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Medical loss ratios in the individual health insurance market varied widely by state in 2010, but group markets varied less. During 2010, prior to the enforcement of the ACA's new federal standards, insurers with low medical loss ratios dominated coverage in the individual market in more than one-third of states, and smaller insurers had lower medical loss ratios than larger insurers. States that regulated loss ratios and premiums in 2010 generally had higher average medical loss ratios. Findings suggest that the new federal standards could support a transition to higher value choices in many state markets.