Antitrust Enforcement
Fixing a Broken System: Policy Responses to Hospital Acquisitions of Physician Practices That Limit Health Care Access for U.S. Consumers
Progressive Policy Institute
Diana Moss, Alix Ware, Lief Lin
By 2023, more than half of all independent physician practices (IPPs) were no longer independent, but owned by hospitals, health systems, or corporate entities, meaning 78% of all U.S. physicians were employed by large provider organizations. Loss of IPPs through vertical consolidation leads to higher prices, reduced access, loss of physician autonomy, and reduced patient choice. This study highlights several areas that contribute to the accelerated rate of consolidation including site-of-service payment differentials, inadequate merger oversight, anticompetitive state regulations, and failure to secure adequate policy support for rural healthcare. The Federal Trade Commission (FTC) and the Department of Justice (DOJ) have rarely interfered in vertical mergers, particularly in the healthcare sector, resulting in the near extinction of IPPS. State Certificate of Need and Certificate of Public Advantage laws limit market entry, insulate market consolidation, and limit antitrust enforcement, further eroding IPP sustainability. This Public Policy Institute study demonstrates that policy reforms must include more robust antitrust enforcement by the FTC, DOJ, and state attorneys general; support for physician autonomy in contracts and governance structures; and special consideration for the amplified impact that vertical consolidation has had in rural healthcare, with marked loss of access to both IPPs and healthcare at large.
Recent Trends in Commercial Health Insurance Market Concentration
Peterson-KFF Health System Tracker
Shameek Rakshit, Jared Ortaliza, Lynne Cotter, Matthew Rae, Cynthia Cox
As research has shown, market concentration has downstream effects such as limiting consumer choice, leveraging market power to manipulate prices, and mixed quality outcomes. This article examines the national, state, and regional trends in the insurer markets for small and large groups and individual coverage, including employer-sponsored coverage, Medicaid managed care and fee-for-service plans, as well as Medicare Advantage from 2013-2023. Enrollment data for self-funded plans is also included. Insurance markets remained moderately to highly concentrated over time with a noticeable but small increase in competition in the individual market starting in 2020, coinciding with increased premium tax credits during the COVID-19 pandemic response. Other notable trends include a shift away from small- and large-group and toward self-funded insurance plans for employers. Importantly, self-funded plans are largely insulated from state regulation and oversight. The largest insurers (UnitedHealth, Kaiser Permanente, Elevance Health, Cigna, CVS Health, and Cigna) held significant market shares across regions in the small and large group markets while Centene held a significant market share in the individual market. Through interactive maps and accessible graphics, the Peterson-KFF Health Tracker gives readers, researchers, and policymakers a birds-eye view of state-level insurance market concentration across the nation.
Healthcare Prices and Payments
Site-Neutral Payment for Routine Services Could Save Commercial Purchasers and Patients Billions
Health Affairs Scholar
Rosalyn C. Murray, Haroon Janjua, Christopher M. Whaley
It is well understood that the U.S. healthcare system is a costly one, owing to many factors such as administrative complexity, high-priced prescription drugs, and expensive technology. Complex reimbursement schemes contribute to ballooning costs as well as market trends favoring consolidation. In fact, Medicare pays different rates for the same service depending on if that service is provided in a physician office, ambulatory surgical center (ASC), or hospital outpatient department (HOPD), incentivizing services in higher-cost settings. The Medicare Payment Advisory Council (MedPAC) recommends site-neutral payments for common procedures, citing considerable cost savings. Utilizing commercial claims data from 2022, the study’s authors tracked services MedPAC deems safe in physician offices or ASCs and calculated the savings if site-neutral payments were implemented and reimbursements were capped at 150% of Medicare payment of non-hospital settings. State-level data revealed an average price for selected services of 448% of Medicare’s physician fee schedule, with a calculated savings with the 150% cap of more than $10 billion. Notably, hospital operating margins experienced only a modest decline with the modeled 150% caps, roughly 0.8% (authors determined national average hospital operating margin to be 16.6%, while acknowledging wide variability across regions). Additional modeling was performed for more modest caps up to 400%, still demonstrating cost savings and modest effects on hospitals’ operating margins. This article is detailed in its methodology and its limitations and offers a thorough examination of possible unintended consequences of pursuing site-neutral payment policy reforms.
The High Cost of American Health Care: Understanding the Deeper Roots of the Crisis
Health Care Analysis
Cyril F. Chang, David M. Mirvis, Asos Mahmood
This Health Care Analysis article looks beyond the often-cited reasons for the persistently high cost of healthcare in the U.S. – namely, lack of federally-imposed price caps, reliance on a fee-for-service payment model, administrative complexity, costly prescription drugs, overuse of specialist physicians, opaque pricing for goods and services, and the presence of private equity in healthcare markets – to explore additional root causes that contribute to high prices. More complex supply- and demand-side factors underpin the pervasive high and ever-growing costs of the U.S. health system. Specifically, the Baumol effect, which explains ever increasing wages regardless of improved quality; price effects subsequent to consolidation; continued reliance on treatment rather than prevention; ready adoption of unproven technologies; use of third-party payors; tax benefits related to employer-sponsored healthcare benefits; and the historical presence of health inequity all work against cost containment. Reform, the authors contend, will come from reckoning with the lack of political will for change, capitalizing on a digital (generative artificial intelligence) revolution for technological efficiency, building on broad transparency in price, and preferencing value-based payment models.
Healthcare Reform
Same as It Ever Was? Persistence and Transformation in U.S. Health Care Policy
Journal of Health Politics, Policy, and Law
Jonathon Oberlander
To ring in the New Year we revisit a previous manuscript, now published article, that we highlighted in July 2025. The end of the calendar year is a great time to take stock, and this article is a wonderful way to better understand U.S. health policy over the past five decades and grasp ideas for possible reforms to maximize access, control costs, and support healthy markets.
Redux: Jonathan Oberlander’s article in the Journal of Health Politics, Policy and Law is a brief, yet thorough, journey through the last several decades of health care reform in the U.S. He argues that the driving forces of reform – the crisis of high cost, inequitable access through lack of universal coverage, and fragmented healthcare financing – have persisted from the inaugural issue of the journal in 1976 until today. The U.S., through cultural, political, and economic influence, continues to treat access to health care as something one “deserves” rather than a universal right. Reform movements range from incrementalism, in which new demographic groups are granted access to insurance coverage, to the more robust change of the 2010 Affordable Care Act that created state-level marketplaces and further expanded Medicaid enrollment. More current reforms include cost containment measures, such as payment and delivery reforms, essentially, decentralized efforts at addressing runaway healthcare cost growth. Oberlander argues that as private insurers play an increasing role in public programs (Medicare and Medicaid), the line between private and public interest blurs and influence from increasingly large health systems further shapes public policy. As evidenced by the 2025 budget debate in Congress, and resulting One Big Beautiful Bill, healthcare cost shifting (to states and individuals) remains preferential to cost cutting and access to coverage continues to be precarious.
Has Corporatization Met Its Match? The Challenge of Making Money by Keeping People Healthy
New England Journal of Medicine
David M. Cutler, Robert S. Huckman
There is an inherent conflict in the U.S. healthcare system: while it would be more economic (and moral) to keep people healthy, the system is reliant on diagnosing and treating people once they are unwell. Like all corporations, healthcare providers seek to increase revenues, minimize costs, and realize a profit. However, reliance on a fee-for-service (FFS) payment model (according to the authors, 70% of physician services were still FFS through 2020) and the resource-heavy hospital delivery of healthcare services prohibit true cost containment and, more importantly, inhibit a market move toward incentivizing health maintenance. Moving care to lower cost settings such as home-hospital care requires social infrastructure that is wanting in many U.S. locales. Reliable access to nutritious food, technology and communication, transportation, and other social supports will be required building blocks in designing a system of delivering health and not just healthcare. Reform will also require new value-based reimbursement models that seek to qualify and quantify benchmarks of health outcomes. While there are few examples of making money while keeping people healthy, nascent partnerships between Target and Kaiser Permanente or Best Buy and Geisinger could shed light on paths forward. As this article elucidates, shifting the system away from paying for medical services to rewarding health outcomes will require significant change in reimbursement models, social infrastructure, and a new and robust understanding of the true value of investing in health over healthcare.
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