	of	Louisiana,	the		                              •	For	family	health	coverage	in	Louisiana	from	
    state’s	biggest	health	insurer,	controls	61	                                  2000	to	2007,	the	average	employer’s	portion	
    percent	of	the	state	commercial	market.	                                      of	annual	premiums	rose	76	percent,	while	the	
    Together	with	UnitedHealth	Group	Inc.,	the	                                   average	worker’s	share	increased	74	percent.5
    second	largest	Louisiana	health	insurer,	they	                              •	From	2000	to	2007,	the	median	earnings	of	
    control	74	percent	of	the	market.1                                            Louisiana	workers	increased	23	percent,	from	
  •	Local	markets	are	more	concentrated;	in	                                      $20,467	to	$25,147.	During	that	time	health	
    Lafayette,	Blue	Cross	and	Blue	Shield	of	                                     insurance	premiums	for	Louisiana	working	
    Louisiana	and	Humana	Inc.	together	hold		                                     families	rose	3.3	times	faster	than	median	
    93	percent	of	the	commercial	market.2                                         earnings.6
  •	Health	insurance	premiums	for	Louisiana	
    working	families	have	skyrocketed,	increasing	                              If	one	company	holds	more	than	a	42	percent		
    75	percent	from	2000	to	2007.3                                              share	of	a	market	the	U.S.	Justice	Department	
  •	For	family	health	coverage	in	Louisiana	during	                             would	consider	that	market	“highly	concentrated.”7	
    that	time,	the	average	annual	combined	                                     This	means	that	an	insurer,	with	impunity,	
    premium	for	employers	and	employees	rose	                                   could	raise	premiums	and/or	reduce	the	variety		
    from	$6,536	to	$11,455.4                                                    of	plans	or	quality	of	services	offered	to	customers.8




    Louisiana Commercial Health Insurance                                         Percent Increase in Premiums vs Income
            Market Concentration                                                          in Louisiana, 2000–2007

                                                                                150
                                                       Blue Cross and
                                                       Blue Shield of           120
                                                         Louisiana

                                                                                90
                                                                                                     75%
        Others
                                              61%
                       26%
                                                                                60

                                                                                30                                                   23%
                                13%

                                                                                 0
                                                                                                  Premiums                   Individual Income
                  UnitedHealth Group Inc.


      Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
      A Comprehensive Study of U.S. Markets: 2007 Update.”




California                                                                                            Louisiana
  HEALTH CARE FOR AMERICA NOW!                                                                                                               LOUISIANA • A35
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Ibid.
3
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
4
 Ibid.
5
 Ibid.
6
 Ibid.
7
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html.
8
 American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	Anticompetitive	
Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.aha.org/aha/
content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




     A36 • LOUISIANA                                                                                              HEALTH CARE FOR AMERICA NOW!
            Results of Market Failure in Maine
•	WellPoint	Inc.,	Maine’s	biggest	health	insurer,	                            •	For	family	health	coverage	in	Maine	from	
  holds	78	percent	of	the	state	commercial	                                     2000	to	2007,	the	average	employer’s	portion	
  market.	Together	with	Aetna	Inc.,	they	control	                               of	annual	premiums	rose	87	percent,	while	the	
  88	percent	of	the	market.1                                                    average	worker’s	share	grew	by	96	percent.5
•	From	2004	to	2007	Anthem	Health	Care,	                                      •	From	2000	to	2007,	the	median	earnings	of	
  WellPoint	Inc.’s	Maine	subsidiary,	saw	profit	                                Maine	workers	increased	17	percent,	from	
  grow	by	89	percent,	from	$40	million	to	$76	                                  $22,163	to	$25,876.	During	that	time	health	
  million,	although	its	membership	grew	by	                                     insurance	premiums	for	Maine	working	
  only	2.4	percent.2                                                            families	rose	5.4	times	faster	than	median	
•	Health	insurance	premiums	for	Maine	working	                                  earnings.6
  families	have	skyrocketed,	increasing	90	
  percent	from	2000	to	2007.3                                                 When	a	firm	has	more	than	a	42	percent	share		
•	For	family	health	coverage	in	Maine	during	                                 of	a	single	market,	the	U.S.	Justice	Department	
  that	time,	the	average	annual	combined	                                     considers	that	market	to	be	“highly	concentrated.”		
  premium	for	employers	and	employees	rose	                                   This	means	that	an	insurer	could	raise	premiums	
  from	$6,915	to	$13,117.4                                                    and/or	reduce	the	variety	of	plans	or	quality	of	
                                                                              services	offered	to	customers	with	impunity.7




    Maine Commercial Health Insurance                                           Percent Increase in Premiums vs Income
          Market Concentration                                                150         in Maine, 2000–2007

                                                                              120
                                                        WellPoint Inc.
                                                                                                    90%
                                                                              90
                                           78%
                                                                              60

                      12%                                                     30                                                   17%
           Others             10%
                                                                               0
                                                                                                Premiums                   Individual Income
                        Aetna Inc.


    Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
    A Comprehensive Study of U.S. Markets: 2007 Update.”




                                                                                                  Maine


HEALTH CARE FOR AMERICA NOW!                                                                                                                    MAINE • A37
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2	
  Northwest	Federation	of	Community	Organizations,	“Insuring	Health	or	Ensuring	Profit?,”	2008.	Accessed	at	http://www.nwfco.org/
pubs/2008.0727_insuring.health.or.ensuring.profit.pdf.
3	
  Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
4	
  Ibid.
5	
  Ibid.
6	
  Ibid.
7	
  US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A38 • MAINE                                                                                                 HEALTH CARE FOR AMERICA NOW!
             Maryland Consumers Pay the Price
             For Health-Insurance Market Failure
     •	CareFirst	Inc.,	owner	of	Maryland’s	BlueCross	                                 of	annual	premiums	rose	65	percent,	while		
       BlueShield	franchise,	is	the	state’s	biggest	health		                          the	average	worker’s	share	grew	63	percent.4
       insurer	with	52	percent	of	the	state	commercial	                             •	From	2000	to	2007,	the	median	earnings	of	
       market.	Together	with	UnitedHealth	Group	                                      Maryland	workers	increased	21	percent,	from	
       Inc.,	they	control	71	percent	of	the	market.1                                  $30,252	to	$36,723.	During	that	time	health	
     •	Health	insurance	premiums	for	Maryland	                                        insurance	premiums	for	Maryland	working	
       working	families	have	skyrocketed,	increasing	                                 families	rose	three	times	faster	than	median	
       64	percent	from	2000	to	2007.2                                                 earnings.5
     •	For	family	health	coverage	in	Maryland	during	
       that	time,	the	average	annual	combined	                                      When	a	firm	has	more	than	a	42	percent	share		
       premium	for	employers	and	employees	rose	                                    of	a	single	market,	the	U.S.	Justice	Department	
       from	$7,287	to	$11,960.3                                                     considers	that	market	to	be	“highly	concentrated.”		
     •	For	family	health	coverage	in	Maryland	from	                                 This	means	that	an	insurer	could	raise	premiums	
       2000	to	2007,	the	average	employer’s	portion	                                and/or	reduce	the	variety	of	plans	or	quality	of	
       	                                                                            services	offered	to	customers	with	impunity.6




       Maryland Commercial Health Insurance                                          Percent Increase in Premiums vs Income
              Market Concentration                                                           in Maryland, 2000–2007
                                                                                   150

                 Others                                                            120
                                                              CareFirst Inc.

                           29%                  52%                                90
                                                                                                        64%
                                                                                   60

                                 19%                                               30                                                   21%

                                                                                    0
                                                                                                     Premiums                   Individual Income
               UnitedHealth Group


         Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
         A Comprehensive Study of U.S. Markets: 2007 Update.”




ne                                                                                                Maryland


     HEALTH CARE FOR AMERICA NOW!                                                                                                              MARYLAND • A39
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
3
 Ibid.
4
 Ibid.
5	
  Ibid.
6
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A40 • MARYLAND                                                                                              HEALTH CARE FOR AMERICA NOW!
 Massachusetts Consumers Pay the Price
  For Health-Insurance Market Failure
 •	Blue	Cross	and	Blue	Shield	of	Massachusetts,	                                •	From	2000	to	2007,	the	median	earnings	of	
   the	state’s	biggest	health	insurer,	controls	                                  Massachusetts	workers	increased	12	percent,	
   50	percent	of	the	state	commercial	market.	                                    from	$30,964	to	$34,542.	During	that	time	
   Together	with	Tufts	Health	Plan,	they	hold	67	                                 health	insurance	premiums	for	Massachusetts	
   percent	of	the	market.1                                                        working	families	rose	6.7	times	faster	than	
 •	Health	insurance	premiums	for	Massachusetts	                                   median	earnings.5
   working	families	have	skyrocketed,	increasing	
   78	percent	from	2000	to	2007.2                                               When	a	firm	has	more	than	a	42	percent	share		
 •	For	family	health	coverage	in	Massachusetts	                                 of	a	single	market,	the	U.S.	Justice	Department	
   during	that	period,	the	average	annual	                                      considers	that	market	to	be	“highly	
   combined	premium	for	employers	and	                                          concentrated.”	This	means	that	an	insurer	could	
   employees	rose	from	$7,341	to	$13,040.3                                      raise	premiums	and/or	reduce	the	variety	of	
 •	For	family	health	coverage	in	Massachusetts,	                                plans	or	quality	of	services	offered	to	customers	
   the	average	employer’s	portion	of	annual	                                    with	impunity.6
   premiums	rose	67	percent,	while	the	average	
   worker’s	share	grew	by	119	percent.4



      Massachusetts Commercial Health                                            Percent Increase in Premiums vs Income
       Insurance Market Concentration                                                 in Massachusetts, 2000–2007
                                                                               150
                                                        Blue Cross and
                                                        Blue Shield of         120
             Others                                     Massachusetts
                                                                               90                    78%
                       33%

                                                 50%                           60

                                                                               30
                                                                                                                                    12%
                            17%
                                                                                0
                                                                                                 Premiums                   Individual Income
          Tufts Health Plan


     Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
     A Comprehensive Study of U.S. Markets: 2007 Update.”




Maryland                                                                                     Massachusetts

 HEALTH CARE FOR AMERICA NOW!                                                                                                        MASSACHUSETTS • A41
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
3
 Ibid.
4
 Ibid.
5
 Ibid.
6
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A42 • MASSACHUSETTS                                                                                         HEALTH CARE FOR AMERICA NOW!
        Michigan Consumers Pay the Price
        For Health-Insurance Market Failure
•	Blue	Cross	and	Blue	Shield	of	Michigan,	                                    •	From	2000	to	2007,	the	median	earnings	of	
  the	state’s	biggest	health	insurer,	controls	                                 Michigan	workers	increased	5	percent,	from	
  65	percent	of	the	state	commercial	market.	                                   $25,910	to	$27,096.	During	that	time	health	
  Together	with	the	Henry	Ford	Health	System,	                                  insurance	premiums	for	Michigan	working	
  they	hold	73	percent	of	the	market.1                                          families	rose	17	times	faster	than	median	
•	Health	insurance	premiums	for	Michigan	                                       earnings.5
  working	families	have	skyrocketed,	increasing	
  78	percent	from	2000	to	2007.2                                              If	one	company	holds	more	than	a	42	percent		
•	For	family	health	coverage	in	Michigan	during	                              share	of	a	market	the	U.S.	Justice	Department	
  this	time,	the	average	annual	combined	                                     would	consider	that	market	“highly	
  premium	for	employers	and	employees	rose	                                   concentrated.”6	This	means	that	an	insurer,	with	
  from	$6,817	to	$12,151.3                                                    impunity,	could	raise	premiums	and/or	reduce	
•	For	family	health	coverage	in	Michigan	from	                                the	variety	of	plans	or	quality	of	services	offered	
  2000	to	2007,	the	average	employer’s	portion	                               to	customers.7
  of	annual	premiums	rose	63	percent,	while	the	
  average	worker’s	share	grew	by	171	percent.4



  Michigan Commercial Health Insurance                                          Percent Increase in Premiums vs Income
         Market Concentration                                                 150       in Michigan, 2000–2007

                                                           BlueCross and      120
                                                           BlueShield of
                                                           Michigan           90                   78%


      Others                                                                  60
                       27%                    65%

                                                                              30
                                                                                                                                    5%
                                8%
                                                                               0
                                                                                                Premiums                   Individual Income
                 Henry Ford
                 Health System

    Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
    A Comprehensive Study of U.S. Markets: 2007 Update.”




                                                                                                Michigan


HEALTH CARE FOR AMERICA NOW!                                                                                                                MICHIGAN • A43
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
3
 Ibid.
4
 Ibid.
5	
  Ibid.
6
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html.
7
 American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	Anticompetitive	
Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.aha.org/aha/
content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A44 • MICHIGAN                                                                                              HEALTH CARE FOR AMERICA NOW!
       Minnesota Consumers Pay the Price
       For Health-Insurance Market Failure
•	Blue	Cross	and	Blue	Shield	of	Minnesota,	the	                                 of	annual	premiums	rose	77	percent,	while	the	
  state’s	biggest	health	insurer,	holds	61	percent	                             average	worker’s	share	grew	by	66	percent.4
  of	the	state	commercial	market.	Together	with	                              •	From	2000	to	2007,	the	median	earnings	of	
  Medica,	the	second	largest,	they	control	85	                                  Minnesota	workers	increased	17	percent,	from	
  percent	of	the	market.1                                                       $26,433	to	$30,963.	During	that	time	health	
•	Health	insurance	premiums	for	Minnesota	                                      insurance	premiums	for	Minnesota	working	
  working	families	have	skyrocketed,	increasing	                                families	rose	4.3	times	faster	than	median	
  74	percent	from	2000	to	2007.2                                                earnings.5
•	For	family	health	coverage	in	Minnesota	
  during	that	time,	the	average	annual	combined		                             When	a	firm	has	more	than	a	42	percent	share		
  premium	for	employers	and	employees	rose	                                   of	a	single	market,	the	U.S.	Justice	Department	
  from	$6,957	to	$12,090.3                                                    considers	that	market	to	be	“highly	concentrated.”		
•	For	family	health	coverage	in	Minnesota	from	                               This	means	that	an	insurer	could	raise	premiums	
  2000	to	2007,	the	average	employer’s	portion		                              and/or	reduce	the	variety	of	plans	or	quality	of	
  	                                                                           services	offered	to	customers	with	impunity.6



 Minnesota Commercial Health Insurance                                          Percent Increase in Premiums vs Income
         Market Concentration                                                 150      in Minnesota, 2000–2007

                                                       Blue Cross and         120
            Others                                     Blue Shield of
                                                       Minnesota
                                                                              90
                                                                                                    74%
                      15%

                                                61%                           60

                                                                              30                                                   17%
                           24%
                                                                               0
                                                                                                Premiums                   Individual Income
                       Medica


    Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
    A Comprehensive Study of U.S. Markets: 2008 Update.”




                                                                                                  Minnesota


HEALTH CARE FOR AMERICA NOW!                                                                                                              MINNESOTA • A45
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	American	Medical	Association,	“Competition	in	health	insurance:	A	comprehensive	study	of	U.S.	markets:	2008	update.”
2
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
3	
  Ibid.
4
 Ibid.
5
 Ibid.
6
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A46 • MINNESOTA                                                                                             HEALTH CARE FOR AMERICA NOW!
            Missouri Consumers Pay the Price
           For Health-Insurance Market Failure
   •	Wellpoint	Inc.’s	Anthem	Blue	Cross	Blue	                                       of	annual	premiums	rose	72	percent,	while	the	
     Shield	subsidiary,	the	state’s	biggest	health	                                 average	worker’s	share	grew	by	91	percent.4
     insurer,	holds	68	percent	of	the	commercial	                                 •	Between	2000	and	2007,	the	median	earnings	
     market.	Together	with	UnitedHealth	Group	                                      of	Missouri	workers	increased	17	percent,	from	
     Inc.	they	control	79	percent	of	the	market.1                                   $22,201	to	$26,037.	During	that	time	health	
   •	Health	insurance	premiums	for	Missouri	                                        insurance	premiums	for	Missouri	working	
     working	families	have	skyrocketed,	increasing	                                 families	rose	4.4	times	faster	than	median	
     76	percent	from	2000	to	2007.2                                                 earnings.5
   •	For	family	health	coverage	in	Missouri	during	
     this	period,	the	average	annual	combined		                                   When	a	firm	has	more	than	a	42	percent	share		
     premium	for	employers	and	employees	rose	                                    of	a	single	market,	the	U.S.	Justice	Department	
     from	$6,731	to	$11,852.3                                                     considers	that	market	to	be	“highly	concentrated.”		
   •	For	family	health	coverage	in	Missouri	from	                                 This	means	that	an	insurer	could	raise	premiums	
     2000	to	2007,	the	average	employer’s	portion		                               and/or	reduce	the	variety	of	plans	or	quality	of	
     	                                                                            services	offered	to	customers	with	impunity.6




     Missouri Commercial Health Insurance                                          Percent Increase in Premiums vs Income
            Market Concentration                                                            in Missouri, 2000–2007
                                                                                 150

                                                          WellPoint Inc.         120

                                                 68%                             90                   76%


                       21%                                                       60

           Others                                                                30                                                   17%
                                 11%

                                                                                  0
                                                                                                   Premiums                   Individual Income
                      UnitedHealth Group

       Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
       A Comprehensive Study of U.S. Markets: 2007 Update.”




nesota                                                                                            Missouri


   HEALTH CARE FOR AMERICA NOW!                                                                                                                MISSOURI • A47
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
3
 Ibid.
4
 Ibid.
5
 Ibid.
6
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A48 • MISSOURI                                                                                              HEALTH CARE FOR AMERICA NOW!
        Montana Consumers Pay the Price
        For Health-Insurance Market Failure
•	Blue	Cross	and	Blue	Shield	of	Montana,	the	                                   premiums	rose	78	percent,	while	the	worker	
  state’s	biggest	health	insurer,	controls	75	                                  share	grew	133	percent.4
  percent	of	the	statewide	commercial	market.	                                •	Between	2000	and	2007,	the	median	earnings	
  Together	with	New	West	Health	Services,	they	                                 of	Montana	workers	increased	16	percent,	
  hold	85	percent	of	the	market.1                                               from	$19,073	to	$22,170.	During	that	time	
•	Health	insurance	premiums	for	Montana	                                        health	insurance	premiums	for	Montana	
  working	families	have	skyrocketed,	increasing	                                working	families	rose	5.5	times	faster	than	
  89	percent	from	2000	to	2007.2                                                median	earnings.5
•	For	family	health	coverage	in	Montana	during	
  that	time,	the	average	annual	combined	                                     When	a	firm	has	more	than	a	42	percent	share		
  premium	for	employers	and	employees	rose	                                   of	a	single	market,	the	U.S.	Justice	Department	
  from	$6,220	to	$11,743.3                                                    considers	that	market	to	be	“highly	concentrated.”		
•	For	family	health	coverage	in	Montana	from	                                 This	means	that	an	insurer	could	raise	premiums	
  2000	to	2007,	the	employer	portion	of	annual		                              and/or	reduce	the	variety	of	plans	or	quality	of	
  	                                                                           services	offered	to	customers	with	impunity.6



  Montana Commercial Health Insurance                                          Percent Increase in Premiums vs Income
         Market Concentration                                                          in Montana, 2000–2007
                                                        Blue Cross and
                                                        Blue Shield of
                                                        Montana                                  89%
                                         75%




                        15%

          Others              10%                                                                                                16%


                             New West Health                                                  Premiums                   Individual Income
                             Services

    Source: American Medical Association, “Competition in Health Insurance:       Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
    A Comprehensive Study of U.S. Markets: 2007 Update.”




                 Arkansas                                                                         Montana

HEALTH CARE FOR AMERICA NOW!                                                                                                              MONTANA • A49
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
3
 Ibid.
4
 Ibid.
5
 Ibid.
6
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html,	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A50 • MONTANA                                                                                               HEALTH CARE FOR AMERICA NOW!
          Nebraska Consumers Pay the Price
          For Health-Insurance Market Failure
  •	Blue	Cross	and	Blue	Shield	of	Nebraska,	the	                                   of	annual	premiums	rose	69	percent,	and	the		
    state’s	biggest	health	insurer,	holds	44	percent	                              average	worker’s	share	also	grew	by	69	percent.4
    of	the	state	commercial	market	for	health	                                   •	From	2000	to	2007,	the	median	earnings	of	
    insurance.	Together	with	UnitedHealth	Group	                                   Nebraska	workers	increased	21	percent,	from	
    Inc.,	they	control	69	percent	of	the	market.1                                  $21,255	to	$25,802.	During	that	time	health	
  •	Health	insurance	premiums	for	Nebraska	                                        insurance	premiums	for	Nebraska	working	
    working	families	have	skyrocketed,	increasing	                                 families	rose	3.2	times	faster	than	median	
    69	percent	from	2000	to	2007.2                                                 earnings.5
  •	For	family	health	coverage	in	Nebraska	during	
    that	time,	the	average	annual	combined	                                      When	a	firm	has	more	than	a	42	percent	share		
    premium	for	employers	and	employees	rose	                                    of	a	single	market,	the	U.S.	Justice	Department	
    from	$6,760	to	$11,434.3                                                     considers	that	market	to	be	“highly	concentrated.”		
  •	For	family	health	coverage	in	Nebraska	from	                                 This	means	that	an	insurer	could	raise	premiums	
    2000	to	2007,	the	average	employer’s	portion		                               and/or	reduce	the	variety	of	plans	or	quality	of	
    	                                                                            services	offered	to	customers	with	impunity.6



    Nebraska Commercial Health Insurance                                          Percent Increase in Premiums vs Income
           Market Concentration                                                           in Nebraska, 2000–2007
                                                                                150
                                                           Blue Cross
              Others                                       and Blue Shield      120
                             31%                           of Nebraska
                                                                                90
                                                                                                      69%
                                                  44%
                                                                                60

                            25%                                                 30                                                   21%


                                                                                  0
                                                                                                  Premiums                   Individual Income
            UnitedHealth Group


      Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
      A Comprehensive Study of U.S. Markets: 2007 Update.”




Missouri                                                                                      Nebraska


  HEALTH CARE FOR AMERICA NOW!                                                                                                               NEBRASKA • A51
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
3
 Ibid.
4
 Ibid.
5
 Ibid.
6
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A52 • NEBRASKA                                                                                              HEALTH CARE FOR AMERICA NOW!
           Nevada Consumers Pay the Price
          For Health-Insurance Market Failure
  •	Nevada’s	biggest	health	insurer,	Sierra	                                       premiums	rose	41	percent,	while	the	average	
    Health	Services	Inc.	(which	was	acquired	by	                                   worker’s	share	grew	by	135	percent.5
    UnitedHealth	Group	Inc.	in	2008)	held	29	                                    •	From	2000	to	2007,	the	median	earnings	of	
    percent	of	the	Nevada	commercial	market	                                       Nevada	workers	increased	21	percent,	from	
    for	health	insurance	in	2007.	Together	with	                                   $25,411	to	$30,859.	During	that	time	health	
    WellPoint	Inc.	they	controlled	57	percent	of	                                  insurance	premiums	for	Nevada	working	families	
    the	market	that	year.1                                                         rose	2.5	times	faster	than	median	earnings.6
  •	Local	markets	were	more	concentrated;	in	
    Carson	City,	Washoe	Health	System	and	                                       If	one	company	holds	more	than	a	42	percent		
    WellPoint	Inc.	together	held	90	percent	of	the	                              share	of	a	market	the	U.S.	Justice	Department	
    commercial	market.2                                                          would	consider	that	market	“highly	
  •	Health	insurance	premiums	for	Nevada	                                        concentrated.”7	The	U.S	Justice	Department	
    working	families	have	skyrocketed,	increasing	                               uses	a	rating	system	based	on	market	share	to	
    55	percent	from	2000	to	2007.3                                               determine	if	a	market	is	concentrated	or	highly	
  •	For	family	health	coverage	in	Nevada	during	                                 concentrated.	If	the	market	is	rated	from	1,000	
    that	period,	the	average	annual	combined	                                    to	1,800,	it	is	considered	to	be	“concentrated.”	
    premium	for	employers	and	employees	rose	                                    Markets	rated	higher	than	1,800	are	deemed	to	
    from	$6,688	to	$10,341.4                                                     be	“highly	concentrated.”	This	means	that	an	
  •	For	family	health	coverage	in	Nevada,	the	                                   insurer	could	raise	premiums	and/or	reduce	the	
    average	employer’s	portion	of	annual		                                       variety	of	plans	or	quality	of	services	offered	to	
    	                                                                            customers	with	impunity.8


     Commercial Health Insurance Market                                           Percent Increase in Premiums vs Income
    Concentration in Carson City, Nevada, Metropolitan Area                                in Nevada, 2000–2007

                                                                                150
                                                      Washoe Health
                                                      System
                                                                                120

                                              77%                               90

                                                                                                      55%
                                                                                60
                       10%
                                                                                30                                                   21%
            Others
                                13%
                                                                                  0
                     WellPoint Inc.                                                               Premiums                   Individual Income


      Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
      A Comprehensive Study of U.S. Markets: 2007 Update.”




Indiana
  HEALTH CARE FOR AMERICA NOW!
                                                                                              Nevada                                            NEVADA • A53
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Ibid.
3
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
4
 Ibid.
5
 Ibid.
6
 Ibid.
7
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.
8
 The	HHI	is	used	by	the	Department	of	Justice	and	the	Federal	Trade	Commission		in	anti-trust	proceedings.	The	HHI	is	the	sum	of	the	
squared	market	shares	of	each	firm	in	the	market.	The	more	competitive	the	market,	the	lower	the	HHI.	The	less	competitive	the	market,	
the	higher	the	HHI.	An	HHI	above	1,800	is	rated	“highly	concentrated.”	An	HHI	between	1,000	and	1,800	is	considered	“concentrated.”	
Accessed	at	http://www.usdoj.gov/atr/public/testimony/hhi.htm.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A54 • NEVADA                                                                                                HEALTH CARE FOR AMERICA NOW!
    New Hampshire Consumers Pay the Price
      For Health-Insurance Market Failure
    •	Anthem	Blue	Cross	and	Blue	Shield,	a	                                       •	For	family	health	coverage	in	New	Hampshire	
      WellPoint	subsidiary,	is	the	state’s	biggest	                                 from	2000	to	2007,	the	average	employer’s	
                                                       	
      health	insurer,	with	51	percent	of	the	commercial	                            portion	of	annual	premiums	rose	72	percent,	
      market.	Together	with	Cigna	Corp.,	New	                                       while	the	average	worker’s	share	grew	by	101	
      Hampshire’s	second	largest	health	insurer,	they	                              percent.5
      control	75	percent	of	the	market.1                                          •	From	2000	to	2007,	the	median	earnings	
    •	Local	markets	are	even	more	concentrated;	                                    of	New	Hampshire	workers	increased	16	
      in	the	Rochester-Dover	area,	WellPoint	and	                                   percent,	from	$27,226	to	$31,596.	During	
      Cigna	Corp.	together	hold	91	percent	of	the	                                  that	time	health	insurance	premiums	for	New	
      commercial	market.2                                                           Hampshire	working	families	rose	4.9	times	
    •	Health	insurance	premiums	for	New	                                            faster	than	median	earnings.6
      Hampshire	working	families	have	skyrocketed,	
      increasing	79	percent	from	2000	to	2007.3                                   If	one	company	holds	more	than	a	42	percent		
    •	For	family	health	coverage	in	New	Hampshire	                                share	of	a	market	the	U.S.	Justice	Department	
      during	that	time,	the	average	annual	combined		                             would	consider	that	market	“highly	
      premium	for	employers	and	employees	rose	                                   concentrated.”7	This	means	that	an	insurer,	with	
      from	$7,525	to	$13,460.4                                                    impunity,	could	raise	premiums	and/or	reduce	
                                                                                  the	variety	of	plans	or	quality	of	services	offered	
                                                                                  to	customers.8



         New Hampshire Commercial Health                                            Percent Increase in Premiums vs Income
          Insurance Market Concentration                                                in New Hampshire, 2000–2007

                                                                                  150

                                                                                  120
            Others

                           25%                                                    90                   79%

                                                              WellPoint Inc.
                                               51%                                60

                            24%                                                   30                                                   16%

           Cigna Corp.                                                             0
                                                                                                    Premiums                   Individual Income


        Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
        A Comprehensive Study of U.S. Markets: 2007 Update.”




higan                                                                                           New Hampshire
    HEALTH CARE FOR AMERICA NOW!                                                                                                        NEW HAMPSHIRE • A55
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Ibid.
3
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
4
 Ibid.
5
 Ibid.
6
 Ibid.
9
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html.
8
 American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	Anticompetitive	
Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.aha.org/aha/
content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A56 • NEW HAMPSHIRE                                                                                         HEALTH CARE FOR AMERICA NOW!
      New Jersey Consumers Pay the Price
      For Health-Insurance Market Failure
 •	Horizon	Blue	Cross	and	Blue	Shield,	New	                                       of	annual	premiums	rose	64	percent,	while	the	
   Jersey’s	biggest	health	insurer,	controls	43	                                  average	worker’s	share	grew	by	97	percent.5
   percent	of	the	state	commercial	market.1                                    •	Between	2000	and	2007,	the	median	earnings	
 •	Local	markets	in	New	Jersey	are	more	                                          of	New	Jersey	workers	increased	15	percent,	
   concentrated;	in	Ocean	City,	Horizon	Blue	                                     from	$31,923	to	$36,700.	During	that	time	
   Cross	and	Blue	Shield	and	Aetna	Inc.	together	                                 health	insurance	premiums	for	New	Jersey	
   hold	74	percent	of	the	commercial	market.2                                     working	families	rose	4.7	times	faster	than	
 •	Health	insurance	premiums	for	New	Jersey	                                      median	earnings.6
   working	families	have	skyrocketed,	increasing	                              	
   71	percent	from	2000	to	2007.3                                              If	one	company	holds	more	than	a	42	percent		
 •	For	family	health	coverage	in	New	Jersey	                                   share	of	a	market	the	U.S.	Justice	Department	
   during	that	time,	the	average	annual	combined		                             would	consider	that	market	“highly	
   premium	for	employers	and	employees	rose	                                   concentrated.”7	This	means	that	an	insurer	
   from	$7,592	to	$12,979.4                                                    could	raise	premiums	and/or	reduce	the	
 •	For	family	health	coverage	in	New	Jersey	from	                              variety	of	plans	or	quality	of	services	offered	to	
   2000	to	2007,	the	average	employer’s	portion	                               customers	with	little	fear	of	resistance.8




    Commercial Health Insurance Market                                           Percent Increase in Premiums vs Income
               Concentration in Ocean City, N.J., Area                                 in New Jersey, 2000–2007
                                                                               150

                                                          Horizon
                                                                               120
                                                          Blue Cross
                                                          and Blue Shield
                                                                               90
       Others                                                                                        71%
                      26%                     58%
                                                                               60

                                                                               30
                               16%                                                                                                  15%

                                                                                0
                 Aetna Inc.                                                                      Premiums                   Individual Income



     Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
     A Comprehensive Study of U.S. Markets: 2007 Update.”




New Hampshire                                                                                        New Jersey
 HEALTH CARE FOR AMERICA NOW!                                                                                                             NEW JERSEY • A57
ENDNOTES
1	
  Since	the	time	the	data	reported	by	the	AMA	was	collected,	Horizon	Blue	Cross	Blue	Shield	has	accumulated	a	larger	share	of	the	
market.	Other	data	in	this	report	show	a	lower	market	share	for	Horizon	from	the	American	Medical	Association,	“Competition	in	health	
insurance:	A	comprehensive	study	of	U.S.	Markets:	2007	update.”	AMA	data	in	this	report	is	based	on	combined	enrollment	in	preferred	
provider	organizations	(PPOs)	and	health	maintenance	organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	
defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	
enrollment	across	all	insurers	in	a	market	multiplied	by	100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	
employer-sponsored	PPO	plans	and	individual	coverage,	and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	
Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 American	Medical	Association,	“Competition	in	health	insurance:	A	comprehensive	study	of	U.S.	Markets:	2007	update.”
3
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
4
 Ibid.
5
 Ibid.
6
 Ibid.
7
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html.
8
 American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	Anticompetitive	
Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.aha.org/aha/
content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A58 • NEW JERSEY                                                                                          HEALTH CARE FOR AMERICA NOW!
    New Mexico Consumers Pay the Price
     For Health-Insurance Market Failure
                                                  	
•	Presbyterian	Healthcare	Services	is	New	Mexico’s	                             from	$19,631	to	$23,565.	During	that	time	
  biggest	health	insurer,	with	30	percent	of	the	                               health	insurance	premiums	for	New	Mexico	
  state	commercial	market.	Together	with	United	                                working	families	rose	4.6	times	faster	than	
  Health	Group	Inc.	the	two	companies	hold	54	                                  median	earnings.5
  percent	of	the	market.1
•	Health	insurance	premiums	for	New	Mexico	                                   If	one	company	holds	more	than	a	42	percent		
  working	families	have	skyrocketed,	increasing	                              share	of	a	market	the	U.S.	Justice	Department	
  92	percent	from	2000	to	2007.2                                              would	consider	that	market	“highly	
•	For	family	health	coverage	in	New	Mexico	                                   concentrated.”6	The	U.S	Justice	Department	
  during	that	time,	the	average	annual	combined		                             uses	a	rating	system	based	on	market	share	to	
  premium	for	employers	and	employees	rose	                                   determine	if	a	market	is	concentrated	or	highly	
  from	$6,222	to	$11,967.3                                                    concentrated.	If	the	market	is	rated	from	1,000	
•	For	family	health	coverage	in	New	Mexico,	                                  to	1,800,	it	is	considered	to	be	“concentrated.”	
  the	average	employer’s	portion	of	annual	                                   Markets	rated	higher	than	1,800	are	deemed	to	
  premiums	rose	114	percent,	while	the	average	                               be	“highly	concentrated.”	This	means	that	an	
  worker’s	share	grew	by	50	percent.4                                         insurer	could	raise	premiums	and/or	reduce	the	
•	Between	2000	and	2007,	the	median	earnings	                                 variety	of	plans	or	quality	of	services	offered	to	
  of	New	Mexico	workers	increased	20	percent	                                 customers	with	impunity.7




       New Mexico Commercial Health                                             Percent Increase in Premiums vs Income
       Insurance Market Concentration                                                 in New Mexico, 2000–2007


                       Others                                                 150

                                                                              120
                                 46%
                                                                                                   92%
                                                                              90

                                                                              60

                          24%                 30%
                                                                              30                                                   20%

                                                  Presbyterian Health          0
            UnitedHealth                          Care Services                                 Premiums                   Individual Income
            Group

    Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
    A Comprehensive Study of U.S. Markets: 2008 Update.”




HEALTH CARE FOR AMERICA NOW!                                                                                                             NEW MEXICO • A59
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	American	Medical	Association,	“Competition	in	health	insurance:	A	comprehensive	study	of	U.S.	markets:	2008	update.”2Families	
USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/premiums-vs-
paychecks-2008.html.
3
 Ibid.
4
 Ibid.
5
 Ibid.
6
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.
7
 The	HHI	is	used	by	the	Department	of	Justice	and	the	Federal	Trade	Commission		in	anti-trust	proceedings.	The	HHI	is	the	sum	of	the	
squared	market	shares	of	each	firm	in	the	market.	The	more	competitive	the	market,	the	lower	the	HHI.	The	less	competitive	the	market,	
the	higher	the	HHI.	An	HHI	above	1,800	is	rated	“highly	concentrated.”	An	HHI	between	1,000	and	1,800	is	considered	“concentrated.”	
Accessed	at	http://www.usdoj.gov/atr/public/testimony/hhi.htm.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A60 • NEW MEXICO                                                                                            HEALTH CARE FOR AMERICA NOW!
     Results of Market Failure in New York
•	GHI,	New	York’s	biggest	health	insurer,	holds		 •	For	family	health	coverage	in	New	York	during	
  26	percent	of	the	state’s	market.	GHI	and	          this	period,	the	average	annual	combined	
  Empire	Blue	Cross	and	Blue	Shield,	a	subsidiary		   premium	for	employers	and	employees	rose	
  of	WellPoint	Inc.,	control	47	percent	of	the	       from	$7,090	to	$12,811.45
  commercial	market.   40
                                                    •	For	family	health	coverage	in	New	York	from	
•	Local	markets	are	even	more	concentrated;	in	       2000	to	2007,	the	average	employer’s	portion	
  Rochester,	Excellus	BlueCross	BlueShield	and	       of	annual	premiums	rose	79	percent,	while	the	
  Preferred	Care 	together	control	94	percent	of	
                41
                                                      average	worker’s	share	increased	88	percent.46
  the	commercial	market.   42
                                                    •	From	2000	to	2007,	the	median	earnings	of	
•	Excellus	reported	net	income	of	$198	million	       New	York	workers	increased	11	percent,	from	
  in	2005.	The	top	three	insurers	posted	a	           $28,153	to	$31,263.	During	that	time	health	
  combined	profit	of	$573	million	from	New	           insurance	premiums	for	New	York	working	
  York	operations	in	2007.43                          families	rose	7.3	times	faster	than	median	
•	Health	insurance	premiums	for	New	York	             earnings.47
  working	families	have	skyrocketed,	increasing	
  81	percent	from	2000	to	2007.44




   Commercial Health Insurance Market                                         Percent Increase in Premiums vs Income
         Concentration in Rochester, New York, Area                                   in New York, 2000–2007

              Others
                                                      Excellus
                         6%
                                                                                              81%

                                              57%

                        37%



     Preffered Care                                                                                                           11%

                                                                                           Premiums                   Individual Income


    Source: American Medical Association, “Competition in Health Insurance:    Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
    A Comprehensive Study of U.S. Markets: 2007 Update.”




               Montana                                                                           New York

HEALTH CARE FOR AMERICA NOW!                                                                                                           NEW YORK • A61
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2	
  Preferred	Care	is	now	called	MVP	Health	Care.	
3	
  American	Medical	Association,	“Competition	in	health	insurance:	A	comprehensive	study	of	U.S.	Markets:	2007	update.”
4	
  Northwest	Federation	of	Community	Organizations,	“Insuring	Health	or	Ensuring	Profit?,”	2008.	Accessed	at	http://www.nwfco.org/
pubs/2008.0727_insuring.health.or.ensuring.profit.pdf.
5	
  Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
6	
  Ibid.
7	
  Ibid.
8	
  Ibid.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A62 • NEW YORK                                                                                              HEALTH CARE FOR AMERICA NOW!
 North Carolina Consumers Pay the Price
  For Health-Insurance Market Failure
•	Blue	Cross	and	Blue	Shield	of	North	Carolina,	                                portion	of	annual	premiums	rose	76	percent,	
  the	state’s	biggest	health	insurer,	holds	53	                                 while	the	average	worker’s	share	grew	by	71	
  percent	of	the	state	commercial	market.	                                      percent.5
  Together	with	UnitedHealth	Group	Inc.,	the	                                 •	From	2000	to	2007,	the	median	earnings	of	
  companies	control	73	percent	of	the	market.1                                  North	Carolina	workers	increased	14	percent,	
•	From	2004	to	2007,	Blue	Cross	and	Blue	Shield	                                from	$23,080	to	$26,316.	During	that	time	
  of	North	Carolina’s	annual	net	income	rose	32	                                health	insurance	premiums	for	North	Carolina	
  percent,	from	$150	million	to	$198	million.2                                  working	families	rose	5.3	times	faster	than	
•	Health	insurance	premiums	for	North	Carolina	                                 median	earnings.6
  working	families	have	skyrocketed,	increasing	
  75	percent	from	2000	to	2007.3                                              When	a	firm	has	more	than	a	42	percent	share		
•	For	family	health	coverage	in	North	Carolina	                               of	a	single	market,	the	U.S.	Justice	Department	
  during	that	time,	the	average	annual	combined		                             considers	that	market	to	be	“highly	concentrated.”		
  premium	for	employers	and	employees	rose	                                   This	means	that	an	insurer	could	raise	premiums	
  from	$6,649	to	$11,618.4                                                    and/or	reduce	the	variety	of	plans	or	quality	of	
•	For	family	health	coverage	in	North	Carolina	                               services	offered	to	customers	with	impunity.7
  from	2000	to	2007,	the	average	employer’s	




      North Carolina Commercial Health                                          Percent Increase in Premiums vs Income
       Insurance Market Concentration                                                in North Carolina, 2000–2007
                                                                              150

           Others                                      Blue Cross and
                                                                              120
                                                       Blue Shield of
                    27%                                North Carolina
                                                                              90
                                                                                                   75%
                                            53%
                                                                              60

                        20%                                                   30                                                   14%

                                                                               0
                                                                                                Premiums                   Individual Income
          UnitedHealth Group Inc.


    Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
    A Comprehensive Study of U.S. Markets: 2007 Update.”




HEALTH CARE FOR AMERICA NOW!                                                                                                        NORTH CAROLINA • A63
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Northwest	Federation	of	Community	Organizations,	“Insuring	Health	or	Ensuring	Profit?,”	2008.	Accessed	at	http://www.nwfco.org/
pubs/2008.0727_insuring.health.or.ensuring.profit.pdf.
3
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
4
 Ibid.
5
 Ibid.
6
 Ibid.
7
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A64 • NORTH CAROLINA                                                                                        HEALTH CARE FOR AMERICA NOW!
     North Dakota Consumers Pay the Price
      For Health-Insurance Market Failure

                                                    	
 •	Noridian	Mutual	Insurance	Co.,	doing	business	 •	For	family	health	coverage	in	North	Dakota	
   as	Blue	Cross	Blue	Shield	of	North	Dakota,	holds		 from	2000	to	2007,	the	average	employer’s	
   89	percent	of	the	state’s	accident	and	health	     portion	of	annual	premiums	rose	70	percent,	
   market,	with	Humana	Inc.	a	distant	second.         while	the	average	worker’s	share	grew	by	86	
 •	Health	insurance	premiums	for	North	Dakota	        percent.3
   working	families	have	skyrocketed,	increasing	 •	From	2000	to	2007,	the	median	earnings	of	
   74	percent	from	2000	to	2007.1                     North	Dakota	workers	increased	26	percent,	
 •	For	family	health	coverage	in	North	Dakota	        from	$19,196	to	$24,255.	During	that	time	
   during	this	period,	the	average	annual	            health	insurance	premiums	for	North	Dakota	
   combined	premium	for	employers	and	                working	families	rose	2.8	times	faster	than	
   employees	rose	from	$6,124	to	$10,674.   2
                                                      median	earnings.4




          North Dakota Health and Accident                                Percent Increase in Premiums vs Income
                 Insurance Market                                               in North Dakota, 2000–2007
                         Concentration 2006

                                                    Noridian Mutual     150
                                                    Insurance Co.,
                                                    doing business as
                                        89%                             120
                                                       BCBS of ND

                                                                        90
                                                                                             74%

                                                                        60

                                                                        30                                                   26%
                      3%
     Time Insurance     3% 6%
     Co.         Medica                                                  0
                 Health    Others                                                         Premiums                   Individual Income
                 Plans

             Source: North Dakota Insurance Department, 2008.                 Sources: Families USA, “Premiums Versus Paychecks,” September 2008.




 ENDNOTES
 1
  Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
 premiums-vs-paychecks-2008.html.
 2
  Ibid.
 3
  Ibid.


North Carolina                                                                           North Dakota
 4
  Ibid.


 150 CARE FOR AMERICA NOW!
  HEALTH                                                                                                                        NORTH DAKOTA • A65
          Ohio Consumers Pay the Price
        For Health-Insurance Market Failure
•	WellPoint	Inc.’s	Anthem	Blue	Cross	and	Blue	                                   average	worker’s	share	grew	by	80	percent.5
  Shield	subsidiary	is	Ohio’s	biggest	health	                                 •	From	2000	to	2007,	the	median	earnings	
  insurer,	controlling	41	percent	of	the	state	                                  of	Ohio	workers	increased	9	percent,	from	
  commercial	market.	Together	with	Medical	                                      $25,017	to	$27,255.	During	that	time	health	
  Mutual	of	Ohio,	they	hold	58	percent	of	the	                                   insurance	premiums	for	Ohio	working	families	
  market.1                                                                       rose	8.5	times	faster	than	median	earnings.6
•	Local	markets	are	even	more	concentrated;	in	                               		
  the	Dayton	area,	WellPoint	and	UnitedHealth	                                If	one	company	holds	more	than	a	42	percent		
  Group	Inc.	together	hold	89	percent	of	the	                                 share	of	a	market	the	U.S.	Justice	Department	
  commercial	market.2                                                         would	consider	that	market	“highly	
•	Health	insurance	premiums	for	Ohio	working	                                 concentrated.”7	The	U.S	Justice	Department	
  families	have	skyrocketed,	increasing	76	                                   uses	a	rating	system	based	on	market	share	to	
  percent	from	2000	to	2007.3                                                 determine	if	a	market	is	concentrated	or	highly	
•	For	family	health	coverage	in	Ohio	during	this	                             concentrated.	If	the	market	is	rated	from	1,000	
  period,	the	average	annual	combined	premium	                                to	1,800,	it	is	considered	to	be	“concentrated.”	
  for	employers	and	employees	rose	from	$6,596	                               Markets	rated	higher	than	1,800	are	deemed	to	
  to	$11,636.4                                                                be	“highly	concentrated.”	This	means	that	an	
•	For	family	health	coverage	in	Ohio	from	2000	                               insurer	could	raise	premiums	and/or	reduce	the	
  to	2007,	the	average	employer’s	portion	of	                                 variety	of	plans	or	quality	of	services	offered	to	
  annual	premiums	rose	75	percent,	while	the	                                 customers	with	impunity.8



   Commercial Health Insurance Market                                          Percent Increase in Premiums vs Income
                Concentration in Dayton, Ohio, Area                                      in Ohio, 2000–2007



                                                         WellPoint Inc.
                                              66%
     Others
                   11%                                                                          76%




                              23%                                                                                                9%
             UnitedHealth
                                                                                             Premiums                   Individual Income
             Group

    Source: American Medical Association, “Competition in Health Insurance:      Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
    A Comprehensive Study of U.S. Markets: 2008 Update.”




A66 • OHIO                                                                                                             HEALTH CARE FOR AMERICA NOW!
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Ibid.
3
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
4
 Ibid.
5
 Ibid.
6
 Ibid.
7
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.
8
 The	HHI	is	used	by	the	Department	of	Justice	and	the	Federal	Trade	Commission		in	anti-trust	proceedings.	The	HHI	is	the	sum	of	the	
squared	market	shares	of	each	firm	in	the	market.	The	more	competitive	the	market,	the	lower	the	HHI.	The	less	competitive	the	market,	
the	higher	the	HHI.	An	HHI	above	1,800	is	rated	“highly	concentrated.”	An	HHI	between	1,000	and	1,800	is	considered	“concentrated.”	
Accessed	at	http://www.usdoj.gov/atr/public/testimony/hhi.htm.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




HEALTH CARE FOR AMERICA NOW!                                                                                                   OHIO • A67
              Oklahoma Consumers Pay the Price
              For Health-Insurance Market Failure
      •	Blue	Cross	and	Blue	Shield	of	Oklahoma,	the	                                  annual	premiums	rose	57	percent,	while	the	
        state’s	biggest	health	insurer,	holds	45	percent	                             average	worker	share	grew	by	77	percent.4
        of	the	commercial	market.	Together	with	                                    •	From	2000	to	2007,	the	median	earnings	of	
        CommunityCare	they	control	71	percent	of	                                     Oklahoma	workers	increased	19	percent,	from	
        the	market.1                                                                  $20,791	to	$24,710.	During	that	time	health	
      •	Health	insurance	premiums	for	Oklahoma	                                       insurance	premiums	for	Oklahoma	working	
        working	families	have	skyrocketed,	increasing	                                families	rose	3.3	times	faster	than	median	
        62	percent	from	2000	to	2007.2                                                earnings.5
      •	For	family	health	coverage	in	Oklahoma	
        during	this	period,	the	average	annual	                                     When	a	firm	has	more	than	a	42	percent	share		
        combined	premium	for	employers	and	                                         of	a	single	market,	the	U.S.	Justice	Department	
        employees	rose	from	$6,937	to	$11,238.3                                     considers	that	market	to	be	“highly	concentrated.”		
      •	For	family	health	coverage	in	Oklahoma	from	                                This	means	that	an	insurer	could	raise	premiums	
        2000	to	2007,	the	average	employer	portion	of		                             and/or	reduce	the	variety	of	plans	or	quality	of	
        	                                                                           services	offered	to	customers	with	impunity.6



       Oklahoma Commercial Health Insurance                                           Percent Increase in Premiums vs Income
              Market Concentration                                                           in Oklahoma, 2000–2007

                                                                                    150
                                                               Blue Cross
                                                               Blue Shield of
                 Others                                                             120
                                                               Oklahoma
                                29%
                                                                                    90
                                                    45%                                                   62%
                                                                                    60
                                  26%
                                                                                    30                                                   19%

              Community Care                                                         0
                                                                                                      Premiums                   Individual Income


          Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
          A Comprehensive Study of U.S. Markets: 2007 Update.”




                                                                                                      Oklahoma
      A68 • OKLAHOMA                                                                                                            HEALTH CARE FOR AMERICA NOW!

150                                                                                                                            150
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
3
 Ibid.
4
 Ibid.
5
 Ibid.
6
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




HEALTH CARE FOR AMERICA NOW!                                                                                             OKLAHOMA • A69
         Oregon Consumers Pay the Price
        For Health-Insurance Market Failure
•	Regence	BlueCross	BlueShield	of	Oregon,	the	                                •	From	2000	to	2007,	the	median	earnings	of	
  state’s	largest	health	insurer,	controlled	26	                                Oregon	workers	increased	18	percent,	from	
  percent	of	the	commercial	market	in	2008.	                                    $22,401	to	$26,444.	During	that	time	health	
  Together	with	Providence	Health	&	Services,	                                  insurance	premiums	for	Oregon	working	
  they	hold	52	percent.1                                                        families	rose	4.7	times	faster	than	median	
•	Local	markets	are	more	concentrated;	in	                                      earnings.7
  Medford,	Regence	BlueCross	BlueShield	of	
  Oregon	and	ODS	Health	Plans	together	hold	                                  If	one	company	holds	more	than	a	42	percent		
  74	percent	of	the	commercial	market.2,3                                     share	of	a	market	the	U.S.	Justice	Department	
•	Health	insurance	premiums	for	Oregon	                                       would	consider	that	market	“highly	
  working	families	have	skyrocketed,	increasing	                              concentrated.”8	The	U.S	Justice	Department	
  85	percent	from	2000	to	2007.4                                              uses	a	rating	system	based	on	market	share	to	
•	For	family	health	coverage	in	Oregon	during	                                determine	if	a	market	is	concentrated	or	highly	
  this	time,	the	average	annual	combined	                                     concentrated.	If	the	market	is	rated	from	1,000	
  premium	for	employers	and	employees	rose	                                   to	1,800,	it	is	considered	to	be	“concentrated.”	
  from	$6,654	to	$12,321.5                                                    Markets	rated	higher	than	1,800	are	deemed	to	
•	For	family	health	coverage	in	Oregon	from	                                  be	“highly	concentrated.”	This	means	that	an	
  2000	to	2007,	the	average	employer’s	portion	                               insurer	could	raise	premiums	and/or	reduce	the	
  of	annual	premiums	rose	77	percent,	while	the	                              variety	of	plans	or	quality	of	services	offered	to	
  average	worker’s	share	grew	by	111	percent.6                                customers	with	impunity.9



   Commercial Health Insurance Market                                           Percent Increase in Premiums vs Income
                 Concentration in Medford, Oregon                                        in Oregon, 2000–2007


                                                   Regence BlueCross          150
                                                   BlueShield of Oregon
                                                                              120
                                               67%                                                 85%
                                                                              90


                       26%                                                    60
       Others
                                                                              30                                                   18%
                                7%

                                                                               0
                               The ODS Cos.                                                     Premiums                   Individual Income


    Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
    A Comprehensive Study of U.S. Markets: 2008 Update.”




A70 • OREGON                                                                                                              HEALTH CARE FOR AMERICA NOW!
ENDNOTES
1	
  AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	American	Medical	Association,	“Competition	in	health	insurance:	A	comprehensive	study	of	U.S.	markets:	2008	update.”
2
 Ibid.
3
 Regence	BlueCross	BlueShield	of	Oregon	lost	a	major	state	wide	contract	in	2009	that	is	likely	to	affect	its	market	share.	See	http://www.
thelundreport.org/resource/regence_loses_major_public_employee_contract.
4
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
5
 Ibid.
6
 Ibid.
7
 Ibid.
8
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.
9
 The	HHI	is	used	by	the	Department	of	Justice	and	the	Federal	Trade	Commission		in	anti-trust	proceedings.	The	HHI	is	the	sum	of	the	
squared	market	shares	of	each	firm	in	the	market.	The	more	competitive	the	market,	the	lower	the	HHI.	The	less	competitive	the	market,	
the	higher	the	HHI.	An	HHI	above	1,800	is	rated	“highly	concentrated.”	An	HHI	between	1,000	and	1,800	is	considered	“concentrated.”	
Accessed	at	http://www.usdoj.gov/atr/public/testimony/hhi.htm.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




HEALTH CARE FOR AMERICA NOW!                                                                                                OREGON •   A71
           Pennsylvania Consumers Pay the Price
            For Health-Insurance Market Failure
     •	In	2007,	the	three	largest	insurers,	Aetna	Inc.,	   premium	for	employers	and	employees	rose	
       Independence	Blue	Cross,	and	Highmark	Blue	         from	$6,721	to	$12,513.3
       Cross	Blue	Shield,	posted	combined	profits	       •	For	family	health	coverage	in	Pennsylvania,	
       of	$381	million	for	business	written	in	the	        the	average	employer’s	portion	of	annual	
       state.	From	2004	to	2007	Highmark’s	profits	        premiums	rose	76	percent,	while	the	average	
       increased	22	percent	even	as	membership	fell	       worker’s	share	grew	by	128	percent.4
       41	percent.1                                      •	From	2000	to	2007,	the	median	earnings	of	
     •	Health	insurance	premiums	for	Pennsylvania	         Pennsylvania	workers	increased	13	percent,	
       working	families	have	skyrocketed,	increasing	      from	$24,834	to	$28,155.	During	that	time	
       86	percent	from	2000	to	2007.2                      health	insurance	premiums	for	Pennsylvania	
     •	For	family	health	coverage	in	Pennsylvania	         working	families	rose	6.4	times	faster	than	
       during	that	time,	the	average	annual	combined		     median	earnings.5



              Pennsylvania Health and Accident                                              Percent Increase in Premiums vs Income
                     Insurance Market                                                             in Pennsylvania, 2000–2007
                                  Concentration 2006
                                                                                          150
                                                      Others
                                                                                          120
                                         41%
                                                                                                                86%
                                                                                          90
         Aetna Inc.
                        6%
                                                                                          60

                                26%               27%
                                                                                          30
                                                                                                                                               13%
                                                            Highmark Blue Cross
          Independence                                                                     0
                                                            Blue Shield
          Blue Cross                                                                                        Premiums                   Individual Income



         Source: National Association of Insurance Commissioners, “2006 Market Share            Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
         Reports for the Top 125 Accident and Health Insurers by State and Countrywide”




th Dakota
    ENDNOTES
                                                                                                        Pennsylvania
     1
      Northwest	Federation	of	Community	Organizations,	“Insuring	Health	or	Ensuring	Profit?,”	2008.	Accessed	at	http://www.nwfco.org/
     pubs/2008.0727_insuring.health.or.ensuring.profit.pdf.
     2
      Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
     premiums-vs-paychecks-2008.html.
     Ibid.
     3


     Ibid.
     4


     Ibid.
     5




     A72 • PENNSYLVANIA                                                                                                               HEALTH CARE FOR AMERICA NOW!
    150                                                                                                               150
  Results of Market Failure in Rhode Island

  •	Blue	Cross	Blue	Shield	of	Rhode	Island,		                                    •	For	family	health	coverage	in	Rhode	Island,	
    the	state’s	biggest	health	insurer,	holds		                                    the	average	employer’s	portion	of	annual	
    79	percent	of	the	state	commercial	market.	                                    premiums	rose	91	percent,	while	the	average	
    Together	with	UnitedHealth	Group	Inc.,	they	                                   worker’s	share	grew	by	58	percent.5
    control	95	percent	of	the	market.1                                           •	Between	2000	and	2007,	the	median	earnings	
  •	From	2004	to	2007	Blue	Cross	Blue	Shield	                                      of	Rhode	Island	workers	increased	17	percent,	
    of	Rhode	Island’s	annual	profits	grew	331	                                     from	$26,164	to	$30,566.	During	that	time	
    percent	to	$61.3	million	from	$14.2	million.	                                  health	insurance	premiums	for	Rhode	Island	
    UnitedHealth’s	profit	on	Rhode	Island	business	                                working	families	rose	five	times	faster	than	
    grew	by	86.7	percent—from	$13.4	million	                                       median	earnings.6
    to	$25.1	million—even	as	its	membership	
    dropped	by	31	percent.2                                                      When	a	firm	has	more	than	a	42	percent	share		
  •	Health	insurance	premiums	for	Rhode	Island	                                  of	a	single	market,	the	U.S.	Justice	Department	
    working	families	have	skyrocketed,	increasing	                               considers	that	market	to	be	“highly	concentrated.”		
    83	percent	from	2000	to	2007.3                                               This	means	that	an	insurer	could	raise	premiums	
  •	For	family	health	coverage	in	Rhode	Island	                                  and/or	reduce	the	variety	of	plans	or	quality	of	
    during	that	time,	the	average	annual	combined		                              services	offered	to	customers	with	impunity.7
    premium	for	employers	and	employees	rose	
    from	$6,904.4



         Rhode Island Commercial Health                                           Percent Increase in Premiums vs Income
         Insurance Market Concentration                                                 in Rhode Island, 2000–2007

                                                    BlueCross
                                                    BlueShield of               150
                                                    Rhode Island
                                                                                120

                                                                                90                   83%
                                              79%

                                                                                60
                      5%
          Others
                               16%                                              30                                                   17%

              UnitedHealth                                                       0
                                                                                                  Premiums                   Individual Income
              Group Inc.

      Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
      A Comprehensive Study of U.S. Markets: 2007 Update.”




  HEALTH CARE FOR AMERICA NOW!                                                                                                           RHODE ISLAND • A73


Oregon                                                                                            Rhode Island
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2	
  Northwest	Federation	of	Community	Organizations,	“Insuring	Health	or	Ensuring	Profit?,”	2008.	Accessed	at	http://www.nwfco.org/
pubs/2008.0727_insuring.health.or.ensuring.profit.pdf.
3	
  Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
4	
  Ibid.
5	
  Ibid.
6	
  Ibid.
7	
  US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A74 • RHODE ISLAND                                                                                          HEALTH CARE FOR AMERICA NOW!
South Carolina Consumers Pay the Price
  For Health-Insurance Market Failure
•	Blue	Cross	Blue	Shield	of	South	Carolina,	the	                                premiums	rose	74	percent,	while	the	average	
  state’s	dominant	insurer,	controls	66	percent	                                worker’s	share	grew	by	82	percent.4
  of	the	South	Carolina	commercial	health	                                    •	Between	2000	and	2007,	the	median	earnings	
  insurance	market.	Together	with	Cigna	Corp.,	                                 of	South	Carolina	workers	increased	13	percent,		
  the	state’s	second	largest	health	insurer,	they	                              from	$23,057	to	$26,140.	During	that	time	
  hold	75	percent	of	the	market.1                                               health	insurance	premiums	for	South	Carolina	
•	Health	insurance	premiums	for	South	Carolina	                                 working	families	rose	5.7	times	faster	than	
  working	families	have	skyrocketed,	increasing	                                median	earnings.5
  76	percent	from	2000	to	2007.2
•	For	family	health	coverage	in	South	Carolina	                               When	a	firm	has	more	than	a	42	percent	share		
  during	that	time,	the	average	annual	combined		                             of	a	single	market,	the	U.S.	Justice	Department	
  premium	for	employers	and	employees	rose	                                   considers	that	market	to	be	“highly	concentrated.”		
  from	$6,600	to	$11,624.3                                                    This	means	that	an	insurer	could	raise	premiums	
•	For	family	health	coverage	in	South	Carolina,	                              and/or	reduce	the	variety	of	plans	or	quality	of	
  the	average	employer’s	portion	of	annual	                                   services	offered	to	customers	with	impunity.6




      South Carolina Commercial Health                                          Percent Increase in Premiums vs Income
       Insurance Market Concentration                                                in South Carolina, 2000–2007
                                                                              150
                                                          Blue Cross
                                                          Blue Shield of      120
                                                          South Carolina

                                            66%                               90                    76%


      Others                                                                  60
                     25%

                                                                              30
                                                                                                                                   13%
                                9%
                                                                               0
                             Cigna Corp.                                                        Premiums                   Individual Income


    Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
    A Comprehensive Study of U.S. Markets: 2007 Update.”




                                                                                                South Carolina

HEALTH CARE FOR AMERICA NOW!                                                                                                        SOUTH CAROLINA • A75
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
3
 Ibid.
4
 Ibid.
5
 Ibid.
6
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A76 • SOUTH CAROLINA                                                                                        HEALTH CARE FOR AMERICA NOW!
      South Dakota Consumers Pay the Price
       For Health-Insurance Market Failure
    •	Wellmark	Blue	Cross	and	Blue	Shield	of	South	                               •	From	2000	to	2007,	the	median	earnings	of	
      Dakota,	the	state’s	dominant	health	insurer,	                                 South	Dakota	workers	increased	17	percent,	
      holds	61	percent	of	the	state	commercial	                                     from	$20,299	to	$23,699.	During	that	time	
      market.	Together	with	Dakotacare,	they	                                       health	insurance	premiums	for	South	Dakota	
      control	71	percent	of	the	market.1                                            working	families	rose	3.3	times	faster	than	
    •	Health	insurance	premiums	for	South	Dakota	                                   median	earnings.5
      working	families	have	skyrocketed,	increasing	
      55	percent	from	2000	to	2007.2                                              When	a	firm	has	more	than	a	42	percent	share		
    •	For	family	health	coverage	in	South	Dakota	                                 of	a	single	market,	the	U.S.	Justice	Department	
      during	that	time,	the	average	annual	combined		                             considers	that	market	to	be	“highly	concentrated.”		
      premium	for	employers	and	employees	rose	                                   This	means	that	an	insurer	could	raise	premiums	
      from	$6,760	to	$10,477.3                                                    and/or	reduce	the	variety	of	plans	or	quality	of	
    •	For	family	health	coverage	in	South	Dakota,	                                services	offered	to	customers	with	impunity.6
      the	average	employer’s	portion	of	annual	
      premiums	rose	58	percent,	while	the	average	
      worker’s	share	grew	46	percent.4



          South Dakota Commercial Health                                            Percent Increase in Premiums vs Income
          Insurance Market Concentration                                                 in South Dakota, 2000–2007
                                                                                  150
                                                         Wellmark
                                                                                  120

           Others                                  61%                            90

                        29%                                                                             55%
                                                                                  60

                                                                                  30                                                   17%
                                   10%

                                                                                   0
                                                                                                    Premiums                   Individual Income
                         Dakotacare


        Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
        A Comprehensive Study of U.S. Markets: 2008 Update.”




th Carolina                                                                                     South Dakota

    HEALTH CARE FOR AMERICA NOW!                                                                                                          SOUTH DAKOTA • A77
ENDNOTES
1	
  AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	American	Medical	Association,	“Competition	in	health	insurance:	A	comprehensive	study	of	U.S.	markets:	2008	update.”	
2
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
3
 Ibid.
4
 Ibid.
5
 Ibid.
6
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A78 • SOUTH DAKOTA                                                                                          HEALTH CARE FOR AMERICA NOW!
        Tennessee Consumers Pay the Price
        For Health-Insurance Market Failure
 •	BlueCross	BlueShield	of	Tennessee,	the	state’s	                               premium	for	employers	and	workers	rose		
   dominant	health	insurer,	holds	45	percent	                                    62	percent	from	$6,550	to	$10,606.4
   of	the	commercial	market.	Together	with	                                    •	For	family	health	coverage	in	Tennessee,	
   UnitedHealth	Group	Inc.,	the	state’s	second	                                  the	average	employer’s	portion	of	annual	
   largest	health	insurer,	they	control	61	percent	                              premiums	rose	58	percent,	while	the	average	
   of	the	market.1                                                               worker’s	share	grew	by	73	percent.5
 •	Blue	Cross	Blue	Shield	of	Tennessee	recorded	                               •	Between	2000	and	2007,	the	median	earnings	
   profit	of	$149	million	in	2004.		UnitedHealth	                                of	Tennessee	workers	increased	12	percent	
   reported	a	721	percent	increase	in	profit	from	                               from	$22,863	to	$25,639.	During	that	time	
   its	Tennessee	operations	from	2004	to	2007.	                                  health	insurance	premiums	for	Tennessee	
   During	that	time	net	earnings	in	the	state	                                   working	families	rose	5.1	times	faster	than	
   climbed	from	$5.6	million	to	$46	million,	                                    median	earnings.6
   while	membership	grew	28	percent.2
 •	Health	insurance	premiums	for	Tennessee	                                    When	a	firm	has	more	than	a	42	percent	share		
   working	families	have	skyrocketed,	increasing	                              of	a	single	market,	the	U.S.	Justice	Department	
   62	percent	from	2000	to	2007.3                                              considers	that	market	to	be	“highly	concentrated.”		
 •	For	family	health	coverage	in	Tennessee	during	                             This	means	that	an	insurer	could	raise	premiums	
   that	time,	the	average	annual	combined		                                    and/or	reduce	the	variety	of	plans	or	quality	of	
   	                                                                           services	offered	to	customers	with	impunity.7



  Tennessee Commercial Health Insurance                                          Percent Increase in Premiums vs Income
          Market Concentration                                                          in Tennessee, 2000–2007

                                                  BlueCross BlueShield
                                                                               150
                                                  of Tennessee
              Others
                                                                               120
                          39%
                                                                               90
                                                                                                    62%
                                                  45%
                                                                               60


                              16%                                              30                                                   12%


                  UnitedHealth
                                                                                0
                                                                                                 Premiums                   Individual Income
                  Group Inc.

     Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
     A Comprehensive Study of U.S. Markets: 2008 Update.”




South Dakota
 HEALTH CARE FOR AMERICA NOW!
                                                                                                            Tennessee                      TENNESSEE • A79
ENDNOTES
1	
  AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	American	Medical	Association,	“Competition	in	health	insurance:	A	comprehensive	study	of	U.S.	markets:	2008	update.”	
2
 Northwest	Federation	of	Community	Organizations,	“Insuring	Health	or	Ensuring	Profit?,”	2008.	Accessed	at	http://www.nwfco.org/
pubs/2008.0727_insuring.health.or.ensuring.profit.pdf.
3
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
4
 Ibid.
5
 Ibid.
6
 Ibid.
7
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A80 • TENNESSEE                                                                                             HEALTH CARE FOR AMERICA NOW!
          Texas Consumers Pay the Price
        For Health-Insurance Market Failure
•	According	to	a	2008	AMA	report,	Health	Care	                                •	For	family	health	coverage	in	Texas,	the	
  Service	Corp.,	the	biggest	Texas	health	insurer,	                             average	employer’s	portion	of	annual	
  controls	44	percent	of	the	state	commercial	                                  premiums	rose	88	percent,	while	the	average	
  market	through	its	BlueCross	BlueShield	of	                                   worker’s	share	grew	by	83	percent.5
  Texas	subsidiary.	Together	with	UnitedHealth	                               •	From	2000	to	2007,	the	median	earnings	of	
  Group	Inc.,	the	second	largest	Texas	health	                                  Texas	workers	increased	15	percent,	from	
  insurer,	they	hold	68	percent	of	the	market.1                                 $23,032	to	$26,484.	During	that	time	health	
•	Some	local	markets	are	even	more	concentrated.		                              insurance	premiums	for	Texas	working	families	
  In	Abilene,	Health	Care	Service	Corp.	has	an	                                 rose	5.8	times	faster	than	median	earnings.6
  85	percent	commercial	market	share.2
•	Health	insurance	premiums	for	Texas	working	                                When	a	firm	has	more	than	a	42	percent	
  families	have	skyrocketed,	increasing	87	                                   share	of	a	single	market,	the	U.S.	Justice	
  percent	from	2000	to	2007.3                                                 Department	considers	that	market	to	be	“highly	
•	For	family	health	coverage	in	Texas	during	that	                            concentrated.”	This	means	that	an	insurer	could	
  time,	the	average	annual	combined	premium	                                  raise	premiums	and/or	reduce	the	variety	of	
  for	employers	and	employees	rose	from	$6,638	                               plans	or	quality	of	services	offered	to	customers	
  to	$12,403.4                                                                with	impunity.7



   Commercial Health Insurance Market                                           Percent Increase in Premiums vs Income
           Concentration in Abilene, Texas, Metro Area                                    in Texas, 2000–2007
                                                                              150

                                                     Health care Service      120
                                                     Corporation (Blue
                                                     Cross Blue Shield                             87%
                                                        of Texas)             90
                                        85%
                                                                              60

                                                                              30                                                   15%
                      6%
          Others              9%                                               0
                                                                                                Premiums                   Individual Income

                        UnitedHealth Group Inc.


    Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
    A Comprehensive Study of U.S. Markets: 2008 Update.”



                                                                                                Texas

HEALTH CARE FOR AMERICA NOW!                                                                                                                    TEXAS • A81
ENDNOTES
1	
  AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	American	Medical	Association,	“Competition	in	health	insurance:	A	comprehensive	study	of	U.S.	markets:	2008	update.”
2
 Ibid.
3
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
4
 Ibid.
5
 Ibid.
6
 Ibid.
7
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	ttp://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A82 • TEXAS                                                                                                 HEALTH CARE FOR AMERICA NOW!
               Utah Consumers Pay the Price
             For Health-Insurance Market Failure
     •	Regence	BlueCross	BlueShield	of	Utah,	the	                                    premiums	rose	83	percent,	while	the	average	
       state’s	dominant	health	insurer,	holds	47	                                    worker’s	share	grew	by	92	percent.4
       percent	of	the	commercial	market.	Together	                                 •	From	2000	to	2007,	the	median	earnings	
       with	Intermountain	Healthcare,	the	second	                                    of	Utah	workers	increased	17	percent,	from	
       largest,	they	control	68	percent	of	the	market.1	                             $21,497	to	$25,205.	During	that	time	health	
     •	Health	insurance	premiums	for	Utah	working	                                   insurance	premiums	for	Utah	working	families	
       families	have	skyrocketed,	increasing	85	                                     rose	4.9	times	faster	than	median	earnings.5
       percent	from	2000	to	2007.2
     •	For	family	health	coverage	in	Utah	during	that	                             When	a	firm	has	more	than	a	42	percent	share		
       time,	the	average	annual	combined	premium	                                  of	a	single	market,	the	U.S.	Justice	Department	
       for	employers	and	employees	rose	from	$6,305	                               considers	that	market	to	be	“highly	concentrated.”		
       to	$11,644.3                                                                This	means	that	an	insurer	could	raise	premiums	
     •	For	family	health	coverage	in	Utah,	the	                                    and/or	reduce	the	variety	of	plans	or	quality	of	
       average	employer’s	portion	of	annual	                                       services	offered	to	customers	with	impunity.6




          Utah Commercial Health Insurance                                           Percent Increase in Premiums vs Income
                Market Concentration                                               150         in Utah, 2000–2007

                                                              Regence              120
                Others                                        BlueCross
                                                              BlueShield                                 85%
                             32%                                                   90

                                                                                   60
                                                      47%

                                                                                   30                                                   17%
                                 21%

                                                                                    0
                                                                                                     Premiums                   Individual Income
                  Intermountain
                  Healthcare

         Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
         A Comprehensive Study of U.S. Markets: 2007 Update.”




as                                                                                                Utah



     HEALTH CARE FOR AMERICA NOW!                                                                                                                    UTAH • A83
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
3
 Ibid.
4
 Ibid.
5	
  Ibid.
6
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A84 • UTAH                                                                                                  HEALTH CARE FOR AMERICA NOW!
        Results of Market Failure in Vermont
 •	Blue	Cross	and	Blue	Shield	of	Vermont,	the	                                   premiums	rose	66	percent,	while	the	average	
   state’s	dominant	health	insurer,	holds	77	                                    worker’s	share	grew	115	percent.4	
   percent	of	the	state’s	commercial	market.	                                  •	From	2000	to	2007,	the	median	earnings	of	
   Together	with	Cigna	Corp.	they	control	90	                                    Vermont	workers	increased	20	percent,	from	
   percent	of	the	market.1                                                       $22,155	to	$26,585.	During	that	time	health	
 •	Health	insurance	premiums	for	Vermont	                                        insurance	premiums	for	Vermont	working	
   working	families	have	skyrocketed,	increasing	                                families	rose	3.7	times	faster	than	median	
   75	percent	from	2000	to	2007.2                                                earnings.5
 •	For	family	health	coverage	in	Vermont	during	
   that	time,	the	average	annual	combined	                                     When	a	firm	has	more	than	a	42	percent	share		
   premium	for	employers	and	employees	rose	                                   of	a	single	market,	the	U.S.	Justice	Department	
   from	$7,054	to	$12,340.3                                                    considers	that	market	to	be	“highly	concentrated.”		
 •	For	family	health	coverage	in	Vermont,	the	                                 This	means	that	an	insurer	could	raise	premiums	
   average	employer’s	portion	of	annual		                                      and/or	reduce	the	variety	of	plans	or	quality	of	
   	                                                                           services	offered	to	customers	with	impunity.6




   Vermont Commercial Health Insurance                                           Percent Increase in Premiums vs Income
          Market Concentration                                                            in Vermont, 2000–2007
                                                                               150
                                                         Blue Cross and
                                                         Blue Shield of        120
                                                         Vermont
                                                                               90                    75%
                                            77%
                                                                               60

                       10%                                                                                                          20%
          Others                                                               30
                               13%
                                                                                0
                                                                                                 Premiums                   Individual Income
                   Cigna Corp.


     Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
     A Comprehensive Study of U.S. Markets: 2007 Update.”




Utah                                                                                                        Vermont



 HEALTH CARE FOR AMERICA NOW!                                                                                                                VERMONT • A85
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
3
 Ibid.
4
 Ibid.
5
 Ibid.
6
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A86 • VERMONT                                                                                               HEALTH CARE FOR AMERICA NOW!
         Virginia Consumers Pay the Price
        For Health-Insurance Market Failure
•	WellPoint	Inc.,	the	state’s	dominant	health	                                  rose	81	percent,	while	the	average	worker’s	
  insurer,	holds	50	percent	of	the	Virginia	market	                             share	grew	85	percent.4
  through	its	Anthem	subsidiary.	Together	with	                               •	From	2000	to	2007,	the	median	earnings	of	
  Aetna	Inc.,	they	control	61	percent	of	the	                                   Virginia	workers	increased	20	percent,	from	
  commercial	market.1                                                           $26,459	to	$31,800.	During	that	time	health	
•	Health	insurance	premiums	for	Virginia	                                       insurance	premiums	for	Virginia	working	
  working	families	have	skyrocketed,	increasing	                                families	rose	4.1	times	faster	than	median	
  83	percent	from	2000	to	2007.2                                                earnings.5
•	For	family	health	coverage	in	Virginia	during	
  that	time,	the	average	annual	combined	                                     When	a	firm	has	more	than	a	42	percent	share		
  premium	for	employers	and	employees	rose	                                   of	a	single	market,	the	U.S.	Justice	Department	
  from	$6,684	to	$12,198.3                                                    considers	that	market	to	be	“highly	concentrated.”		
•	For	family	health	coverage	in	Virginia,	the		                               This	means	that	an	insurer	could	raise	premiums	
  average	employer’s	portion	of	annual	premiums	    	                         and/or	reduce	the	variety	of	plans	or	quality	of	
  	                                                                           services	offered	to	customers	with	impunity.6
  	



   Virginia Commercial Health Insurance                                         Percent Increase in Premiums vs Income
           Market Concentration                                               150        in Virginia, 2000–2007

                                                                              120
            Others
                                                         WellPoint Inc.
                                                                                                   83%
                                                                              90
                      39%
                                                50%                           60

                                                                              30                                                   20%

                              11%
                                                                               0
                                                                                                Premiums                   Individual Income
                  Aetna Inc.

    Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
    A Comprehensive Study of U.S. Markets: 2007 Update.”




                                                                                                Virginia


HEALTH CARE FOR AMERICA NOW!                                                                                                                  VIRGINIA • A87
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
3
 Ibid.
4
 Ibid.
5
 Ibid.
6
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A88 • VIRGINIA                                                                                              HEALTH CARE FOR AMERICA NOW!
            Washington Consumers Pay the Price
            For Health-Insurance Market Failure
       •	Premera	Blue	Cross,	Washington’s	largest	                                   •	From	2000	to	2007,	the	median	earnings	of	
         insurer,	holds	38	percent	of	the	commercial	                                  Washington	workers	increased	16	percent,	
         market.	Together	with	Regence	BlueShield,	the	                                from	$26,761	to	$31,143.	During	that	time	
         second	largest	health	insurer	in	the	state,	they	                             health	insurance	premiums	for	Washington	
         control	61	percent	of	the	market.1                                            working	families	rose	5.3	times	faster	than	
       •	In	Wenatchee,	Premera	Blue	Cross	holds		                                      median	earnings.6
         86	percent	of	the	commercial	market,	and	
         together	with	Cigna	Corp.,	they	control	92	                                 If	one	company	holds	more	than	a	42	percent		
         percent.2                                                                   share	of	a	market	the	U.S.	Justice	Department	
       •	Health	insurance	premiums	for	Washington	                                   would	consider	that	market	“highly	
         working	families	have	skyrocketed,	increasing	                              concentrated.”7	The	U.S	Justice	Department	
         87	percent	from	2000	to	2007.3                                              uses	a	rating	system	based	on	market	share	to	
       •	For	family	health	coverage	in	Washington	                                   determine	if	a	market	is	concentrated	or	highly	
         during	that	time,	the	average	annual	combined		                             concentrated.	If	the	market	is	rated	from	1,000	
         premium	for	employers	and	employees	rose	                                   to	1,800,	it	is	considered	to	be	“concentrated.”	
         from	$6,496	to	$12,120.4                                                    Markets	rated	higher	than	1,800	are	deemed	to	
       •	For	family	health	coverage	in	Washington,	                                  be	“highly	concentrated.”	This	means	that	an	
         the	average	employer’s	portion	of	annual	                                   insurer	could	raise	premiums	and/or	reduce	the	
         premiums	rose	98	percent,	while	the	average	                                variety	of	plans	or	quality	of	services	offered	to	
         worker’s	share	grew	60	percent.5                                            customers	with	impunity.8



          Commercial Health Insurance Market                                           Percent Increase in Premiums vs Income
          Concentration in the Wenatchee, Washington, Metro Area                             in Washington, 2000–2007

                                                                                     150
                                                           Premera
                                                           Blue Cross                120

                                              86%                                                          87%
                                                                                     90

                                                                                     60

                                                                                     30                                                   16%
                                 8%
                                       6%                                             0
                       Others
                                                                                                       Premiums                   Individual Income
                                       Cigna Corp.


           Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
           A Comprehensive Study of U.S. Markets: 2007 Update.”




inia   HEALTH CARE FOR AMERICA NOW!                                                                 Washington                                  WASHINGTON • A89
ENDNOTES
1
 AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
2
 Ibid.
3
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
4
 Ibid.
5
 Ibid.
6
 Ibid.
7
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.
8
 The	HHI	is	used	by	the	Department	of	Justice	and	the	Federal	Trade	Commission		in	anti-trust	proceedings.	The	HHI	is	the	sum	of	the	
squared	market	shares	of	each	firm	in	the	market.	The	more	competitive	the	market,	the	lower	the	HHI.	The	less	competitive	the	market,	
the	higher	the	HHI.	An	HHI	above	1,800	is	rated	“highly	concentrated.”	An	HHI	between	1,000	and	1,800	is	considered	“concentrated.”	
Accessed	at	http://www.usdoj.gov/atr/public/testimony/hhi.htm.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A90 • WASHINGTON                                                                                            HEALTH CARE FOR AMERICA NOW!
    West Virginia Consumers Pay the Price
     For Health-Insurance Market Failure
 •	Coventry	Health	Care	Inc.,	the	state’s	biggest	                             •	From	2000	to	2007,	the	median	earnings	of	
   health	insurer,	controls	36	percent	of	the	West	                              West	Virginia	workers	increased	19	percent,	
   Virginia	commercial	market.	Together	with	                                    from	$19,876	to	$23,599.	During	that	time	
   Acordia	Inc.,	the	second	largest,	they	control	                               health	insurance	premiums	for	West	Virginia	
   54	percent	of	the	market.1                                                    working	families	rose	four	times	faster	than	
 •	Some	local	markets	are	more	concentrated.	In	                                 median	earnings.6
   Charleston,	Coventry	and	Aetna	Inc.	together	
   hold	67	percent	of	the	commercial	market.2                                  If	one	company	holds	more	than	a	42	percent		
 •	Health	insurance	premiums	for	West	Virginia	                                share	of	a	market	the	U.S.	Justice	Department	
   working	families	have	skyrocketed,	increasing	                              would	consider	that	market	“highly	
   75	percent	from	2000	to	2007.3                                              concentrated.”7	The	U.S	Justice	Department	
 •	For	family	health	coverage	in	West	Virginia	                                uses	a	rating	system	based	on	market	share	to	
   during	that	time,	the	average	annual	                                       determine	if	a	market	is	concentrated	or	highly	
   combined	premium	for	employers	and	                                         concentrated.	If	the	market	is	rated	from	1,000	
   employees	rose	from	$6,844	to	$11,970.4                                     to	1,800,	it	is	considered	to	be	“concentrated.”	
 •	For	family	health	coverage	in	West	Virginia,	                               Markets	rated	higher	than	1,800	are	deemed	to	
   the	average	employer’s	portion	of	annual	                                   be	“highly	concentrated.”	This	means	that	an	
   premiums	rose	81	percent,	while	the	average	                                insurer	could	raise	premiums	and/or	reduce	the	
   worker’s	share	increased	56	percent.5                                       variety	of	plans	or	quality	of	services	offered	to	
                                                                               customers	with	impunity.8



        West Virginia Commercial Health                                          Percent Increase in Premiums vs Income
        Insurance Market Concentration                                                 in West Virginia, 2000–2007
                                                                               150

                 Others                                                        120

                             46%
                                                                               90                    75%

                                                                               60

                                                 36%                                                                                19%
                                                                               30
                           18%
                                                       Coventry                 0
                Acordia                                                                          Premiums                   Individual Income



     Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
     A Comprehensive Study of U.S. Markets: 2008 Update.”




Washington
 HEALTH CARE FOR AMERICA NOW!                                                                               West Virginia               WEST VIRGINIA • A91
ENDNOTES
1	
  AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
only.	American	Medical	Association,	“Competition	in	health	insurance:	A	comprehensive	study	of	U.S.	markets:	2008	update.”	
2
 Ibid.
3
 Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
premiums-vs-paychecks-2008.html.
4
 Ibid.
5
 Ibid.
6
 Ibid.
7
 US	Department	of	Justice,	“The	Herfindahl-Hirschman	Index.”	Accessed	at	http://www.usdoj.gov/atr/public/guidelines/horiz_book/	
15.html;	American	Hospital	Association,	“The	Case	for	Reinvigorating	Antitrust	Enforcement	for	Health	Plan	Mergers	and	
Anticompetitive	Conduct	to	Protect	Consumers	and	Providers	and	Support	Meaningful	Reform,”	May	11,	2009.	Accessed	at	http://www.
aha.org/aha/content/2009/pdf/09-05-11-antitrust-rep.pdf.
8
 The	HHI	is	used	by	the	Department	of	Justice	and	the	Federal	Trade	Commission		in	anti-trust	proceedings.	The	HHI	is	the	sum	of	the	
squared	market	shares	of	each	firm	in	the	market.	The	more	competitive	the	market,	the	lower	the	HHI.	The	less	competitive	the	market,	
the	higher	the	HHI.	An	HHI	above	1,800	is	rated	“highly	concentrated.”	An	HHI	between	1,000	and	1,800	is	considered	“concentrated.”	
Accessed	at	http://www.usdoj.gov/atr/public/testimony/hhi.htm.


This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.




A92 • WEST VIRGINIA                                                                                         HEALTH CARE FOR AMERICA NOW!
           Wyoming Consumers Pay the Price
           For Health-Insurance Market Failure
 •	The	state’s	top	insurer,	Blue	Cross	Blue	Shield		 •	For	family	health	coverage	in	Wyoming,	
   of	Wyoming,	holds	70	percent	of	the	commercial		    the	average	employer’s	portion	of	annual	
   market.	The	second	biggest,	UnitedHealth	           premiums	rose	121	percent,	while	the	average	
   Group	Inc.,	controls	15	percent.1                   worker’s	share	increased	167	percent.4
 •	Health	insurance	premiums	for	Wyoming	            •	From	2000	to	2007,	the	median	earnings	of	
   working	families	have	skyrocketed,	increasing	      Wyoming	workers	increased	28	percent,	from	
   129	percent	from	2000	to	2007.   2
                                                       $20,765	to	$26,561.	During	that	time	health	
 •	For	family	health	coverage	in	Wyoming	during	       insurance	premiums	for	Wyoming	working	
   that	time,	the	average	annual	combined	             families	rose	4.6	times	faster	than	median	
   premium	for	employers	and	employees	rose	           earnings.5
   from	$5,605	to	$12,824.3


   Wyoming Commercial Health Insurance                                             Percent Increase in Premiums vs Income
         Market Concentration                                                              in Wyoming, 2000–2007

                                                     Blue Cross Blue Shield      150
                                                     of Wyoming                                       129%
                                                                                 120

                                              70%                                90

        Others          15%                                                      60

                                                                                                                                      28%
                                15%                                              30

                                                                                  0
                    UnitedHealth Group Inc.                                                        Premiums                   Individual Income


       Source: American Medical Association, “Competition in Health Insurance:         Sources: Families USA, “Premiums Versus Paychecks,” September 2008.
       A Comprehensive Study of U.S. Markets: 2007 Update.”




 ENDNOTES
Pennsylvania
 1

                                                                                                     Wyoming
  AMA	data	in	this	report	are	based	on	combined	enrollment	in	preferred	provider	organizations	(PPOs)	and	health	maintenance	
 organizations	(HMOs)	in	states	and	metropolitan	statistical	areas	(MSAs)	as	defined	by	the	U.S.	Census	Bureau.	The	AMA	calculates	
 market	share	by	dividing	an	insurer’s	enrollment	in	a	given	product	by	the	total	enrollment	across	all	insurers	in	a	market	multiplied	by	
 100.	Total	enrollment	is	for	commercial	products	only,	including	self-insured	employer-sponsored	PPO	plans	and	individual	coverage,	
 and	does	not	include	Medicare,	Medicaid,	or	Children’s	Health	Insurance	Program	enrollments.	Self-insured	employer	plans	refer	to	PPOs	
 only.	Accessed	at	http://www.ama-assn.org/go/competition2007.
 2
  Families	USA,	“Premiums	versus	Paychecks,”	September	2008.	Accessed	at	http://www.familiesusa.org/resources/publications/reports/
 premiums-vs-paychecks-2008.html.
 3
  Ibid.
 4
  Ibid.
 5
  Ibid.


 This	report	makes	use	of	data	published	by	the	American	Medical	Association	(AMA),	which	is	not	a	member	of	the	Health	Care	for	
 150
 America	Now	coalition.	The	AMA	did	not	collaborate	with	HCAN	on	this	report.

 HEALTH CARE FOR AMERICA NOW!                                                                                                                 WYOMING • A93
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FOR AMERICA             NOW!
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