25% in 2004 and 18% in 2005. Meanwhile, the number of participating plans dropped to seven as of 2003, and "more than two dozen cities, counties and school districts" (representing 4% of membership) left CalPERS as of 2004 because of high medical insurance rates. A 2006 study by the Government Accountability Office determined that from 1997 through 2002 the average annual growth in CalPERS premiums (6.5%) was lower than that of the Federal Employees Health Benefits Program (FEHBP, 8.5%) and of other surveyed employer-sponsored health benefit programs (7.1%); however, between 2003 and 2006–7, the average annual growth rate in CalPERS premiums (14.2%) was higher than that of FEHBP (7.3%) and of other surveyed employer-sponsored health benefit programs (10.5%). As of 2008, CalPERS eliminated copayments for preventive care visits, raised copayments for other types of office visits, and took other measures in an attempt to reduce costs. In 2010, Blue Shield of California, Dignity Health, and Hill Physicians Medical Group initiated an integrated health management program (similar to an Accountable Care Organization) that covered 41,000 CalPERS members. In 2019, CalPERS provided more than $9.2 billion in health benefits for 1.5 million active and retired state, public agency, and school workers and their dependents. Therefore, it was the nation's second largest public purchaser of health benefits, behind the FEHBP which covered "about 8 million federal employees, retirees, and their dependents". Of the enrollees, 59% are state employees and 41% are local government and school employees; 68% are working and 32% are retired. Enrollees can join three types of plans: 68% are enrolled in health maintenance organization plans administered by Blue Shield of California and by Kaiser Permanente. 25% are enrolled in preferred provider organization plans called "PERS Select," "PERSCare," and "PERS Choice," which are administered by Anthem Blue Cross (the California subsidiary of WellPoint). 7% are enrolled in "association" plans for the California Correctional Peace Officers Association, the California Association of Highway Patrolmen, and the Peace Officers Research Association of California. Long-term care benefits California's "Public Employees' Long-Term Care Act," as passed in 1990 and amended in 1996, led to CalPERS' administering a Long-Term Care Program for "California public employees and retirees, as well as their spouses, parents, parents-in-law, adult children and adult siblings between the ages of 18 and 79." Described as the "largest self-funded program of its kind", the program provides "nursing home care, residential assisted living, home health care,