It's unlikely the uninsured rate will rise as sharply as some advocates feared a year ago.

This article was published on Friday, August 16, 2024 in KFF Health News.

By Phil Galewitz

Trisha Byers left behind one crucial item when she moved to North Carolina last year to be closer to her family after suffering a brain injury: health insurance.

In Massachusetts, Byers, 39, was enrolled in Medicaid, the government health program that covers low-income people. But she was ineligible in North Carolina, which had not yet expanded Medicaid coverage under the Affordable Care Act. She said she racked up thousands of dollars in unpaid emergency room bills while uninsured for several months after her move.

Then in December, North Carolina joined 39 other states and Washington, D.C., in widening Medicaid eligibility to include adults with incomes up to 138% of the federal poverty level, or $20,783 for an individual.

"I could finally get all the doctor appointments I needed," said Byers, one of more than 500,000 North Carolinians who gained coverage.

The North Carolina expansion came amid the biggest upheaval in Medicaid's nearly six-decade history. Since April 2023 — when protections that had blocked states from disenrolling Medicaid beneficiaries during the pandemic expired — states have disenrolled more than 24 million people whom they said no longer qualified or had failed to renew coverage.

This Medicaid "unwinding" led to fears that the number of people without insurance would spike. But it also coincided with moves in more than a dozen states to expand health coverage for lower-income people, including children, pregnant women, and the incarcerated.

These expansions will mitigate the effects of the unwinding to some degree, though it's still unclear how much. Five states have not finished culling their rolls, and the effect on the uninsured rate won't be clear until the U.S. Census Bureau releases official figures in September of next year.

"The pandemic was destructive and concerning and clearly demonstrated that Medicaid is so crucially important for our national safety net," said Jennifer Babcock, senior vice president for Medicaid policy at the Association for Community Affiliated Plans, a trade group representing nonprofit health insurers that cover people on Medicaid. "These expansions are incredibly meaningful."

Unwinding-era expansions include:

• South Dakota, like North Carolina, expanded Medicaid coverage under the Affordable Care Act last year. About 22,000 people enrolled in the first eight months.
   
• In July, Oregon launched a Medicaid-like coverage option for those who earn too much to qualify for Medicaid under federal limits. The plan is available to all adults with incomes between 138% and 200% — up to $30,120 for an individual — of the federal poverty level. More than 50,000 people have enrolled so far, Oregon officials say.
   
• In January, a new federal law required states to allow children to stay covered under Medicaid for at least a year after signing up. Several states are going beyond that: Oregon, New Mexico, and Washington, for example, allow children to stay covered up to age 6. California passed legislation to expand continuous eligibility for children up to age 4 but has not yet implemented the policy.
   
• Three states widened income eligibility for children to qualify for Medicaid: Arizona, Maine, and North Dakota.
   
• This year, Utah began offering a Medicaid-like coverage option for children regardless of immigration status, though the program is capped at about 2,000 children.
   
• Several states expanded coverage for pregnant women. Nevada, North Dakota, and Tennessee widened income eligibility to make it easier for pregnant women to qualify for Medicaid. Alabama and Maryland expanded eligibility to cover those who are pregnant regardless of immigration status. And Maine, Oregon, and Vermont extended postpartum coverage to 12 months, up from two. With those changes, 47 states now offer one year of postpartum coverage.
   
• In June, five states — Illinois, Kentucky, Oregon, Utah, and Vermont — received approval from the Biden administration to extend Medicaid coverage to incarcerated people up to 90 days before their release. Those states will join several states, including California, Massachusetts, Montana, and Washington, in offering that coverage.

States, which split funding of Medicaid with the federal government, typically expand Medicaid eligibility during times of economic growth when they have more revenue. But several other factors have contributed to the expansion trend. These include heightened awareness over rising maternal mortality rates and new restrictions on abortion, which have reinforced the need for expansions for pregnant women, said Allison Orris, a senior fellow with the left-leaning Center on Budget and Policy Priorities.

In particular, the pandemic showed how important health coverage is to ensure people's health and communities' safety from infectious diseases, Orris said. "It is not surprising to see states look at their Medicaid programs and find ways to strengthen in the midst of the unwinding," she said.

For example, while federal Medicaid funding cannot be used for people living in the country unlawfully, a small but growing number of states have used their money to expand coverage to residents lacking legal status.

During the pandemic, as a requirement to gain extra federal funding, states were prohibited from cutting off Medicaid coverage even for those no longer eligible. The experience showed states the benefits of keeping people enrolled, rather than churning them in and out as their income fluctuates, Orris said. It also brought the nation's uninsured rate to a record-low 7.7%.

Some advocates fear the unwinding of that pandemic-era policy will reverse key gains. A KFF survey published in April found 23% of adults reported being uninsured after they were disenrolled from Medicaid in 2023. A Centers for Disease Control and Prevention report released Aug. 6 found the uninsured rate rose to 8.2% in the first quarter of 2024, from 7.7% in the same quarter in 2023.

Enrollment increased by about 23 million people during the pandemic. As of Aug. 1, with about 85% of the unwinding completed, roughly 14.8 million people have been removed from Medicaid rolls. As a result, it's unlikely the uninsured rate will rise as sharply as some advocates feared a year ago, said Jennifer Tolbert, deputy director of the Program on Medicaid and the Uninsured at KFF, a health information nonprofit that includes KFF Health News.

"We have seen some amazing coverage expansion in places like Oregon and California," said Ben Anderson, deputy senior director of health policy at Families USA, a consumer advocacy group. "But if you live in Texas, Florida, and Georgia, since the pandemic your health coverage has been disrupted in ways that were preventable by state leaders." Those three states are among the 10 that have chosen not to expand Medicaid under the ACA.

Still, Anderson said, the effect of the expansions, even in a limited number of states, will ensure some people can better afford health care and avoid medical debt.

The unwinding process has been rife with fumbling, particularly in states that didn't steer enough resources to connect people with coverage. A study by the federal Government Accountability Office released in July revealed a Centers for Medicare & Medicaid Services' finding that almost all states made mistakes that led to eligible individuals losing Medicaid coverage.

The recent Medicaid expansions provide examples of how some states prioritize health coverage, particularly for certain vulnerable groups.

Tricia Brooks, a Medicaid expert at Georgetown University, noted that some states are "targeting little pockets of coverage and doing it for a variety of reasons."

Getting and keeping children insured means they are more likely to have a regular health provider and be ready to learn in school, she said. "There is no doubt there is a return on investment," she said.

Medicaid advocates wonder, though, whether a second Trump administration would curtail coverage expansions. Republicans have signaled they do not want to extend the federal subsidies that reduce what lower-income people pay for ACA marketplace plans and that are scheduled to expire in 2025.

"We are bracing for that potential impact," said Erin Delaney, director of healthcare policy at the Progressive Policy Institute.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Researchers have largely concluded that hospital desegregation improved the health of Black patients over the long term.

This article was published on Thursday, August 15, 2024 in KFF Health News.

By Lauren Sausser

MOUND BAYOU, Miss. — In the center of this historically Black city, once deemed "the jewel of the Delta" by President Theodore Roosevelt, dreams to revitalize an abandoned hospital building have all but dried up.

An art deco sign still marks the main entrance, but the front doors are locked, and the parking lot is empty. These days, a convenience store across North Edwards Avenue is far busier than the old Taborian Hospital, which first shut down more than 40 years ago.

Myrna Smith-Thompson, who serves as executive director of the civic group that owns the property, lives 100 miles away in Memphis, Tennessee, and doesn't know what's to become of the deteriorating building.

"I am open to suggestions," said Smith-Thompson, whose grandfather led a Black fraternal organization now called the Knights and Daughters of Tabor. In 1942, that group established Taborian Hospital, a place staffed by Black doctors and nurses that exclusively admitted Black patients, during a time when Jim Crow laws barred them from accessing the same health care facilities as white patients.

"This is a very painful conversation," said Smith-Thompson, who was born at Taborian Hospital in 1949. "It's a part of my being."

A similar scenario has played out in hundreds of other rural communities across the United States, where hospitals have faced closure over the past 40 years. In that regard, the story of Mound Bayou's hospital isn't unique.

But there's more to this hospital closure than the loss of inpatient beds, historians say. It's also a tale of how hundreds of Black hospitals across the U.S. fell casualty to social progress.

The Civil Rights Act of 1964 and the enactment of Medicare and Medicaid in 1965 benefited millions of people. The federal campaign to desegregate hospitals, culminating in a 1969 court case out of Charleston, South Carolina, guaranteed Black patients across the South access to the same health care facilities as white patients. No longer were Black doctors and nurses prohibited from training or practicing medicine in white hospitals. But the end of legal racial segregation precipitated the demise of many Black hospitals, which were a major source of employment and a center of pride for Black Americans.

"And not just for physicians," said Vanessa Northington Gamble, a medical doctor and historian at George Washington University. "They were social institutions, financial institutions, and also medical institutions."

In Charleston, staff members at a historically Black hospital on Cannon Street started publishing a monthly journal in 1899 called The Hospital Herald, which focused on hospital work and public hygiene, among other topics. When Kansas City, Missouri, opened a hospital for Black patients in 1918, people held a parade. Taborian Hospital in Mound Bayou included two operating rooms and state-of-the-art equipment. It's also where famed civil rights activist Fannie Lou Hamer died in 1977.

"There were Swedish hospitals. There were Jewish hospitals. There were Catholic hospitals. That's also part of the story," said Gamble, author of "Making a Place for Ourselves: The Black Hospital Movement, 1920-1945."

"But racism in medicine was the main reason why there was an establishment of Black hospitals," she said.

By the early 1990s, Gamble estimated, there were only eight left.

"It has ripple effects in a way that affect the fabric of the community," said Bizu Gelaye, an epidemiologist and program director of Harvard University's Mississippi Delta Partnership in Public Health.

Researchers have largely concluded that hospital desegregation improved the health of Black patients over the long term.

One 2009 study focusing on motor vehicle accidents in Mississippi in the '60s and '70s found that Black people were less likely to die after hospital desegregation. They could access hospitals closer to the scene of a crash, reducing the distance they would have otherwise traveled by approximately 50 miles.

An analysis of infant mortality, published in 2006 by economists at the Massachusetts Institute of Technology, found that hospital desegregation in the South substantially helped close the mortality gap between Black and white infants. That's partly because Black infants suffering from illnesses such as diarrhea and pneumonia got better access to hospitals, the researchers found.

A new analysis, recently accepted for publication in the Review of Economics and Statistics, suggests that racism continued to harm the health of Black patients in the years after hospital integration. White hospitals were compelled to integrate starting in the mid-1960s if they wanted to receive Medicare funding. But they didn't necessarily provide the same quality of care to Black and white patients, said Mark Anderson, an economics professor at Montana State University and co-author of the paper. His analysis found that hospital desegregation had "little, if any, effect on Black postneonatal mortality" in the South between 1959 and 1973.

Nearly 3,000 babies were born at Taborian Hospital before it closed its doors in 1983. The building remained vacant for decades until 10 years ago, when a $3 million federal grant helped renovate the facility into a short-lived urgent care center. It closed again only one year later amid a legal battle over its ownership, Smith-Thompson said, and has since deteriorated.

"We would need at least millions, probably," she said, estimating the cost of reopening the building. "Now, we're back where we were prior to the renovation."

In 2000, the hospital was listed as one of the most endangered historic places in Mississippi by the Mississippi Heritage Trust. That's why some people would like to see it reopened in any capacity that ensures its survival as an important historical site.

Hermon Johnson Jr., director of the Mound Bayou Museum, who was born at Taborian Hospital in 1956, suggested the building could be used as a meeting space or museum. "It would be a huge boost to the community," he said.

Meanwhile, most of the hospital's former patients have died or left Mound Bayou. The city's population has dropped by roughly half since 1980, U.S. Census Bureau records show. Bolivar County ranks among the poorest in the nation and life expectancy is a decade shorter than the national average.

A community health center is still open in Mound Bayou, but the closest hospital is in Cleveland, Mississippi, a 15-minute drive.

Mound Bayou Mayor Leighton Aldridge, also a board member of the Knights and Daughters of Tabor, said he wants Taborian Hospital to remain a health care facility, suggesting it might be considered for a new children's hospital or a rehabilitation center.

"We need to get something back in there as soon as possible," he said.

Smith-Thompson agreed and feels the situation is urgent. "The health care services that are available to folks in the Mississippi Delta are deplorable," she said. "People are really, really sick."

Lauren Sausser: lsausser@kff.org, @laurenmsausser

The growth in Medicare Advantage enrollment is due to a number of factors, including the availability of plans that charge no premium (other than the Part B premium), and extra benefits offered by most Medicare Advantage plans.

This article was published on Monday, August 8, 2024 in KFF Health News.

By Meredith Freed, Jeannie Fuglesten Biniek, Anthony Damico, and Tricia Neuman

Medicare Advantage enrollment has been on a steady climb for the past two decades following changes in policy designed to encourage a robust role for private plan options in Medicare. After a period of some instability in terms of plan participation and enrollment, The Medicare Modernization Act of 2003 created stronger financial incentives for plans to participate in the program throughout the country and renamed private Medicare plans Medicare Advantage. In 2024, 32.8 million people are enrolled in a Medicare Advantage plan, accounting for more than half, or 54 percent, of the eligible Medicare population, and $462 billion (or 54%) of total federal Medicare spending (net of offsetting receipts, such as premiums). Medicare Advantage enrolls a disproportionate share of people of color in Medicare as well as an increasing number of dual eligible beneficiaries. The average Medicare beneficiary in 2024 has access to 43 Medicare Advantage plans, the same as in 2023, but more than double the number of plans offered in 2018.

The growth in Medicare Advantage enrollment is due to a number of factors, including the availability of plans that charge no premium (other than the Part B premium), and extra benefits offered by most Medicare Advantage plans. Nearly all Medicare Advantage plans offer some benefits not included in traditional Medicare, such as coverage of dental, vision, or hearing services, often for no additional premium. Medicare beneficiaries are also drawn to the financial protection that comes with an out-of-pocket limit, which Medicare Advantage plans are required to provide, while traditional Medicare has no out-of-pocket cap on spending. On the other hand, Medicare Advantage plans have limited provider networks and apply cost management tools such as prior authorization, which traditional Medicare does not.

Generally, research shows that Medicare pays more to private Medicare Advantage plans for enrollees than their costs would be in traditional Medicare. The Medicare Payment Advisory Commission (MedPAC) reports that plans receive payments from CMS that are 122% of spending for similar beneficiaries in traditional Medicare, on average, translating to an estimated $83 billion in higher spending in 2024. As Medicare Advantage takes on a more dominant presence in the Medicare program, and with current payments to plans higher for Medicare Advantage than for traditional Medicare for similar beneficiaries, policymakers have become increasingly focused on how well Medicare’s current payment methodology for Medicare Advantage is working to enhance efficiency and hold down beneficiary costs and Medicare spending.

To better understand trends in the growth of the program, this brief provides current information about Medicare Advantage enrollment, by plan type and firm, and shows how enrollment varies by state and county. A second, companion analysis describes Medicare Advantage premiums, out-of-pocket limits, supplemental benefits offered, and prior authorization requirements in 2024. This analysis does not provide detailed information by enrollee characteristics, such as race/ethnicity, income, or dual status, because that information is not available.

Highlights for 2024:

• More than half (54%) of eligible Medicare beneficiaries are enrolled in Medicare Advantage in 2024. The share of Medicare beneficiaries in Medicare Advantage plans varies across states, ranging from 2% to 63%. In 7 states, AL, CT, MI, HI, ME, FL, RI (and Puerto Rico), 60% or more of all Medicare beneficiaries are enrolled in Medicare Advantage plans, an increase from 3 states in 2023.
• More than one-third (37%) of Medicare beneficiaries live in a county where at least 60 percent of all Medicare beneficiaries are enrolled in Medicare Advantage plans. Three counties (excluding those in Puerto Rico) enroll 80% or more of Medicare beneficiaries in Medicare Advantage plans: Monroe County, NY (Rochester; 82%), Starr, Texas (81%), and Miami-Dade County, Florida (80%). At the same time, 8 percent of all Medicare beneficiaries nationwide live in a county with relatively low enrollment, where less than one third of all Medicare beneficiaries are enrolled in Medicare Advantage plans. The wide variation in county enrollment rates reflect several factors, such as differences in firm strategy, urbanicity of the county, Medicare payment rates, number of Medicare beneficiaries, health care use patterns, and historical Medicare Advantage market penetration.
• Medicare Advantage enrollment is highly concentrated among a small number of firms, with UnitedHealthcare and Humana accounting for nearly half (47%) of all Medicare Advantage enrollees nationwide. In more than a quarter of all U.S. counties (29%; or 931 counties), these two firms account for at least 75 percent of Medicare Advantage enrollment. Since 2017, the market share for UnitedHealthcare and CVS Health has increased (25% to 29% and 8% to 12%, respectively), Humana (18%) and Cigna (2%) have held steady, while other firms’ share of total enrollment has slightly decreased (Blue Cross Blue Shield (BCBS) affiliates, Kaiser Permanente, and Centene). Small firms (which each account for less than 2% of enrollment) have a smaller share of the market in 2024 than in 2017 (19% to 16%).

More than half of eligible Medicare beneficiaries are enrolled in Medicare Advantage in 2024

In 2024, more than half (54%) of eligible Medicare beneficiaries – 32.8 million people out of 61.2 million Medicare beneficiaries with both Medicare Parts A and B – are enrolled in Medicare Advantage plans. Medicare Advantage enrollment as a share of the eligible Medicare population has jumped from 19% in 2007 to 54% in 2024 (Figure 1).

Between 2023 and 2024, total Medicare Advantage enrollment grew by about 2.1 million beneficiaries, or 7 percent – a similar growth rate as the prior year (8%). The Congressional Budget Office (CBO) projects that the share of all Medicare beneficiaries enrolled in Medicare Advantage plans will rise to 64% by 2034 (Figure 2).

In 2024, nearly two-thirds of Medicare Advantage enrollees are in individual plans that are open for general enrollment.

More than 6 in 10 Medicare Advantage enrollees (62%), or 20.5 million people, are in plans generally available to all beneficiaries for individual enrollment (Figure 3). That is an increase of 0.9 million enrollees compared to 2023. Individual plans have declined as a share of total Medicare Advantage enrollment since 2010 (71%).

More than 6.6 million Medicare beneficiaries are enrolled in special needs plans in 2024, more than double the enrollment in 2019.

More than 6.6 million Medicare beneficiaries are enrolled in special needs plans (SNPs). SNPs restrict enrollment to specific types of beneficiaries with significant or relatively specialized care needs, or who qualify because they are eligible for both Medicare and Medicaid. Enrollment in SNPs increased by 16 percent between 2023 and 2024, and accounts for 20 percent of total Medicare Advantage enrollment in 2024, an increase from 12 percent in 2010. Since 2019, SNP enrollment has more than doubled from 2.92 million to 6.64 million (Figure 4). This increase is due in part to the increasing number of SNP plans  available on average and more dual eligible individuals having access to these plans.

Most SNP enrollees (88%) are in plans for beneficiaries dually enrolled in both Medicare and Medicaid (D-SNPs). Another 10 percent of SNP enrollees are in plans for people with severe chronic or disabling conditions (C-SNPs) and 2 percent are in plans for beneficiaries requiring a nursing home or institutional level of care (I-SNPs).

While D-SNPs are designed specifically for dually-eligible individuals, 1.2 million Medicare beneficiaries with full Medicaid benefits were enrolled in Medicare Advantage plans generally available to all beneficiaries (not designed specifically for this population) in 2021, while 2.3 million full dual eligible individuals were in D-SNPs. D-SNPs have increasingly become the main source of Medicare Advantage coverage for dual eligible individuals.

SNP enrollment varies across states. In the District of Columbia and Puerto Rico, SNP enrollees comprise about half of all Medicare Advantage enrollees (49% in DC and 51% in PR). In nine states, SNP enrollment accounts for at least a quarter of Medicare Advantage enrollment: 46% in MS, 34% in AR, 33% in LA and NY, 28% in FL and GA, and 25% in CT, SC and AL.

C-SNP enrollment in 2024 (about 675,000 people) is 45% higher than it was in 2023 – an increase of about 210,000 enrollees. Nearly all (97%) C-SNP enrollees are in plans for people with diabetes or cardiovascular conditions in 2024. Enrollment in I-SNPs has been increasing slightly, with approximately 115,000 enrollees in 2024, up from about 103,000 in 2023.

Slightly less than one in five (17% or about 5.7 million) Medicare Advantage enrollees are in a group plan offered to retirees by an employer or union.

Group enrollment as a share of total Medicare Advantage enrollment has fluctuated between 17% to 20% since 2010, but the actual number has increased from 1.8 million in 2010 to 5.7 million in 2024 (Figure 5). With a group plan, an employer or union contracts with an insurer and Medicare pays the insurer a fixed amount per enrollee to provide benefits covered by Medicare. For example, 13 states provide health insurance benefits to their Medicare-eligible retirees exclusively through Medicare Advantage plans.

As with other Medicare Advantage plans, employer and union group plans may provide additional benefits and/or lower cost sharing than traditional Medicare and are eligible for bonus payments if they obtain required quality scores. The employer or union (and sometimes the retiree) may also pay an additional premium for these supplemental benefits. Group enrollees comprise a quarter or more of Medicare Advantage enrollees in nine states: Alaska (100%), Michigan (38%), New Jersey (33%), West Virginia (31%), Maryland (30%), Illinois (29%), Vermont (27%), Kentucky (26%), and Connecticut (25%).

The share of Medicare beneficiaries in Medicare Advantage plans varies by state and county

The share of Medicare beneficiaries in Medicare Advantage plans varies across states, ranging from 2% to 63%.

In 30 states, Medicare Advantage enrollees account for more than half of all Medicare beneficiaries, including in 7 states, AL, CT, MI, HI, ME, FL, RI (and Puerto Rico) where 60% or more of all Medicare beneficiaries are enrolled in Medicare Advantage plans (Figure 6). In contrast, Medicare Advantage enrollment is relatively low (less than 40%) in 13 states, including five states with less than 30% of beneficiaries enrolled in a Medicare Advantage plan – AK, MD, ND, SD, and WY – all of which (beside MD) are mostly rural. Overall, Puerto Rico has the highest Medicare Advantage penetration, with 95 percent of Medicare beneficiaries enrolled in a Medicare Advantage plan. A decade ago, the share of Medicare beneficiaries in Medicare Advantage plans did not exceed 50 percent in any state (other than Puerto Rico).

The share of Medicare beneficiaries enrolled in Medicare Advantage varies widely across counties.

For example, in Florida, 60% of all Medicare beneficiaries in the state are enrolled in Medicare Advantage, ranging from 21% in Monroe County (Key West) to 80% in Miami-Dade County (Figure 7). In Ohio, 57% of all Medicare beneficiaries are enrolled in Medicare Advantage, with the share ranging from 32% in Mercer County (Celina) to 69% in Stark County (Canton).

In 2024, more than a third (37%) of Medicare beneficiaries live in a county where at least 60 percent of all Medicare beneficiaries in that county are enrolled in Medicare Advantage plans (618 counties). That is substantially more than in 2010 when just 3 percent of the Medicare population lived in a county where 60 percent or more of Medicare beneficiaries were enrolled in a Medicare Advantage plan (83 counties). Many counties with high Medicare Advantage penetration are centered around relatively large, urban areas, such as Monroe County, NY (82%), which includes Rochester, and Allegheny County, PA (74%), which includes Pittsburgh. In contrast, 8 percent of Medicare beneficiaries live in a county where less than one third of all Medicare beneficiaries in that county are enrolled in Medicare Advantage plans (849 counties). Counties with relatively low enrollment tend to be less populated rural areas. However, others, such Montgomery County, MD (27%) and Suffolk, NY (31%), which includes much of Long Island, are in more populous areas. (This county-level analysis excludes Medicare Advantage enrollment in Connecticut. See methods for more details.)

Variation in the share of eligible Medicare beneficiaries who are enrolled in a Medicare Advantage plan is explained by a combination of factors, including firm-level strategies to target particular geographic areas, the urbanicity of the county and state, variation in Medicare payment rates, the number and characteristics of people eligible for Medicare, health care use patterns, and the historical Medicare Advantage market penetration.

Medicare Advantage enrollment is highly concentrated among a small number of firms

The average Medicare beneficiary is able to choose from Medicare Advantage plans offered by 8 firms in 2024, one fewer than in 2023 and 2022, and one-third of beneficiaries (33%) can choose among Medicare Advantage plans offered by 10 or more firms.

UnitedHealthcare and Humana account for nearly half of all Medicare Advantage enrollees nationwide in 2024.

Despite most beneficiaries having access to plans operated by several different firms, Medicare Advantage enrollment is highly concentrated among a small number of firms. UnitedHealthcare, alone, accounts for 29% of all Medicare Advantage enrollment in 2024, or 9.4 million enrollees. Together, UnitedHealthcare and Humana (18%) account for nearly half (47%) of all Medicare Advantage enrollees nationwide, the same as in 2023. In more than a quarter of counties (29%; or 931 counties), these two firms account for at least 75% of Medicare Advantage enrollment. These counties include East Baton Rouge (Baton Rouge), LA (81%), Clark County (Las Vegas), NV (79%), Travis County (Austin), FL (78%), and El Paso County (Colorado Springs), CO (76%). (Again, this county-level analysis does not include Connecticut.)

BCBS affiliates (including Anthem BCBS plans) account for 14% of enrollment, and four firms (CVS Health, Kaiser Permanente, Centene, and Cigna) account for another 23% of enrollment in 2024.

UnitedHealthcare and Humana have consistently accounted for a relatively large share of Medicare Advantage enrollment.

UnitedHealthcare has had the largest share of Medicare Advantage enrollment and largest growth in enrollment since 2010, increasing from 20 percent of all Medicare Advantage enrollment in 2010 to 29 percent in 2024. Humana has also had a high share of Medicare Advantage enrollment, though its share of enrollment has grown more slowly, from 16 percent in 2010 to 18 percent in 2024. BCBS plans share of enrollment has been more constant over time but has declined moderately since 2014.

CVS Health, which purchased Aetna in 2018, has seen its share of enrollment double from 6 percent in 2010 to 12 percent in 2024. Kaiser Permanente now accounts for 6 percent of total enrollment, a moderate decline as a share of total Medicare Advantage enrollment since 2010 (9%), mainly due to the growth of enrollment in plans offered by other insurers and only a modest increase in enrollment growth for Kaiser Permanente over that time. However, for those insurers that have seen declines in their overall share of enrollment, the actual number of enrollees for each insurer is larger than it was in 2010.

By absolute numbers, CVS Health had the largest growth in plan year enrollment, increasing by 758,000 beneficiaries between March 2023 and March 2024. Humana had the second largest growth in plan year enrollment, with an increase of about 472,000 beneficiaries between March 2023 and March 2024. UnitedHealthcare plans had the third highest growth in plan year enrollment, increasing by 456,000 beneficiaries – the first time in 8 years it did not have the largest plan growth among all firms. BCBS plans had the fourth largest growth in plan enrollment with an increase of about 283,000, followed by Kaiser Permanente, increasing by about 45,000 beneficiaries between March 2023 and March 2024. However, Centene had fewer enrollees, with enrollment declining by about 202,000 between March 2023 and March 2024.

Meredith Freed, Jeannie Fuglesten Biniek, and Tricia Neuman are with KFF. Anthony Damico is an independent consultant.

If Harris wins the presidency, she'll have a wide range of options to blunt hospitals' monopolistic behavior nationwide.

This article was published on Monday, August 5, 2024 in KFF Health News.

By Bernard J. Wolfson and Phil Galewitz

When Kamala Harris was California's top prosecutor, she was concerned that mergers among hospitals, physician groups, and health insurers could thwart competition and lead to higher prices for patients. If she wins the presidency in November, she'll have a wide range of options to blunt monopolistic behavior nationwide.

The Democratic vice president could influence the Federal Trade Commission and instruct the departments of Justice and Health and Human Services to prioritize enforcement of antitrust laws and channel resources accordingly. Already, the Biden administration has taken an aggressive stance against mergers and acquisitions. In his first year in office, President Joe Biden issued an executive order intended to intensify antitrust enforcement across multiple industries, including health care.

Under Biden, the FTC and DOJ have fought more mergers than they have in decades, often targeting health care deals.

"What Harris could do is set the tone that she is going to continue this laser focus on competition and health care prices," said Katie Gudiksen, a senior health policy researcher at University of California College of the Law, San Francisco.

The Harris campaign didn't respond to a request for comment.

For decades, the health industry has undergone consolidation despite government efforts to maintain competition. When health systems expand, adding hospitals and doctor practices to their portfolios, they often gain a large enough share of regional health care resources to command higher prices from insurers. That results in higher premiums and other health care costs for consumers and employers, according to numerous studies.

Health insurers have also consolidated in recent decades, leaving only a handful controlling most markets.

Health care analysts say it's possible for Harris to slow the momentum of consolidation by blocking future mergers that could lead to higher prices and lower-quality care. But many of them agree the consolidation that has already taken place is an inescapable feature of the U.S. health care landscape.

"It's hard to unscramble the eggs," said Bob Town, an economics professor at the University of Texas.

There were nearly 1,600 hospital mergers in the U.S. from 1998 to 2017 and 428 hospital and health system mergers from 2018 to 2023, according to a KFF study. The percentage of community hospitals that belong to a larger health system rose from 53 in 2005 to 68 in 2022. And in another sign of market concentration, as of January, well over three-quarters of the nation's physicians were employed by hospitals or corporations, according to a report produced by Avalere Health.

Despite former President Donald Trump's hostility to regulation as a candidate, his administration was active on antitrust efforts — though it did allow one of the largest health care mergers in U.S. history, between drugstore chain CVS Health and the insurer Aetna. Overall, Trump's Justice Department was more aggressive on mergers than past Republican administrations.

Harris, as California's attorney general from 2011 to 2017, jump-started health care investigations and enforcement.

"She pushed back against anticompetitive pricing," said Rob Bonta, California's current attorney general, who is a Democrat.

One of Harris' most impactful decisions was a 2012 investigation into whether consolidation among hospitals and physician practices gave health systems the clout to demand higher prices. That probe bore fruit six years later after Harris' successor, Xavier Becerra, filed a landmark lawsuit against Sutter Health, the giant Northern California hospital operator, for anticompetitive behavior. Sutter settled with the state for $575 million.

In 2014, Harris was among 16 state attorneys general who joined the FTC in a lawsuit to dismantle a merger between one of Idaho's largest hospital chains and its biggest physician group. In 2016, Harris joined the U.S. Department of Justice and 11 other states in a successful lawsuit to block a proposed $48.3 billion merger between two of the nation's largest health insurers, Cigna and Anthem.

Attempts to give the state attorney general the power to nix or impose conditions on a wide range of health care mergers have been fiercely, and successfully, opposed by California's hospital industry. Most recently, the hospital industry persuaded state lawmakers to exempt for-profit hospitals from pending legislation that would subject private equity-backed health care transactions to review by the attorney general.

A spokesperson for the California Hospital Association declined to comment.

As attorney general of California, Harris' work was eased by the state's deep-blue political hue. Were she to be elected president, she could face a less hospitable political environment, especially if Republicans control one or both houses of Congress. In addition, she could face opposition from powerful health care lobbyists.

Though it often gets a bad rap, consolidation in health care also confers benefits. Many doctors choose to join large organizations because it relieves them of the administrative headaches and financial burdens of running their own practices. And being absorbed into a large health system can be a lifeline for financially troubled hospitals.

Still, a major reason health systems choose to expand through acquisition is to accumulate market clout so they can match consolidation among insurers and bargain with them for higher payments. It's an understandable reaction to the financial pressures hospitals are under, said James Robinson, a professor of health economics at the University of California-Berkeley.

Robinson noted that hospitals are required to treat anyone who shows up at the emergency room, including uninsured people. Many hospitals have a large number of patients on Medicaid, which pays poorly. And in California, they face a series of regulatory requirements, including seismic retrofitting and nurse staffing minimums, that are expensive. "How are they going to pay for that?" Robinson said.

At the federal level, any effort to blunt anticompetitive mergers would depend in part on how aggressive the FTC is in pursuing the most egregious cases. FTC Chair Lina Khan has made the FTC more proactive in this regard.

Last year, the FTC and DOJ jointly issued new merger guidelines, which suggested the federal government would scrutinize deals more closely and take a broader view of which ones violate antitrust laws. In September, the FTC filed a lawsuit against an anesthesiology group and its private equity backer, alleging they had engaged in anticompetitive practices in Texas to drive up prices.

In January, the agency sued to stop a $320 million hospital acquisition in North Carolina.

Still, many transactions don't come to the attention of the FTC because their value is below its $119.5 million reporting threshold. And even if it heard about more deals, "it is very underresourced and needing to be very selective in which mergers they challenge," said Paul Ginsburg, a professor of the practice of health policy at the University of Southern California's Sol Price School of Public Policy.

Khan's term ends in September 2024, and Harris, if elected, could try to reappoint her, though her ability to do so may depend on which party controls the Senate.

Harris could also promote regulations that discourage monopolistic behaviors such as all-or-nothing contracting, in which large health systems refuse to do business with insurance companies unless they agree to include all their facilities in their networks, whether needed or not. That behavior was one of the core allegations in the Sutter case.

She could also seek policies at the Department of Health and Human Services, which runs Medicare and Medicaid, that encourage competition.

Bonta, California's current attorney general, said that, while there are bad mergers, there are also good ones. "We approve them all the time," he said. "And we approve them with conditions that address cost and that address access and that address quality."

He expects Harris to bring similar concerns to the presidency if she wins.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

Bernard J. Wolfson: bwolfson@kff.org, @bjwolfson

Phil Galewitz: pgalewitz@kff.org, @philgalewitz