From 064ea7f2926934a0d94df10697fa356e7f032cc7 Mon Sep 17 00:00:00 2001 From: Teleo Agents Date: Thu, 12 Mar 2026 11:38:05 +0000 Subject: [PATCH] vida: extract from 2025-07-24-kff-medicare-advantage-2025-enrollment-update.md - Source: inbox/archive/2025-07-24-kff-medicare-advantage-2025-enrollment-update.md - Domain: health - Extracted by: headless extraction cron (worker 3) Pentagon-Agent: Vida --- ...tical integration during CMS tightening.md | 6 +++ ...or-disease-specific-managed-care-models.md | 44 +++++++++++++++++ ...ment-to-primary-medicare-delivery-model.md | 38 +++++++++++++++ ...-enrollment-despite-nominal-plan-choice.md | 41 ++++++++++++++++ ...worsens-rather-than-improves-efficiency.md | 48 +++++++++++++++++++ ...rofits from health rather than sickness.md | 6 +++ ...rics but only 14 percent bear full risk.md | 6 +++ ...dicare-advantage-2025-enrollment-update.md | 18 ++++++- 8 files changed, 206 insertions(+), 1 deletion(-) create mode 100644 domains/health/chronic-condition-special-needs-plans-grew-71-percent-in-2025-signaling-explosive-demand-for-disease-specific-managed-care-models.md create mode 100644 domains/health/medicare-advantage-crossed-majority-enrollment-in-2023-marking-structural-transformation-from-supplement-to-primary-medicare-delivery-model.md create mode 100644 domains/health/medicare-advantage-market-is-an-oligopoly-with-unitedhealth-and-humana-controlling-46-percent-of-enrollment-despite-nominal-plan-choice.md create mode 100644 domains/health/medicare-advantage-overpayment-gap-grew-4-7x-from-2015-to-2025-while-enrollment-only-doubled-showing-scale-worsens-rather-than-improves-efficiency.md diff --git a/domains/health/Devoted is the fastest-growing MA plan at 121 percent growth because purpose-built technology outperforms acquisition-based vertical integration during CMS tightening.md b/domains/health/Devoted is the fastest-growing MA plan at 121 percent growth because purpose-built technology outperforms acquisition-based vertical integration during CMS tightening.md index 2f3e3f834..bcafec9c3 100644 --- a/domains/health/Devoted is the fastest-growing MA plan at 121 percent growth because purpose-built technology outperforms acquisition-based vertical integration during CMS tightening.md +++ b/domains/health/Devoted is the fastest-growing MA plan at 121 percent growth because purpose-built technology outperforms acquisition-based vertical integration during CMS tightening.md @@ -23,6 +23,12 @@ Devoted was built from scratch on the Orinoco platform — a unified AI-native o Since [[proxy inertia is the most reliable predictor of incumbent failure because current profitability rationally discourages pursuit of viable futures]], UnitedHealth's $9 billion annual technology spend directed at optimizing existing infrastructure (consolidating 18 EMRs, AI scribing within legacy workflows) rather than rebuilding around prevention is textbook proxy inertia. The margin from coding arbitrage rationally prevents pursuit of the purpose-built alternative. + +### Additional Evidence (extend) +*Source: [[2025-07-24-kff-medicare-advantage-2025-enrollment-update]] | Added: 2026-03-12 | Extractor: anthropic/claude-sonnet-4.5* + +The 2024-2025 enrollment shifts show market consolidation continuing: Humana lost 297K members while UnitedHealthGroup gained 505K. This suggests that even among large incumbents, market share is concentrating toward the largest player (UHG at 29% share, 9.9M enrollees). Devoted's 121% growth rate stands in stark contrast to Humana's contraction, supporting the claim that purpose-built technology creates competitive advantage during regulatory tightening. The overall MA market grew 4% (1.3M enrollees), meaning Devoted is growing 30x faster than the market while a major incumbent (Humana, 17% share) is shrinking. This pattern is consistent with the thesis that acquisition-based vertical integration (Humana's model) underperforms purpose-built technology platforms (Devoted's model) when CMS tightens payment and increases compliance scrutiny. + --- Relevant Notes: diff --git a/domains/health/chronic-condition-special-needs-plans-grew-71-percent-in-2025-signaling-explosive-demand-for-disease-specific-managed-care-models.md b/domains/health/chronic-condition-special-needs-plans-grew-71-percent-in-2025-signaling-explosive-demand-for-disease-specific-managed-care-models.md new file mode 100644 index 000000000..e2f2b8e37 --- /dev/null +++ b/domains/health/chronic-condition-special-needs-plans-grew-71-percent-in-2025-signaling-explosive-demand-for-disease-specific-managed-care-models.md @@ -0,0 +1,44 @@ +--- +type: claim +domain: health +description: "C-SNP enrollment surge from 2024-2025 indicates that chronic disease management is the fastest-growing MA segment outpacing dual-eligible and institutional SNPs" +confidence: experimental +source: "Kaiser Family Foundation, Medicare Advantage in 2025: Enrollment Update and Key Trends" +created: 2025-07-24 +--- + +# Chronic condition special needs plans grew 71 percent in 2025 signaling explosive demand for disease-specific managed-care models + +Chronic Condition Special Needs Plans (C-SNPs) experienced 71% enrollment growth from 2024 to 2025, reaching 1.2M enrollees (16% of all SNP enrollment). This growth rate far exceeds the overall MA growth rate of 4% and even exceeds the broader SNP category growth. + +C-SNPs are designed for beneficiaries with specific severe or disabling chronic conditions (diabetes, ESRD, cardiovascular disorders, chronic heart failure). The explosive growth indicates that disease-specific care coordination models are finding product-market fit, likely driven by: + +1. **Metabolic disease epidemic**: The prevalence of diabetes, obesity, and related conditions creates a large addressable population +2. **GLP-1 medication management**: Chronic conditions requiring expensive pharmaceutical management benefit from integrated care coordination +3. **CMS payment incentives**: Risk adjustment and quality bonuses favor plans that can demonstrate outcomes improvement in chronic populations +4. **Technology enablement**: Remote monitoring and AI-augmented care management make chronic condition coordination operationally viable at scale + +For context, the SNP landscape in 2025: +- D-SNPs (dual-eligible): 6.1M (83% of SNPs) — largest but slower growth +- C-SNPs (chronic conditions): 1.2M (16%) — **71% growth** +- I-SNPs (institutional): 115K (2%) + +The C-SNP growth rate suggests that chronic disease management is becoming the primary vector for MA innovation and differentiation, not just dual-eligible or institutional care. + +## Evidence +- KFF 2025 data: C-SNP enrollment 1.2M, 71% year-over-year growth +- C-SNPs grew from 14% of SNP enrollment in 2020 to 16% in 2025 +- Overall MA growth rate 4% vs C-SNP growth 71% + +## Limitations +Single-year growth spike could be anomalous. Need 2026 data to confirm sustained trajectory vs. one-time enrollment shift. The causal drivers (metabolic epidemic, GLP-1 demand, payment incentives, technology) are plausible but not directly confirmed by this source. + +--- + +Relevant Notes: +- [[GLP-1 receptor agonists are the largest therapeutic category launch in pharmaceutical history but their chronic use model makes the net cost impact inflationary through 2035.md]] +- [[Big Food companies engineer addictive products by hacking evolutionary reward pathways creating a noncommunicable disease epidemic more deadly than the famines specialization eliminated.md]] +- [[the healthcare attractor state is a prevention-first system where aligned payment continuous monitoring and AI-augmented care delivery create a flywheel that profits from health rather than sickness.md]] + +Topics: +- [[domains/health/_map]] diff --git a/domains/health/medicare-advantage-crossed-majority-enrollment-in-2023-marking-structural-transformation-from-supplement-to-primary-medicare-delivery-model.md b/domains/health/medicare-advantage-crossed-majority-enrollment-in-2023-marking-structural-transformation-from-supplement-to-primary-medicare-delivery-model.md new file mode 100644 index 000000000..447a3a6eb --- /dev/null +++ b/domains/health/medicare-advantage-crossed-majority-enrollment-in-2023-marking-structural-transformation-from-supplement-to-primary-medicare-delivery-model.md @@ -0,0 +1,38 @@ +--- +type: claim +domain: health +description: "MA enrollment reaching 51% in 2023 represents the inflection point where managed care became the default Medicare experience rather than an alternative option" +confidence: proven +source: "Kaiser Family Foundation, Medicare Advantage in 2025: Enrollment Update and Key Trends" +created: 2025-07-24 +--- + +# Medicare Advantage crossed majority enrollment in 2023 marking structural transformation from supplement to primary Medicare delivery model + +Medicare Advantage enrollment reached 51% of eligible beneficiaries in 2023 (30.8M enrollees), crossing the majority threshold for the first time in the program's history. By 2025, enrollment reached 34.1M (54% penetration), and CBO projects 64% penetration by 2034. + +This is not incremental growth but a structural inflection point. When more than half of Medicare beneficiaries are in managed care rather than traditional fee-for-service, the political economy of Medicare reform fundamentally changes. Traditional Medicare is becoming the minority program, which shifts the default assumption about what "Medicare" means for future beneficiaries. + +The growth trajectory shows consistent acceleration: +- 2007: 7.6M (19%) +- 2015: 16.2M (32%) +- 2020: 23.8M (42%) +- 2023: 30.8M (51%) — **majority threshold crossed** +- 2025: 34.1M (54%) +- 2034 (projected): 64% + +The 2023 crossing point is the structural marker because it represents the moment when MA shifted from "alternative coverage option" to "primary Medicare delivery model." This has cascading implications for provider networks, benefit design, regulatory focus, and the political feasibility of MA reform. + +## Evidence +- KFF Medicare Advantage 2025 enrollment data showing 51% penetration in 2023, 54% in 2025 +- CBO projection of 64% penetration by 2034 +- Growth rate of 4% (1.3M enrollees) from 2024-2025 showing sustained momentum + +--- + +Relevant Notes: +- [[the healthcare attractor state is a prevention-first system where aligned payment continuous monitoring and AI-augmented care delivery create a flywheel that profits from health rather than sickness.md]] +- [[value-based care transitions stall at the payment boundary because 60 percent of payments touch value metrics but only 14 percent bear full risk.md]] + +Topics: +- [[domains/health/_map]] diff --git a/domains/health/medicare-advantage-market-is-an-oligopoly-with-unitedhealth-and-humana-controlling-46-percent-of-enrollment-despite-nominal-plan-choice.md b/domains/health/medicare-advantage-market-is-an-oligopoly-with-unitedhealth-and-humana-controlling-46-percent-of-enrollment-despite-nominal-plan-choice.md new file mode 100644 index 000000000..4c94441e2 --- /dev/null +++ b/domains/health/medicare-advantage-market-is-an-oligopoly-with-unitedhealth-and-humana-controlling-46-percent-of-enrollment-despite-nominal-plan-choice.md @@ -0,0 +1,41 @@ +--- +type: claim +domain: health +description: "Market concentration metrics show duopoly control despite average of 9+ plan options per beneficiary revealing that choice architecture does not equal competitive markets" +confidence: proven +source: "Kaiser Family Foundation, Medicare Advantage in 2025: Enrollment Update and Key Trends" +created: 2025-07-24 +--- + +# Medicare Advantage market is an oligopoly with UnitedHealth and Humana controlling 46 percent of enrollment despite nominal plan choice + +The Medicare Advantage market exhibits classic oligopoly structure despite the appearance of competitive choice. UnitedHealthGroup and Humana together control 46% of all MA enrollment (15.6M of 34.1M enrollees), with UHG alone holding 29% market share (9.9M enrollees). + +The top five parent organizations control 70% of the market: +- UnitedHealth Group: 9.9M (29%) +- Humana: 5.7M (17%) +- CVS Health (Aetna): 4.1M (12%) +- Elevance Health: 2.2M (7%) +- Kaiser Foundation: 2.0M (6%) +- All others: 10.3M (30%) + +Geographic concentration is even more extreme: 815 counties (26% of all counties) have 75%+ enrollment concentration in just UHG and Humana. This means in over a quarter of US counties, three out of four MA beneficiaries are enrolled in one of two parent organizations. + +The nominal choice architecture—average of 9 plan options per beneficiary, with 36% having 10+ options—obscures the underlying market structure. Multiple plan brands from the same parent organization create the appearance of competition while market power remains concentrated. This is choice theater, not competitive markets. + +The 2024-2025 enrollment shifts reveal consolidation dynamics: Humana lost 297K members while UHG gained 505K, suggesting the market is concentrating further rather than diversifying. + +## Evidence +- KFF 2025 data: UHG 29% share, Humana 17% share, combined 46% +- 815 counties (26%) with 75%+ concentration in UHG + Humana +- Average 9 plan options per beneficiary masks parent organization concentration +- Humana -297K enrollees, UHG +505K enrollees (2024-2025) + +--- + +Relevant Notes: +- [[Devoted is the fastest-growing MA plan at 121 percent growth because purpose-built technology outperforms acquisition-based vertical integration during CMS tightening.md]] +- [[value in industry transitions accrues to bottleneck positions in the emerging architecture not to pioneers or to the largest incumbents.md]] + +Topics: +- [[domains/health/_map]] diff --git a/domains/health/medicare-advantage-overpayment-gap-grew-4-7x-from-2015-to-2025-while-enrollment-only-doubled-showing-scale-worsens-rather-than-improves-efficiency.md b/domains/health/medicare-advantage-overpayment-gap-grew-4-7x-from-2015-to-2025-while-enrollment-only-doubled-showing-scale-worsens-rather-than-improves-efficiency.md new file mode 100644 index 000000000..e5357e9c4 --- /dev/null +++ b/domains/health/medicare-advantage-overpayment-gap-grew-4-7x-from-2015-to-2025-while-enrollment-only-doubled-showing-scale-worsens-rather-than-improves-efficiency.md @@ -0,0 +1,48 @@ +--- +type: claim +domain: health +description: "Federal spending premium over FFS equivalent increased from $18B to $84B as MA scaled from one-third to half of Medicare demonstrating that market maturity has not reduced overpayment" +confidence: proven +source: "Kaiser Family Foundation, Medicare Advantage in 2025: Enrollment Update and Key Trends" +created: 2025-07-24 +--- + +# Medicare Advantage overpayment gap grew 4.7x from 2015 to 2025 while enrollment only doubled showing scale worsens rather than improves efficiency + +Medicare Advantage federal spending exceeded fee-for-service equivalent costs by $84B in 2025 (20% per-person premium), up from $18B in 2015. The spending gap grew 4.7x while enrollment roughly doubled (16.2M to 34.1M), demonstrating that scale and market maturity have made the overpayment problem worse, not better. + +This contradicts the standard efficiency narrative that managed care competition would drive down costs as the market matured. Instead: + +**2015 baseline:** +- Enrollment: 16.2M (32% penetration) +- Overpayment: $18B +- ~1/3 of eligible beneficiaries enrolled + +**2025 current state:** +- Enrollment: 34.1M (54% penetration) +- Overpayment: $84B (20% per-person premium) +- Enrollment increased 2.1x +- Overpayment increased 4.7x + +The per-person premium of 20% in 2025 means CMS pays MA plans $1.20 for every $1.00 it would spend on the same beneficiary in traditional Medicare. At 34.1M enrollees, this 20% premium compounds to $84B in excess federal spending. + +The divergence between enrollment growth (2.1x) and spending gap growth (4.7x) indicates that either: +1. Risk adjustment gaming has accelerated as plans learned to optimize coding +2. Supplemental benefits and plan richness have increased faster than efficiency gains +3. Market concentration (UHG + Humana = 46%) enables pricing power that extracts rents rather than competing on efficiency + +This trajectory is fiscally unsustainable and explains why CMS is implementing aggressive reforms like the 2027 chart review exclusion targeting upcoded diagnoses. + +## Evidence +- KFF 2025 data: $84B overpayment (20% per-person premium) +- 2015 baseline: $18B overpayment when ~1/3 enrolled +- Spending gap grew 4.7x while enrollment grew 2.1x + +--- + +Relevant Notes: +- [[CMS 2027 chart review exclusion targets vertical integration profit arbitrage by removing upcoded diagnoses from MA risk scoring.md]] +- [[the healthcare attractor state is a prevention-first system where aligned payment continuous monitoring and AI-augmented care delivery create a flywheel that profits from health rather than sickness.md]] + +Topics: +- [[domains/health/_map]] diff --git a/domains/health/the healthcare attractor state is a prevention-first system where aligned payment continuous monitoring and AI-augmented care delivery create a flywheel that profits from health rather than sickness.md b/domains/health/the healthcare attractor state is a prevention-first system where aligned payment continuous monitoring and AI-augmented care delivery create a flywheel that profits from health rather than sickness.md index 7cae923d2..11bb7e2cb 100644 --- a/domains/health/the healthcare attractor state is a prevention-first system where aligned payment continuous monitoring and AI-augmented care delivery create a flywheel that profits from health rather than sickness.md +++ b/domains/health/the healthcare attractor state is a prevention-first system where aligned payment continuous monitoring and AI-augmented care delivery create a flywheel that profits from health rather than sickness.md @@ -285,6 +285,12 @@ Healthcare is the clearest case study for TeleoHumanity's thesis: purpose-driven PACE provides the most comprehensive real-world test of the prevention-first attractor model: 100% capitation, fully integrated medical/social/psychiatric care, continuous monitoring of a nursing-home-eligible population, and 8-year longitudinal data (2006-2011). Yet the ASPE/HHS evaluation reveals that PACE does NOT reduce total costs—Medicare capitation rates are equivalent to FFS overall (with lower costs only in the first 6 months post-enrollment), while Medicaid costs are significantly HIGHER under PACE. The value is in restructuring care (community vs. institution, chronic vs. acute) and quality improvements (significantly lower nursing home utilization across all measures, some evidence of lower mortality), not in cost savings. This directly challenges the assumption that prevention-first, integrated care inherently 'profits from health' in an economic sense. The 'flywheel' may be clinical and social value, not financial ROI. If the attractor state requires economic efficiency to be sustainable, PACE suggests it may not be achievable through care integration alone. + +### Additional Evidence (confirm) +*Source: [[2025-07-24-kff-medicare-advantage-2025-enrollment-update]] | Added: 2026-03-12 | Extractor: anthropic/claude-sonnet-4.5* + +Medicare Advantage enrollment trajectory confirms the payment alignment thesis: MA crossed 50% penetration in 2023 and reached 54% by 2025, with CBO projecting 64% by 2034. This means the majority of Medicare beneficiaries are now in capitated, risk-bearing payment models rather than fee-for-service. The C-SNP (chronic condition special needs plans) segment grew 71% in 2025, indicating that disease-specific care coordination—where plans profit from preventing complications rather than billing for treatments—is the fastest-growing MA segment. However, the $84B overpayment gap (20% per-person premium over FFS) shows that current MA plans are extracting rents rather than delivering the efficiency gains that aligned payment theoretically enables. The attractor state exists structurally (majority of beneficiaries in capitated models), but the path to it is contested by incumbents optimizing for risk adjustment gaming rather than health outcomes. + --- Relevant Notes: diff --git a/domains/health/value-based care transitions stall at the payment boundary because 60 percent of payments touch value metrics but only 14 percent bear full risk.md b/domains/health/value-based care transitions stall at the payment boundary because 60 percent of payments touch value metrics but only 14 percent bear full risk.md index eb54caa1d..de6f146bc 100644 --- a/domains/health/value-based care transitions stall at the payment boundary because 60 percent of payments touch value metrics but only 14 percent bear full risk.md +++ b/domains/health/value-based care transitions stall at the payment boundary because 60 percent of payments touch value metrics but only 14 percent bear full risk.md @@ -23,6 +23,12 @@ The Making Care Primary model's termination in June 2025 (after just 12 months, PACE represents the extreme end of value-based care alignment—100% capitation with full financial risk for a nursing-home-eligible population. The ASPE/HHS evaluation shows that even under complete payment alignment, PACE does not reduce total costs but redistributes them (lower Medicare acute costs in early months, higher Medicaid chronic costs overall). This suggests that the 'payment boundary' stall may not be primarily a problem of insufficient risk-bearing. Rather, the economic case for value-based care may rest on quality/preference improvements rather than cost reduction. PACE's 'stall' is not at the payment boundary—it's at the cost-savings promise. The implication: value-based care may require a different success metric (outcome quality, institutionalization avoidance, mortality reduction) than the current cost-reduction narrative assumes. + +### Additional Evidence (extend) +*Source: [[2025-07-24-kff-medicare-advantage-2025-enrollment-update]] | Added: 2026-03-12 | Extractor: anthropic/claude-sonnet-4.5* + +Medicare Advantage represents the largest-scale implementation of full-risk value-based payment in US healthcare, with 34.1M enrollees (54% of Medicare beneficiaries) in capitated plans. This is the opposite of the 'stall at the payment boundary' pattern—MA has crossed the boundary and put the majority of Medicare spending under full risk. However, the $84B overpayment gap (growing 4.7x while enrollment doubled) suggests that full-risk payment alone does not guarantee efficiency. The market concentration data (UHG + Humana = 46% of enrollment, 815 counties with 75%+ duopoly concentration) indicates that the payment model has been captured by oligopoly dynamics. This extends the original claim: value-based care stalls at the payment boundary in fragmented markets, but crossing the boundary into full-risk capitation does not automatically deliver value if market structure enables rent extraction. The attractor state requires both aligned payment AND competitive market structure. + --- Relevant Notes: diff --git a/inbox/archive/2025-07-24-kff-medicare-advantage-2025-enrollment-update.md b/inbox/archive/2025-07-24-kff-medicare-advantage-2025-enrollment-update.md index 303b9f5a9..8ed678e6d 100644 --- a/inbox/archive/2025-07-24-kff-medicare-advantage-2025-enrollment-update.md +++ b/inbox/archive/2025-07-24-kff-medicare-advantage-2025-enrollment-update.md @@ -7,9 +7,15 @@ date: 2025-07-24 domain: health secondary_domains: [] format: data -status: unprocessed +status: processed priority: high tags: [medicare-advantage, enrollment, market-concentration, market-share, kff] +processed_by: vida +processed_date: 2026-03-11 +claims_extracted: ["medicare-advantage-crossed-majority-enrollment-in-2023-marking-structural-transformation-from-supplement-to-primary-medicare-delivery-model.md", "medicare-advantage-market-is-an-oligopoly-with-unitedhealth-and-humana-controlling-46-percent-of-enrollment-despite-nominal-plan-choice.md", "chronic-condition-special-needs-plans-grew-71-percent-in-2025-signaling-explosive-demand-for-disease-specific-managed-care-models.md", "medicare-advantage-overpayment-gap-grew-4-7x-from-2015-to-2025-while-enrollment-only-doubled-showing-scale-worsens-rather-than-improves-efficiency.md"] +enrichments_applied: ["Devoted is the fastest-growing MA plan at 121 percent growth because purpose-built technology outperforms acquisition-based vertical integration during CMS tightening.md", "the healthcare attractor state is a prevention-first system where aligned payment continuous monitoring and AI-augmented care delivery create a flywheel that profits from health rather than sickness.md", "value-based care transitions stall at the payment boundary because 60 percent of payments touch value metrics but only 14 percent bear full risk.md"] +extraction_model: "anthropic/claude-sonnet-4.5" +extraction_notes: "Four new claims extracted covering the structural inflection point (MA crossing 50% in 2023), market concentration dynamics (UHG+Humana duopoly), C-SNP explosive growth (71% YoY), and the overpayment gap acceleration (4.7x growth vs 2.1x enrollment growth). Three enrichments applied to existing claims on Devoted's growth, the healthcare attractor state, and value-based care payment boundaries. The curator note was correct: the spending gap growing 4.7x while enrollment only doubled is the key structural insight—scale is making the overpayment problem worse, not better." --- ## Content @@ -79,3 +85,13 @@ tags: [medicare-advantage, enrollment, market-concentration, market-share, kff] PRIMARY CONNECTION: [[the healthcare attractor state is a prevention-first system where aligned payment continuous monitoring and AI-augmented care delivery create a flywheel that profits from health rather than sickness]] WHY ARCHIVED: Essential market structure data — the enrollment trajectory and concentration metrics ground claims about where the US healthcare system is actually heading vs. where theory says it should go. EXTRACTION HINT: The spending gap growing 4.7x while enrollment only doubled is the key structural insight — scale is making the overpayment problem worse, not better. + + +## Key Facts +- MA enrollment trajectory: 7.6M (19%) in 2007 → 34.1M (54%) in 2025 +- CBO projects 64% MA penetration by 2034 +- MA market share 2025: UHG 29%, Humana 17%, CVS/Aetna 12%, Elevance 7%, Kaiser 6% +- 815 counties (26%) have 75%+ enrollment concentration in UHG + Humana +- SNP enrollment 2025: D-SNPs 6.1M (83%), C-SNPs 1.2M (16%), I-SNPs 115K (2%) +- Average 9 parent organization options per beneficiary, 36% have 10+ options +- Employer/union group MA plans: 5.7M enrollees (17%), first year of flat growth in ~10 years