Anthem provides Blue Cross / Blue Shield nationally for employers with employees scattered all over the country. Their main customer is the United States government – which gave the Obama administration substantial leverage to blackmail Anthem. The Affordable Care Act required the Medicare / Medicaid operation within HHS to sign up at least two multistate health insurers to offer insurance in states which chose not to set up an exchange. It was down to the evening of the final day before Anthem agreed to sign the contract. Anthem provides insurance in states or areas where there is not an existing Blue Cross affiliate.
The notion of expanded multi-state health insurance operations in what has been regulated by state insurance commissions has to be attractive to Anthem. It comes with complications, which are that the cost controls in health insurance are gained by herding physicians into group practices with prenegotiated prices and discounts.
Organizing that on a national basis is a huge job and might draw an anti trust action if Anthem were too heavy handed – however in the end, health insurance is a “cost plus” business. When they pay a claim, it is not coming out of profits, it is just building the case for higher insurance premiums next year. Blue Cross and Shield were created to maximize profits for hospitals and doctors, after all. It largely solved the issue of patients who refused or were unable to pay by forcing them to prepay ahead of time. This was especially helpful when the patient died and the family refused to pay.