INDIANAPOLIS - Rising unemployment, swine flu and the threat of health care reform all ganged up on managed care companies in the third quarter and could hurt their performance heading into 2010. But most of the large publicly traded health insurers reported better-than-expected profit growth for the latest period, and analysts still see strong core businesses beneath the challenges facing the industry.

"I would say they're holding their own in a very, very bad situation," BMO Capital Markets analyst Dave Shove said.

On Thursday, Philadelphia-based Cigna Corp. reported a third-quarter profit that soared 92 percent, as improving equity markets helped turn around the performance of a discontinued business the insurer maintains but no longer markets.

Cigna joined Minnetonka, Minn.-based UnitedHealth Group Inc., Hartford, Conn.-based Aetna Inc. and Louisville, Ky.-based Humana Inc. in recording earnings growth that stretched into the double digits compared with the third quarter of 2008, when the economy was mired in a deep slump.

Cigna also reported a drop in commercial health insurance enrollment, another trend it shares with its competitors. All the major health insurers aside from Aetna reported declines in enrollment driven by employers cutting jobs and reducing the number of people covered by private health insurance plans.

Even Aetna said it expects to lose as many as 650,000 members this year due to group health insurance cuts.

"It's rather frustrating, but it's a fact of life," Aetna Chief Financial Officer Joe Zubretsky said last week. "You have an account that's enjoying your services, it's priced well, it's meeting all of its objectives. But if they shed 5-to-7 percent of their payroll, that's lost members and lost revenue and profit."

Those job cuts deliver a double-whammy by increasing the number of people who continue their employer-sponsored insurance coverage under the federal law known as COBRA.

Earlier this year, the government started offering temporary subsidies that pay 65 percent of the cost of COBRA coverage, which is normally too expensive for most people to afford when they lose a job.

UnitedHealth and Indianapolis-based WellPoint Inc. both said they've seen an increase in their COBRA enrollment, normally a money-draining customer base.