In some large urban areas you can theoretically support several HMO’s with their own hospitals competing. More rural areas can support only one medical center and the largest insurer will be able to negotiate the best price thereby gaining a real advantage.

One of the big stated reasons for the Affordable Care Act was to increase competition in the individual market since many markets are dominated by just one or two insurers, but so far early indications are a mixed bag. The Kaiser Family Foundation looked at seven states with their own exchanges which have put out more comprehensive enrollment data. It found increased competition in two states but decreased competition in another two. From KFF:

Only scattered information is available so far on enrollment across plans.  Seven state-run exchanges have released market share data, but these enrollment numbers do not include individual market enrollment outside of the exchange. Off-exchange individual markets will continue to exist alongside exchanges, so exchange enrollment alone does not tell the whole story of consumer choice and competition.

Nonetheless, early indications suggest that some exchange markets are more competitive than their states’ individual markets before the ACA.  In particular, the two largest states, California and New York, have significantly more competitive exchange markets compared to their individual markets in 2012.  Two states (Connecticut and Washington) that have also been successful at enrolling consumers seem to have less competition than in their 2012 individual markets.  Results from the remaining states generally show either similar levels of competition as their pre-ACA markets or mixed signs.

These only very preliminary results and things could still change. It will probably take at least another year or two to get a real sense of the impact since many insurers will probably reassess their business strategies after they have some real-world data to analysis.

That said, I doubt the ACA will make most markets more competitive because it doesn’t change the core dynamics which drove concentration in the first place. In some large urban areas you can theoretically support several HMO’s with their own hospitals competing. More rural areas can support only one medical center and the largest insurer will be able to negotiate the best price thereby gaining a real advantage. Without some significant changes, like all-payer, the insurance market in such places is unlikely to ever be competitive. Creating shopping websites and slightly increasing the number buying insurance simply doesn’t change the basic economics.

Photo by Henry Alva, used under Creative Commons License