Competition and Vertical Integration in Dental Insurance: The GAO Weighs In

By Mike Adelberg, NADP Executive Director

On March 9, 2026, the General Accounting Office (GAO) released its report (link) on market concentration and vertical integration in private dental and vision insurance. The study was conducted in response to the introduction of the DOC Access bill – HR 1521 (2025-2026), which seeks to prohibit dental and vision insurance carriers from offering providers contracts that require providers to charge insured members at the negotiated rate after the person’s annual maximum is used up. (Note: This practical impact of this provision would be to transfer money from consumers to providers.)

Topline Finding: It also noted that market concentration varies significantly across states. The GAO suggests that the top three group dental insurance carriers in a state have a median share of 66.8% of the state’s group dental market, while the top three group vision insurance issuers in a state have a median share of 77.4%. GAO did not offer any recommendations regarding its findings.

The report is issued at a time of heightened sensitivity to market concentration and vertical integration across the U.S. economy—fueled by concerns that this type of economic activity can impact affordability for consumers. Both are discussed below.

Market Concentration

• Reasonable people can differ regarding the point at which an industry is “too concentrated.” But the GAO did not determine that, nationally, there is concerning concentration in the dental insurance industry. Not only did the GAO decline to articulate any concern in this regard, but it showed that dental insurance is less concentrated than vision insurance (nor am I suggesting that vision insurance is overly concentrated).
• GAO focuses much of its analysis on the market share of the three largest carriers in a given state. However, three carriers can, in and of themselves, be strong competition, especially when each of the three carriers offers a wide range of products with different coverages and price points.
• The GAO’s data suggests there is less robust competition in small-population and rural states. This generalization holds true across most industries. In dental, less competition in a small state is usually traceable to long term relationships between a carrier and employers or providers in that market. There is little reason to think that consolidation has created market concentration. Even in rural states, there are rarely less than 20 dental carriers competing for business.

• There are limitations to the GAO’s analysis that do not do full justice to the level of real-world competition to provide dental coverage. Chief among them:
  • The GAO’s analysis does not include products and carriers that sell only to self-insured businesses, so carriers with large books of business are not included in the GAO’s counts.
  • Dental discount savings plans, which compete with traditional dental insurance in the group and individual markets, are also excluded from the GAO’s analysis.

Publicly available industry analyses show that dental insurance is not among the more highly concentrated U.S. sectors. Broader reviews of market concentration consistently identify numerous industries across finance, technology, telecommunications, transportation, retail, energy, and media that are far more concentrated than dental insurance. GAO interviews included a few dental industry critics who shared observations about their lack of leverage to negotiate contract terms and rates with insurers. However, this is from a small group of vocal stakeholders, and GAO did not seek a statistically valid sample to substantiate these comments. In the absence of statistically valid sampling or corroborating market-wide data, such observations should be understood as anecdotal rather than reflective of the industry.

Vertical Integration

The GAO did not find vertical integration in the dental insurance market beyond a few isolated acquisitions. Further, it did not find any studies that document vertical integration in the dental insurance market.

If the ultimate concern of Congress is maintaining consumer affordability, then lawmakers can be re-assured about dental benefits. Nationally, premiums rise only 1-2 percent a year and, as documented in a previous blog, consumer protections in dental benefits are increasing. This track record stands up to scrutiny and is premised on the large number of carriers (a national median of 39 carriers per state) competing for business.