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On November 9, the Indiana Department of Health issued a Certificate of Public Advantage (COPA) to allow Union Hospital to acquire Terre Haute Regional Hospital. The proposed merger would effectively combine the two only acute care hospitals in Vigo County and create a near‐monopoly for inpatient hospital services in the Terre Haute, Indiana area. The proposed acquisition drew opposition from the Federal Trade Commission (FTC) (under both the Biden and Trump administrations) and the state's own Attorney General (AG). The COPA prevents state enforcement to challenge the merger as an antitrust violation. This is Indiana’s first use of a COPA, and due to recently enacted legislation, it may be the last.

History of the Case

Union Health, parent company of the 341-bed Union Hospital, has been exploring the acquisition of the 278-bed Terre Haute Regional Hospital since at least 2021. Union Health submitted an application for the COPA in September 2023. In September 2024, the Biden administration's FTC issued a comment letter opposing the COPA, which led Union Health to withdraw its application in November 2024. The application was resubmitted in February 2025. In March, the Trump administration's FTC reaffirmed its opposition to the COPA. Also in March, Yale Economist Zack Cooper submitted an analysis to the Indiana Department of Health opposing the merger's approval. In April, the state’s own Attorney General, Todd Rokita, also formally opposed the merger in a letter sent to the Indiana Department of Health. The Department of Health approved the COPA in November 2025.

Certificates of Public Advantage and Antitrust Oversight

A COPA is a state regulatory mechanism that allows otherwise anticompetitive health care transactions to proceed by substituting active state oversight for market competition. When a COPA is granted, the merging entities receive immunity from state antitrust enforcement, but only so long as the state affirmatively determines that the public benefits of the transaction outweigh the harms of reduced competition and actively supervises the combined entity on an ongoing basis. This interpretation of state action immunity was articulated in the Supreme Court’s decision in FTC v. Phoebe Putney Health System, Inc. (2013).  In that case, the Court held that state-action antitrust immunity applies only when 1) anticompetitive conduct is clearly articulated and affirmatively expressed as state policy and 2) is actively supervised by the state. The first part of state action immunity typically requires legislative action to establish a process by which entities can apply for a COPA and the second requires ongoing review and oversight by a state agency. States using COPAs typically impose detailed conditions related to pricing, quality, access, and reporting, and require continuous monitoring to ensure the merged system operates in a manner consistent with the public interest rather than simply exercising monopoly power.

History of Indiana’s COPA Law

In 2021, Indiana enacted SB 416 which allows for entities to apply for a COPA. Nineteen states, including Indiana,  have legislative authority that allows merging parties to apply for COPAs; most of them enacted these laws after 1993.  Five more states, including North Carolina and Montana, have repealed their COPA statutes. In 2025, Indiana enacted SB 119, which prohibits any new COPA applications after May 13, 2025, meaning that the Union-Terre Haute COPA will be the only one issued under the law. Interestingly, the 2025 bill to end COPA submissions was championed by Indiana Senator Ed Charbonneau, an architect of the 2021 law.  Future Indiana legislatures have the option of reviving the COPA law.

The FTC, under both Republican and Democratic administrations, has long been opposed to using COPAs to allow otherwise monopolistic hospital mergers. The reasons for the FTC’s opposition include that COPAs exacerbate the widespread problems of hospital consolidation (including higher prices and reduced patient access) and can reduce hospital employee wage growth. The FTC has also noted that monitoring and compliance are difficult. For states, "regulatory fatigue, staff turnover, and changes in funding priorities at state agencies can lead to less vigorous supervision", but the FTC also has noted the significant resources hospitals have to devote to compliance with COPA conditions, often leading them to lobby for repeal of the COPA oversight. When a COPA is repealed, revoked, or terminated, the FTC states that “the community is often left with a hospital monopoly that can exercise its market power without constraint.”

Nature of the Objections to the Indiana Merger

The FTC’s September 2024 opposition letter estimated that the Indiana merger would result in Union Health having a combined market share of nearly 74% of all commercially insured inpatient hospital services in Vigo County Indiana, and would “likely impose higher costs and could lead to worse healthcare outcomes for Indiana patients, as well as lower wage growth for hospital workers". The March 2025 statement from the FTC echoed the concerns from the previous letter, stating that the "repackaged COPA application presents the same problems as before. Competition consistently results in better outcomes for patients and workers than consolidation subject to COPAs”, and urged the state to reject the COPA application.

The state AG's opposition letter claimed that the merger would create a regional monopoly, harming care access, stifling innovation, and allowing for unchecked pricing, and urged the Department of Health to reject the COPA application. The Attorney General stated, "We all understand that hospitals face distinct challenges, but consolidation at the expense of free-market competition is not the way to address those challenges”.

Economist Zack Cooper’s analysis indicated that the merger would give Union Health a local market share from 75% to 100%, creating a de facto monopoly in the local hospital market, and estimated that the merger would raise prices at the hospitals by 10% to 30%, raise local insurance premiums by 3% to 10%, lower nurses’ wages by approximately 5%, and would result in approximately 500 job losses outside the health sector.

Why is Indiana Using a COPA?

Given the concerns about using a COPA, one might ask why the state would approve it in this case. The Indiana COPA law required the Department of Health to find that the merger will improve health outcomes, access, and care quality beyond any harm caused by reduced competition before issuing a COPA. In its determination letter, the Department stated that the aggregate benefits arising from the proposed merger, which included a list of commitments made by the merging parties relating to quality, prices, preservation of access, etc., were sufficient to outweigh the potential disadvantages attributable to a reduction in competition. The Department recognizes that the merger creates a monopoly for inpatient hospital services, but believes the commitments made by the parties were sufficient to counter any potential harms.

Commitments made by the merging parties span quality, pricing, access, service enhancements, employment, population health, and other community impacts, and include an average aggregate price cap of 265% of Medicare, restrictions on billing changes related to site neutrality, and the introduction of direct-to-employer contracts. Union Health will have new reporting requirements, must hold public listening sessions, and must create a “Healthier Together” transparency website.  Under the COPA, the Indiana Department of Health will have active oversight of these commitments.  Many of the commitments have a time window, and will not stay in effect after a certain number of years (this varies from commitment to commitment).  According to the Department of Health’s Determination Letter, “[d]uring the COPA Pricing Term (approximately 10 years if Union Health terminates the COPA at the earliest permissible time), Union Health and the other members of the Combined Enterprise shall comply with the Pricing Commitments and the Terms and Conditions.”  In 2005, Indiana enacted HB 1004 which states that if a nonprofit hospital’s aggregate average inpatient and outpatient hospital prices are more than the statewide average inpatient and outpatient hospital prices, it risks losing its nonprofit status.  Since Union Health is a nonprofit, this could limit what they charge after the COPA conditions expire.

Indiana Governor Mike Braun stated that the “result of this merger will be lower prices and more healthcare services available to residents of Terre Haute and Vigo County because of the strict operating terms and conditions that Union Health accepted," bringing “long-term improvement to the community’s health outcomes.”

Union Health has claimed the move will secure long-term local healthcare access, and also claimed that a hospital monopoly couldn’t result in higher prices since “[h]ealth insurance plans determine pricing for services for 98.4% of its patients,” and that “Federal government programs will continue to set rates for Union Hospital and commercial and Medicare Advantage plans will continue to robustly negotiate rates with Union Hospital as they do today.”

How Well Have COPAs Functioned in Other States?

Looking at examples of when COPAs were issued in other states does not inspire confidence in the long-term prognosis for Terre Haute’s market.

In Montana, Benefis Health System was formed in 1996 under a COPA, which was repealed in 2007, after Benefis lobbied for the repeal. Prices increased significantly after the repeal of the COPA.

In 1998, Mission Health formed in North Carolina under a COPA and saw commercial inpatient prices jump by 20% under it. After the COPA was repealed in 2015 (with Mission lobbying for its repeal), Mission Health was acquired by HCA and prices rose by 38%.  Mark A. Hall, Professor of Law and Public Health at Wake Forest University published a deep dive on “Lessons Learned From HCA’s Purchase of Mission Hospital in Asheville, North Carolina” available on The Source’s website.

MaineHealth acquired Southern Maine Medical Center via a COPA in 2009, which resulted in substantial commercial inpatient price increases during the COPA (at least 38%), and after the COPA expired in 2015, for a total price increase of at least 50% during the COPA and post-COPA period.

In 2018, Ballad Health was formed via a COPA. According to KFF Health News, emergency room wait times more than tripled afterward, and the system has continually failed to meet quality standards.

Moving Forward

Given the history of COPAs, optimism for Terre Haute's healthcare future should be tempered. Economist Zack Cooper has noted that many of the assurances made by Union Health are time-limited and has stated that “as soon as the COPA expires, we’re going to see double-digit price increases”.

In most situations, COPA oversight has been an insufficient substitute for hospital market competition for providing what's best for patients and workers. States should strongly consider allowing federal and state regulators to examine mergers to determine whether they would result in negative price or quality effects, and to use legal means to prevent such mergers.

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