In its 12th annual study, the American Medical Association finds low levels of competition among commercial health insurers in 71 percent of 386 metropolitan areas analyzed in all 50 states and the District of Columbia.

Absence of competition means physicians in small practices have little leveraging in negotiating fee structures with insurers, who also take advantage of patients by raising premiums and dictating care, the association contends. In order, the 10 states with the least competitive markets, based on 2011 data, are Alabama, Hawaii, Michigan, Delaware, Alaska, South Carolina, North Dakota, Nebraska, Louisiana and Rhode Island.

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